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 s
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 first 2 weeks post-op

5. Amputee Project – Do you have a Protocol?
Of the 29 involved in the survey, two thirds DID NOT have a protocol
Most found the reason for this is that they had several doctors with differing treatment options and therefore majority had guidelines or recommendations

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
Overall, FASF were generally regarded as a good place to start when choosing standing equipment and then quickly progressed to PUF
Vascular amputees were singled out here with specific instructions that they are 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 Don't do it as routine If allowed, surgeons restrict this
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 Why Not? 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
Very Similar to standing balance equipment reasons

21. Any Limits on STS practice?
This category we only added after making the initial calls
Therefore this category is only out of 20, so we have 9 hospitals not asked
Of the 20 asked, 95% did NOT have limits on STS

22. Hopping Of those asked, 80% said YES to hopping
This category we only added after making the initial calls
Therefore this category is only out of 20, so we have 9 hospitals not asked
Of the 20 asked, 80 % said YES to hopping
Of those asked, 80% said YES to hopping

23. Hopping Why hopping? Why No 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
Most stated that they will try the standing transfer first and then try pivot or slide board next
Some felt that the Slide board is under utilised
In the pre-op phase some mentioned that they arrange amputee equipment with the OT prior to the operation including: w/chair, slideboard etc. They stated they work closely with the OT on Day 1 and often do the first transfer with the OT.

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
If Northern Beaches were to follow how the majority of NSW acute care amputee physiotherapist were treating their patients, we would be following the above outcomes of the project

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
Could have questioned the relationship of the physiotherapists with the surgeon or surgeons, as it became clear (especially with rigid dressings) that those with good communication, open dialogue and discussion expressed positive outcomes for their patients

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?