Northern Beaches Amputee QI project

1. Northern Beaches Amputee QI project Review of NSW hospitals acute lower limb amputee protocols and treatment practices Katherine Henry – Physiotherapist Manly and Mona Vale Hospital Katie Lee – Physiotherapy Manager at Manly, Mona Vale and Hornsby Hospital

2. 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

3. Amputee Project • In total: 29 eligible hospitals • At 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

4. 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 first2 weeks post-op

5. Amputee Project – Do you have a Protocol?

6. Standing Balance

7. 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

8. Standing Balance Equipment

9. 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

10. Lower Limb Exercises in Standing

11. Lower Limb Exercises in Standing • Why 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

12. Lower Limb Exercises in Standing • Why? • 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 * Private Hospital Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

13. Rigid Dressings

14. Rigid Dressings • Why? • 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 * Private Hospital Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

15. 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 * Main reason given for Rigid Dressings not being done Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

16. Prone Lying

17. Prone Lying Why 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

18. STS practice

19. 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

20. STS practice Equipment

21. Any Limits on STS practice?

22. Hopping Of those asked, 80% said YES to hopping

23. Hopping • Why 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

24. Preferred Transfer Method

25. Acute or Rehab Hospital

26. Public or Private Hospitals

27. 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

28. 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

29. 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

30. Questions?