Better Care, Better Health, Better Value A Better Rehabilitative Care System

Transitioning to a Regional Rehabilitative Care Program in Waterloo Wellington LHIN

Frail Elderly / Medically Complex Stream of Care

Amputation Care Pathway – Introductory Webinar

1. To Introduce WW Rehabilitative Care System Stakeholders to the Lower Extremity Amputee Care Pathway.

2. To identify best practices to improve the continuity of care, patient access/flow and outcomes for the lower extremity amputee.

3. To identify the resources in development to support lower extremity amputees to be more empowered and able to self manage their rehabilitation and ongoing health care needs as an amputee.

4. To support a model of rehabilitative care.

Objectives

THANK YOU!

Committee Members:

Was developed by Stephanie Beadle (PT) in consultation with:

• The GRH Prosthetic and Orthotic Clinic Team: Dr. Doug Dittmer, Simon Cooper (CP), Andreas Schirm (CP).

• The SJHCG Amputee Clinic: Janice Centrione (PT), Marty Robinson (CP)

• Amputee Clinics from across the province (London, Ottawa, Toronto)

• Emmi Perkins

• Terrie Dean

• Lindsay Ogilvie

• The FE/MC committee

• Physiotherapists from CMH, GRH:KW-site, GGH

• Physiotherapists and Occupational Therapists from CCAC provider agencies.

• Marlene Miranda (CCAC)

• Diana McDougall (GHR-diabetic clinic)

• Debbie Hollahan (WWDCC)

Care Path Development Process

Committee Members:

• Literature review was undertaken to identify key best practices for amputee care throughout the continuum.

• Information gathering from range of stakeholders.

• Draft care path prepared and shared for feedback from key stakeholders.

• Revision of care path and supporting documentation completed and shared with key stakeholders.

• Webinar development.

Care Path Development Process

Committee Members:

• Amputees are a medically complex and diverse population with multiple and specialized needs.

• Access to the specialized amputee team (ADP authorized clinics) and collaboration amongst health care providers is essential.

• Multiple factors contribute to a patient’s appropriateness and potential for success with a prosthesis.

• There are numerous medical and psychosocial benefits to achieving successful prosthetic use.

• Patient’s benefit from receiving consistent information.

Key Themes

Deliverable/Action Who

Week#1 Introductory

webinar Webinar

Stream Lead Steering Committee

Week#2 Internal Analysis Internal review of care path, high level internal gap analysis and identification of opportunities

Each Organization

Week #3 Q and A Webinar

Webinar Stream Lead Steering Committee

Questions about the pathway & best/leading practices, details about challenges/barriers to implementation

Each Organization

Week #4 Internal Analysis

Completion and submission of template describing: • Feedback about/endorsement of care path • high level gap analysis • internal prioritization of opportunities • Barriers/challenges to implementation • identification full implementation plan and timeline

Each Organization

Due Monday, October 30th

Monthly Report to Rehabilitative Care Council

All pathways & supporting materials are available @

www.regionalhealthprogramsww.com

Rehabilitative Care System Website

Pre-op

• Need to consider

• Patient’s identified as requiring amputation benefit from pre-operative access to the Specialized Amputee Team (SAT).

• When time or the patent’s medical status does not allow there should be a mechanism for communication and collaboration between the surgical team and the amputee team.

– The opportunity to assess and discuss patient potential for prosthetic use may assist in decision-making regarding level of amputation to attempt.

Pre-op

Pre-op Continued…

• A key determinant of potential prosthetic success is pre-operative fitness: access to pre-operative physiotherapy assessment, intervention, community programs.

• Link to best practices in diabetic care, wound care, smoking cessation and self-management practices is essential for this population.

Pre-op Continued

Acute:

• Prompt referral to the SAT for appropriate patients (medically stable and interested in being considered for prosthetic trial).

– Allows for the SAT to support and monitor patient in regards to appropriate exercise activities, appropriate residual limb management in preparation for prosthetic fitting.

• Early mobilization focusing on key mobility needs for safe function in the home environment without a prosthesis.

Acute

Acute Continued…

• Early identification of a patient requiring further rehabilitation to achieve safe mobilization in the home environment without a prosthesis leads to referral to in patient rehabilitation unit.

• In the transtibial amputee knee flexion contractures, prolonged wound healing and poor residual limb shaping results in delay to prosthetic fitting.

– Rigid or semi-rigid post-op dressings are supported in the literature as best practice.

Acute Continued

In-patient Rehab:

• Focus of admission:

– Safe mobilization for return to home prior to prosthetic training.

– Preparation/conditioning for prosthetic training.

• Residual limb shaping: The selection of edema/shaping management must result in the safest, most consistent method and may change as patient moves from acute care to rehab and assessment in the SAT.

In-Patient Rehab

In-patient Rehab:

• Initial visit to the SAT team includes a comprehensive, multi disciplinary assessment by the specialized team

• Assessment in the SAT includes screening for diabetic management:

– Referral to the Waterloo Wellington Regional Diabetes Coordination Centre for all patients who have not already been referred.

Assessment in the SAT

In-patient Rehab:

• Amputee Teams have access to wound care expertise/nursing, social work, dietician, and occupational therapy.

• Referral to PT for pre-gait involvement and for gait training is established as a standing order from the Amputee teams.

• Ongoing follow-up: A preventative approach is taken in the SAT’s monitoring those patients at higher risk for challenges related to their prosthetic management in order to avoid more significant issues.

Assessment in the SAT Continued

Outpatient:

• Pre-gait training, focused on ROM, strengthening, single leg stance tolerance, and activity tolerance, edema control/residuum shaping, monitoring of wound healing:

• GAIT TRAINING: Focused on achieving a level of meaningful, functional prosthetic use for the patient. The level patients achieve is variable, but is intended to increase their independence, health and wellness and quality of life.

Outpatient Rehabilitation

Community:

• Establish mechanism for communication and collaboration between the surgical teams and Specialized Amputee teams.

• Establish a seamless referral process from the surgical teams and acute care to the Specialized Amputee teams.

• The SAT’s to finalize patient information: Amputee care brochure, exercise packages, information/education packages.

– Submit these for approval to the appropriate facility committees as required.

• Must link with the future development of best practice guidelines for diabetic care and wound care.

Next Steps

• Data collection: what are the questions, are they the right questions and

does current data collection provide answers? • 2011-2012: 121 cases of which: 33 transfemoral, 47 transtibial

– These are new amputees entering the system with ongoing needs. We cannot for get those ongoing needs.

• 2012-2013: GRH P&O clinic had 445 visits in the weekly clinic. – But not just amputees, and does not include pre-gait and gait intervention.

• What about clinical measures? • Opportunity: to collaborate to collect meaningful data and use this to

improve patient care.

Next Steps Continued Next Steps Continued

The appendices with collaboration will evolve to represent consistent information and messaging to patients, families and caregivers. This will support and promote better adherence and self-management for patients. Appendix A: Referral process to the ADP registered SAT's Appendix B: GRH Prosthetic and Orthotic Clinic referral/SJHC Prosthetic Clinic Referral . Appendix C: New amputee brochure (DRAFT) Appendix D: Acute care exercises BKA (DRAFT) Appendix E:Acute care exercises AKA (DRAFT)

Appendices

Appendix F: Rehab exercises BKA (DRAFT) Appendix G: Rehab exercises AKA (DRAFT) Appendix H: Upper extremity exercises (DRAFT) Appendix I: Smoker's helpline Appendix J: SAT assessment form Appendix K: Monofilament test Appendix L: BKA information package (DRAFT) Appendix M: AKA information package (DRAFT)

Appendices Continued

1. British Society of Rehabilitation Medicine, Standards and Guidelines in Amputee and Prosthetic Rehabilitation, October 2003.

2. Bates, B.E., Hallenback, R., Ferrario, T., Kwong, P.L., Kurichi, J.E., Steineman, M.G., Xie, D., Patient-, Treatment-, and Facility-Level Structural Characteristics Associated With the Receipt of Preoperative Lower Extremity Amputation Rehabilitation. M R. 2013 January ; 5(1): 16–23.

3. Brigham & Women’s Hospital, Department of Rehbilitation Services, Physical Therapy; Standard of Care: Lower Extremity Amputation, 2011.

4. Model of Amputee Rehabilitation in South Australia; Statewide Rehabilitation Clinical Network

5. Demey, D., Post-amputation rehabilitation in an emergency crisis: from preoperative to the community, International Orthopasdices 2012; 36: 2003-2005.

6. Johannesson A, Larsson G-U, Ramstrand N, Lauge-Pedersen H, Wagner P, Atroshi I: Outcomes of a standardized surgical and rehabilitation program in transtibial amputation for peripheral vascular disease: A prospective cohort study. Am J Phys Med Rehabil 2010;89:293–303.

References Used

7. GTA Rehab Network: Amputee Definition Framework, 2007.

8. Hakimi, K.N., Pre-operative rehabilitation evaluation of the dysvascular patient prior to amputation. Phys Med Rehabil Clin N Am. 2009

9. Synder, R. J. Diabetes: Offloading difficult wounds. Lower Extremity Review, November 2009.

10. Spruit-van Eijk, M., van der Linde, H., Buijck, B. Geurts, A., Zuidema, S., Koopmans, R., Predicting prosthetic use in elderly patients after major lower limb amputation. Prosthet Orthot Int 2012 36: 45-52.

11. Hamamura, S., Chin, T., Kuroda, T., Akisue, T., Iguchi, T., Kohno, H., A Kitagawa, A., Tsumura, N., Kurosaka, M. Factors Affecting Prosthetic Rehabilitation Outcomes in Amputees of Age 60 Years and Over. Journal of International Medical Research 2009 37: 1921

12. Sanson, K., O’Connor, R.J., Neumann, V., Bhakata, B., Can simple clinical tests predict walking ability after prosthetic rehabilitation. J Rehabil Med 2012; 44: 968–974.

References Used Continued

13. Fleury, A.M., Salih, A.S., Peel N.M., Rehabilitation of the older vascular amputee: A review of the literature. Geriatr Gerontol Int 2013; 13: 264–273.

14. Chin, T., Sawamura, S., Shiba, R., Effect of physical fitness on prosthetic ambulation in elderly amputees. Am J Phys Med Rehabil 2006; 85: 992-996.

15. Uustal, H., Prosthetic Rehabilitation Issues in the Diabetic and Dysvascular Amputee, Phys Med Rehabil Clin N Am 2009; (20) 689-703

16. Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee care. Arch Phys Med Rehabil 2006;87(3 Suppl 1):S34-43.

17. Knetsche, R.P., Leopold, S.S., Brage, M.E., Inpatient Management of Lower Extremity Amputations, Orthotics and Prosthetics for the Foot and Ankle, June 2001; 6(2): 229-241.

18. Nawijn, S.E., van der Linde, S.E., Emmelot, C.H., Hofstad, C.J., Stump management after trans-tibial amputation: A systemtatic review. Prothet Orthot Int, 2005; 29(13): 13-26.

References Used Continued

19. Woodburn, K.R., Sockalingham, S., Gilmore, H., Condie, M. E., Ruckley, C.V., A randomised trial of rigid stump dressing following trans-tibial amputation for peripheral arterial insufficiency, Prosthet Orthot Int 2004 28: 22

20. Deutsch, A., ENGLISH, R.D., Vermeer, T.C., PAMELA S. Murray, P.S., Condous, M., Removable rigid dressings versus soft dressings: a randomized, controlled study with dysvascular, trans-tibial amputees, Prosthetics and Orthotics International August 2005; 29(2): 193 – 200

21. Janchai, S., Boonhong, J. Tiamprasit, J., Comparison of Removable Rigid Dressing and Elastic Bandage in Reducing the Residual Limb Volume of below Knee Amputees. J Med Assoc Thai 2008; 91 (9): 1441-6.

22. Louie, S., Lai, F., Poon, C., Leung, S., Wan, I., Wong, S., Residual Limb Management for Persons With Transtibial Amputation: Comparison of Bandaging Technique and Residual Limb Sock. JPD, 2010, 22(3): 194-201.

23. Alsancak, S., Kose, S.K., Altinkaynak, H., Effect of elastic bandaging and prosthesis on the decrease in stump volume, Acta Orthop Traumatol Turc 2011;45(1):14-22

24. Wong, C.K., Edelstein, J.E., Unna and Elastic Dressing: Comparison of their Effects on Function of Adult With Amputation and Vascular Disease, Arch Phys Med Rehabil, Sept 2000, 81(9): 1191-8.

References Used Continued

25. MacLean, N., Fick, G.H., The Effect of Semirigid Dressing on Below-Knee Amputations, PHYS THER. 1994; 74:668-673.

26. Vigier, S., Casillas, J., Dulieu, V., Rouhier-Marcer, I., D’Athis, P., Didier, J., Healing of Open Stump Wounds After Vascular Below-knee Amputation: Plaster Cast Socket with Silicon Sleeve Versus Elastic Compression, Arch Phys Med Rehabil, 1999; 80: 1327-30.

27. Smith, D.G., McFarland, L.V., Sangeorzan, B.J., Reiber, G.E., Czerniecki, J.M., Postoperative dressing and management strategies for transtibial amputation: A critical review. JRRD 2003, 40 (3)213-224.

28. Henry, A.J., Hevelone, N.D., Hawkins, A.T., Watkins, M.T. , Belkin, M., Nguyen, L.L., Factors predicting resource utilization and survival after major amputation. J. Vasc.Surg. 2013; 57: 784-790.

29. Frlan-Vrgoc, L., Vrbanic, T.S., Kraguljac, D., Kovacevic, M., Functional Outcaom Assessment of Lower Limb Amputees and Prosthetic Users with a 2- Minute Walk Test, Coll. Antropol 2011: 35 (4) 1215-1218.

30. Larsson, B., Johannesson, A., Andersson, I.H., Atroshi, I., The Locomotor Capabilities Index; Validity and reliability of the Swedish version in adults with lower limb amputation. Health and Quality of Life Outcomes 2009: 7(44)

References Used Continued

31. Deathe, A.B., Wolfe, D.L., Devlin, M., Hebert, J.S., Miller, W.C., Pallaveshi, L., Selection of outcome measures in lower extremity amputation rehabilitation: ICF activities. Disability and Rehabilitation, 2009: 3118) 1455-1273.

32. Bouch, E., Burns, K., Geer, E. Fuller, M., Rose, A., Rehabilitation, Guidance for the multidisciplinary team on the management of post-operative oedema in lower limb amputees.

33. Sansam, K., Neumann, V., O’Connor, R., Bhakta, B., Predicting walking ability following lower limb amputation: A systematic review of the literature, J Rehabil Med 2009; 41:593-603.

34. Limb Prostheses Policy and Administration Manual, Assistive Devices Porgram, Ministry of Health and Long-Term Care, September 2012.

References Used Continued