Lower extremity amputation protocol: a pilot enhanced recovery pathway for vascular amputees

O’Banion, Leigh Ann; Qumsiyeh, Yazen; Matheny, Heather; Siada, Sammy; Yan, Yueqi; Hiramoto, Jade S.; Rome, Cambia; Dirks, Rachel; Prentice, A

doi:10.1016/j.jvscit.2022.08.003

Cited by 7 publications

(6 citation statements)

References 31 publications

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“…1) The identi ed barriers may not be isolated to one institution; others have attempted to initiate a postoperative LEAP at the institutional level. 13,34 This study ts within a multi-level process (Fig. 2) in which system level efforts have already been enacted including post-amputation rehabilitation CPGs 3,4 and the American Physical Therapy Association limb loss educational curricular guideline.…”

Section: Discussionmentioning

confidence: 99%

“…2), the recommended automated multidisciplinary referral system would address institutional barriers such as insu cient patients with which to gain experience and multidisciplinary communication or coordination. 13,34 This single recommendation could have multiple downstream effects. All professions could be automatically alerted to their roles to optimize multidisciplinary communication and coordination, all clinicians would have access to relevant outcome measures through the electronic documentation system, and more people with LEA would be referred, taking advantage of the fact that productivity was not a major barrier.…”

Section: Discussionmentioning

confidence: 99%

“…This descriptive cross-sectional study was approved by the Institutional Review Board of the participating major US medical center, which cares for people after LEA in various intensive care and medical units. An anonymous Qualtrics™ (Qualtrics, Provo, UT, USA) survey was sent to a convenience sample of 389 multidisciplinary clinical professionals who could provide postoperative LEAP care, 13 including rehabilitation medicine and vascular surgery physicians, prosthetists, nursing staff, and occupational, physical, and recreational therapy professionals. A 60% response rate was the recommended goal.…”

Section: Methodsmentioning

confidence: 99%

“…10 Early postoperative mobilization facilitates rehabilitation and shorten lengths-of-stay. 11 Adopting CPG recommendations including post-amputation limb dressings 12 and early mobilization 13 may improve rehabilitation outcomes and decrease postoperative length-of-stay 14,15 as recently piloted in a lower extremity amputation protocol (LEAP) by one institution. 13 One of many challenges that inhibit implementation of evidence-based rehabilitation practice may be that post-amputation care is multidisciplinary by nature.…”

mentioning

confidence: 99%

“…11 Adopting CPG recommendations including post-amputation limb dressings 12 and early mobilization 13 may improve rehabilitation outcomes and decrease postoperative length-of-stay 14,15 as recently piloted in a lower extremity amputation protocol (LEAP) by one institution. 13 One of many challenges that inhibit implementation of evidence-based rehabilitation practice may be that post-amputation care is multidisciplinary by nature. 16 Multiple disciplines play important roles in peri-operative amputation care focused on wound healing, self-care, and mobility.…”

mentioning

confidence: 99%

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Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators

Beckley,

Wong

2024

Preprint

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Background: Implementing evidence-based clinical practice guidelines (CPGs) requiring multidisciplinary efforts for relatively small clinical populations such as people undergoing lower extremity amputations, may present special challenges. People with chronic vascular diseases face wound healing and mobilization challenges that delay rehabilitation and hospital discharge. Lower extremity amputation protocols (LEAP) including postoperative limb dressings and early mobilization improve healing, functional outcomes, and reduce hospital lengths-of-stay—but require multidisciplinary coordination. The purpose of this study was to identify barriers and facilitators to implementing a multidisciplinary evidence-based LEAP for postoperative rehabilitation after amputation. Methods: This cross-sectional organization and provider-level study included a convenience sample of 238 multidisciplinary professionals from an urban medical center. An anonymous survey, developed using the Theoretical Domains Framework, explored barriers and facilitators in the knowledge, clinical skills, and personal/contextual domains. Analysis was descriptive with barriers rank ordered. Results: Clinicians responded from medicine (17.3%), nursing (16.0%), prosthetics (5.8%), physical therapy (36.0%), occupational therapy (24.0%), and recreational therapy (0.9%). Self-rated knowledge was low: 93.3% were unfamiliar with amputation rehabilitation CPGs and 60.9% were unfamiliar with problems delaying hospital discharge. Self-rated clinical competence was low corresponding to minimal reported experience with post-amputation limb wrapping or early mobilization. Potential barriers included unfamiliarity with the evidence, limited clinical training and confidence, insufficient patients, and inadequate interdisciplinary communication and coordination. Facilitators included clinician readiness to change and knowledge of early mobilization evidence. Conclusions: Identifying barriers and facilitators led to provider and organization-level recommendations organized using the behavior change wheel to consider the capability, opportunity, and motivation domain functions. An automated multidisciplinary referral system with standard order set emerged as a proximal strategy to potentially affect all three domains and multiple implementation mechanisms while leveraging clinician attitude may provide a path towards LEAP implementation.

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