Northern Beaches Amputee QI project

Review of NSW hospitals acute lower limb amputee protocols and treatment practices

Katherine Henry – Physiotherapist Manly and Mona Vale HospitalKatie Lee – Physiotherapy Manager at Manly, Mona Vale and Hornsby Hospital

Amputee Project• Issue: No formal acute lower limb protocol at

NBHS and wide variety of treatment options regarding physiotherapy. Physiotherapists with different levels of amputee experience

• Using the contacts from : Enable NSW Accredited Amputee Clinics List, AustPar Website and Acute NSW hospital lists

• Contacted 41 different hospitals around NSW• Of the 41:• 1 never replied to multiple calls, messages and emails• 2 were paediatric hospitals and excluded• 9 were outpatient/day rehab/slow stream or had no

involvement in acute rehab

Amputee ProjectIn total: 29 eligible hospitalsAt each hospital, spoke with a

Physiotherapist involved in acute amputees or had extensive knowledge of acute amputees

Used a standard questionnaire and flow chart

Each participating physio was asked their reasoning behind their acute amputee care choices and their direct quotes recorded

Amputee Project Of the 29 eligible and who were in contact, they were

asked about:◦ Protocol◦ Standing Balance and Equipment◦ Lower Limb Exercises in Standing◦ Rigid Dressings◦ Prone Lying◦ STS and Equipment◦ Limits on STS◦ Hopping◦ Private and Public ◦ Acute and Rehab hospitals

Included if they treated amputee patients within first 2 weeks post-op

Amputee Project – Do you have a Protocol?

Standing Balance

Standing Balance• Why its done:- All who tolerate, except bilateral amputees- Preparation for prosthesis- To prepare for independent transfers and mobility- Strengthen intact leg and core - As per doctors/surgeons protocol- It’s Functional- Always standing balance- Definitely- Important, especially for AKA to learn how to

stand, as they will need to put their prosthesis on in standing

- Need to get them going Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Standing Balance Equipment

Standing Balance Equipment• Why FASF?

- Only Equipment available on acute wards- Surgeon preference - Guidelines recommend it

Why Parallel Bars- Easier

Why Other Equipment?- Want vascular patients to use the rail and crutches- Finding Standing Table Best- FASF can hurt shoulder and can be a falls risk- Rehab preference not to use FASF

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Lower Limb Exercises in Standing

Lower Limb Exercises in StandingWhy Not?

◦ Spend most time lying in bed

◦ Not routinely, if falls risk, will not use

◦ Surgeons limit this, won’t allow them to SOOB or attempt mobility

◦ Tend to do bed exercises initially due to older population

◦ Standing balance may be an issue

◦ If patient is a falls risk, will not use

◦ More Supine and seated (including Swiss ball) exercises initially

◦ Can’t with Bilateral amputees

◦ Co-morbidities

◦ Limited time

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Lower Limb Exercises in StandingWhy?

◦ Everyone does it

◦ Surgeon preference

◦ Strengthen

◦ Done with Exercise Physiologist*

◦ Strength in standing is important, the earlier the better

◦ Protocol

◦ Improves standing tolerance

◦ Increased blood flow to the stump to desensitise associated pain

◦ Physiological benefits of standing

◦ Psychological benefits of standing

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

* Private Hospital

Rigid Dressings

Rigid DressingsWhy?

◦ Recommended best practice in NSW Health Amputee Care Standards

◦ Protection and safety issues

◦ Vascular team wants them Day 5, ortho team Day 2

◦ Policy of Surgeon

◦ Good support from surgical team, they put it on in theatre

◦ Used with silicone liners to assist healing *

◦ Protection of stump

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

* Private Hospital

Rigid Dressings• Why Not?

- Biggest Issue with amputees- Policy of Surgeon*- Not done in acute hospital and therefore too late to be done in

rehab- Depends on the vascular surgeon- Surgeon wants only a back slab to prevent contractures- Only 1 surgeon wants it but the other 5 surgeons don’t- Depends on level of experience of physio on ward, had issues

with junior or in-experienced physios in past causing complications when it has been done

- Surgeons want to view the wound

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

* Main reason given for Rigid Dressings not being done

Prone Lying

Prone LyingWhy Not?

- Don't do it as routine- If allowed, surgeons restrict this- Patients find it too difficult- Limited by drain(s) or attachments- Limited physiotherapy treatment time

Why?- Of course- As soon as medically stable- Protocol- Will always try to get into prone but it can be difficult- Stretches the hip, minimise hip flexion contracture- Surgeon preference- Try and persist with it- Best on double plinth

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

STS practice

STS practice Why

- Transfers is primary goal- Definitely- Tonnes, main exercise- Improve unaffected limb strength and endurance- They do it on acute but don’t in rehab- Surgeon preference- Start of functional training

• Why Not?- Time poor on acute wards- Not routinely

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

STS practice Equipment

Any Limits on STS practice?

Hopping

Of those asked, 80% said YES to hopping

HoppingWhy hopping?

- Long distance if tolerated- Definitely- Got to hop, haven’t they?- Surgeon preference- Limit to 10m max, short distances to and from bathroom- Don’t want them relying on w/chair

Why No hopping?- Rehab preference for patient not to hop if going to get a prosthesis

- May not need it in future

- Not a natural gait

- Dangerous if they fall

Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Preferred Transfer Method

Acute or Rehab Hospital

Public or Private Hospitals

Amputee QI project Outcomes and recommendations for NBHS:

Should work on Standing Balance with FASF, PUF or parallel bars (if available)

Should work on Lower Limb Ex in Standing Should do Rigid Dressings Should do Prone Lying Should do STS practice with FASF or parallel bars (if

available) and use clinical judgement for limits Should do hopping, if appropriate and using clinical

judgement Should try Standing Transfer initially but if can’t

manage, use clinical judgement and try pivot or slide board

Scope to involve more OT input in the acute phase

How could this Project have been improved?

Expanding the questionnaire to involve:• Age of amputees (average or range)• Number of amputees at the hospital

each year• Average level at which amputations

occur• Reasons for the amputations• Asked the same questions to those

treating amputees in the rehab phase

Future of Acute Amputee Care on the Northern Beaches

Currently, using this information (including Amputee Care Standards) to help develop an acute amputee protocol in discussion with the surgeons and other involved medical and allied health staff

Protocol will be focused on Acute Amputee Care at Manly and Hornsby

Increased support for this protocol to meet with Amputee Care Standards and to improve outcomes of amputee patients at Manly and Hornsby

Questions?