Amputee Care Pathway Questions and Answers

Transcription

1 Amputee Care Pathway Questions and Answers 1. Question: Can there be one referral form to SAT clinic (both clinics on same form) that is filled out in acute care post-op so that no matter where the client goes the referral has been initiated? Answer: The goal/vision is to have one referral for the SAT Clinic. A new form would need to be approved by both the GRH and SJHCG forms committee. The plan is to create a form and submit to the forms committee for approval. 2. Question: Is CCAC able to support an LOA for all amputees? Answer: This would require a rep from CCAC to comment. The questions will be put in writing and submitted to Martina Rosza. 3. Question: Will facilities pay for transportation between cities for clients to attend SAT clinic prior to D/C? Now clients go to the first available bed for rehab which may not be in their community. Answer: This question has not been asked of the facilities at this time. If a patient is receiving their inpatient rehabilitation at a facility that is not where the SAT they would access is located the inpatient rehab team can determine how urgently they should be seen in the SAT. If it is not essential that the patient be seen arrangements can be made for the patient to be assessed shortly after their discharge home. A visit date could be provided once the discharge date from hospital is established. In cases where the inpatient rehabilitation team feels that assessment in the SAT in necessary and urgent (i.e. to assist with discharge planning or other complex concerns) if the patient can safely be transported by family they should be asked to assist with this. If the patient has access to Mobility Plus (i.e. from CMH to GRH) transport can be booked. Asking the facility to pay should be considered only in cases where there are no other transport options and the rehabilitation team feels the SAT assessment is urgent to assist with discharge planning or other complex issues. 4. Question: Have community exercise programs been investigated as a means to maintain or improve strength while awaiting wound healing / prosthetic fitting? Answer: Not specifically, but there are potential partnerships that have been identified. For example engaging the YMCA s, both Kitchener and Cambridge have activation programs in addition to programs for patients in wheelchairs. These organizations could be contacted to establish the special needs amputees may have in order to participate in this program. Other options in the KW-Cambridge area include Sunnyside, Parkwood and Fairview Mennonite homes. Similar options in Guelph need to be identified. Need to create a smaller FE/MC working group to lead the implementation plan development and to create solutions to the gaps in the care path. Anyone interested in the smaller working group forward your information to Melissa or Stephanie. 5. Question: Presently there appears to be a gap in the SAT clinic for wound care particularly with nursing. Has there been any investigation into developing a communication system from CCAC nursing or ambulatory care wound clinics to the SAT clinic to better understand healing timelines? Answer: Need to develop communication with CCAC wound care nursing team to find out who is the lead nurse for a patient. This is a gap that has been identified between the care path and wound care. CCAC is developing a wound care pathway, and the smaller working group could work with the CCAC to further build on the care path.

2 6. Question: Is there a recommendation of wait time for clients to access outpatient services from acute care or rehab? Answer: The research did not appear to specify recommendations about wait times, in terms of number of days. Stephanie will review this again to confirm. Clients cannot wait too long to access outpatient services as delays can lead to secondary problems. Recommendation for wait times will assist facilities when prioritizing patients. Organizations can strive to meet recommended wait times and then try to improve. We likely need to come to a consensus as a group. 7. Question: What tools are used to decide appropriateness for prosthetic intervention? Answer: There are numerous tools that can be used: strength testing, ROM measure, single stance time, ability to hop, arm ergometry testing, cognitive screening, circulatory screening (pedal pulse, sensation, skin changes, monofilament testing), surgical wound assessment (degree of healing etc.), residual limb shape and length assessment, psychosocial history (i.e. supports available to pt.). The results of these evaluations must be reviewed by the interdisciplinary team to achieve consensus on whether the patient is appropriate for prosthetic trial. Currently there is not a single standard way that this is determined. 8. Question: There are increased demands on outpatient therapy with all the clinical pathways. Has there been any thought into developing community exercise or functional activity programs for high riskmedically complex clients who need to maintain or improve their level of fitness but do not necessarily need the expertise of a PT or OT? Answer: Goal to engage the community, and empower patient and family in terms of their important role in being adherent with recommendations. The Caredove tool will be used to identify appropriate community resources for these patients and to support the transition of patients back into the community. 9. Question: Are there gait performance measures, fitness evaluation measures or burden of care tools and metrics that would be recommended to assist in the decision to transition to the community from formalized outpatient PT services? Answer: Numerous tools exist; however, the care path is not prescriptive to indicate which specific tool to use. The pathway will be amended to include a more comprehensive list of tools that are available. 10. Question: As for residual limb shaping: If a client and family have demonstrated that they cannot manage stump wrapping, will there be a process to get alternative methods (i.e. shrinker or silicone liner) before first SAT visit? Answer: There is a need to create a process between acute and rehab. Research indicates tensor wrapping is not ideal. Regarding in-servicing nursing staff for tensoring skills: this has been attempted on a few occasions at Freeport and the impact appears to be short lived. Diagrams have been placed in patient rooms and still the quality of wrapping technique is often poor. Ideally, patient and families need to be educated to do this. If patients and families are not able to achieve sufficient skill then alternatives need to be considered. Silicone liners are cost prohibitive as the patient changes in volume they require replacement of the liners. Off-the-shelf compression garments are a less expensive alternative. We could work with the prosthetists to measure patients for this. There is also the option of tubigrip shrinkers and the SAT PT s could develop instructions for this to be used in the acute care site. It is an economical method to provide some compression in the acute phase until either proper tensoring or a compression garment can be put in place.

3 11. Question: Were surgeons (orthopedic and vascular) consulted during the care path development especially with regards to the dressing recommendations and shaping? Answer: These stakeholders were informally consulted during the development of the care pathway, but now will be more engaged as we look to implementation. Dr. Dittmer has initiated some of this contact. Stephanie can discuss next steps to connect with the surgeons as we move forward. 12. Question: Do all patients operated on in Guelph have to attend the SAT in Guelph? Or could they be referred to Kitchener if that is closer to their home? Answer: No, they can be referred to the location that best meets the long term need of the patient. A single referral form should help ensure that patients can attend the SAT program closest to their home. 13. Question: How far in advance should patients be referred to the specialized amputee team (SAT) preoperatively? Through the surgeon s office? Or the pre-op clinic (these patients are only seen a few weeks to a month before surgery)? Answer: This is difficult to say as most amputations are emergent. If it is a planned amputation, it is suggested that we refer the patient once the decision is made to proceed with surgery. If a surgical date has been set the date should be indicated on the referral in order to book accordingly. If the date of surgery is unknown regarding an elective amputation the patient can still be referred to the SAT. 14. Question: If the patient can t be referred to the SAT pre-operatively (owing to time or medical stability), when does the SAT team want the referral (on Discharge?)? Answer: A single referral form will be part of the process in acute care. Patients can be referred once medically stable. Patients who want to be considered for prosthesis should be referred. 15. Question: Communication between SAT & surgical team who is the surgical team referring to (surgeon, surgical nurses post-operative, and rehab?) Answer: The surgeon and the unit - as noted previously Dr. Dittmer will be engaged to assist with physician to physician communication. 16. Question: There is a recommendation to link patients to wound care, smoking cessation, diabetic care & self-management practices? What specific resources are you referring to? Answer: There is a need to link these patients to multiple community resources due to the complex nature of this patient population. The pathway does include information regarding the smoker s help line and the WW Central intake for Diabetic Education. The carepath will be reviewed to ensure clarity on these points. Regarding CCAC wound care, we will look at the potential to have physio staff refer patients to the CCAC wound care program. 17. Question: What happens to a client who does not qualify for a prosthesis? Answer: An extension could be added to the care pathway when completing sustainability planning. These patients are likely quite frail and complex and therefore will be discussed with the FEMC steering committee to determine the most appropriate path for these patients. 18. Question: What is the rehab admission criteria for the Amputee patient population? Answer: This is similar to any inpatient rehab applicant. The General in-patient Rehabilitative Care program provides intensive, goal-oriented rehabilitation for medically stable patients who require nursing or medical care that cannot be provided at home or in the community. The length of stay is goal dependent and is targeted to range between 7-40 days as required to improve strength, endurance, or functioning to support transition to the community. Occupational therapy and physiotherapy is based on

4 a model of 60 minutes of total therapy daily, 5-7 times per week with a therapist or therapy assistant. Care plans are individualized and will be adjusted according to the individual s tolerance level 19. Question: How often (? Daily) and for what duration (? Five days) should therapy staff see these patients post-operatively? Answer: The literature is not specific in terms of recommended days of therapy and timing. Some links to other pathways may be useful to look at to guide this recommendation. Stephanie will do this and amend the pathway as able. 20. Question: Was Best Practice (BP) identified that recommends when to take down the post-operative stump dressing? Answer: Currently some surgeons are waiting 2-3 days at GGH. There are a range of practices identified, including leaving a rigid dressing on for a prolonged period. The most prevalent information for transtibial is in regard to a rigid (cast) dressing, rather than a soft dressing being applied to prevent knee flexion contracture. Otherwise the recommendations would be linked to best practices in wound care. The RNAO is a good resource for this. The pathway will be clarified on this point. 21. Question: Dressings: there was a recommendation for semi rigid or rigid dressings. However no information was provided on dressing materials that should be used. I.e. is a Zimmer an acceptable type of rigid dressing? Answer: A Zimmer is not identified as a rigid dressing in the literature. This refers to plaster casting. As we move forward with implementation discussion with the surgeons will need to take place. 22. Question: There was no discussion about acute pain management/phantom limb pain in the postoperative phase. Were there best practice resources available around these topics? Answer: Pain is a significant concern, though the literature review for this pathway did not include pain control specifically related to amputees. The sources used to refer to typical pain management as it relates to analgesic use and medications for neuropathic pain (i.e. gabapentin). The pain issues typically exist prior to amputation being considered (even prior to the pre-op phase) related to the patient s chronic wound issues. 23. Question: Also, many times in the pre-op phase, we do not have time or the patient is too ill to refer to the outpatient SAT. In that case we would be looking at intervention while admitted to the hospital - i.e. appropriate surface, positioning, bed exercised etc. Answer: Yes. 24. Question: I see the Braden is in the appendix, but when should it be completed? Answer: This should be used in acute care to determine risk for pressure ulcers. 25. Question: Are there any other outcome measures for this population? I don't see the FIM mentioned in the inpatient rehab section? Answer: The FIM should be included in the care pathway and Stephanie will include it. 26. Question: The other care pathways explicitly referenced the decision making matrix and the use of Caredove to support transitions of care. Should this also be included in the amputations pathway? Answer: The care pathways will be reviewed and this will be added to ensure consistency.

5 27. Question: Who are we supposed to refer patients to for fitting? In Guelph we refer to Dr. Galvin, who are we to be referring to now? Answer: ADP indicates for new amputees that the patient should get an interdisciplinary assessment. Dr. Galvin no longer sees amputees. Currently surgeons are signing off on ADP forms, but this will need to be looked at in the future. 28. Question: If we are unsure or it is unlikely a patient will use a prosthesis (I.e. a very old patient with limited mobility pre amputation), is a referral to the SAT required? Answer: If unsure then yes the patient should be referred. If it is unlikely and the patient does not wish to be considered then the referral is not required. If it is unlikely, but the patient insists they want to be considered then a referral is appropriate. The SAT can then support the referral source in the determination and recommendation that prosthetic use is not appropriate. 29. Question: If a pt. has a revision (e.g. BKA AKA) should another referral to the SAT be made? Answer: To be safe, yes, however, the SAT may already be aware of the situation. 30. Question: Are dressing recommendations different for BKA vs. AKA? Answer: Yes. No rigid dressing is suggested for AKA. Traditional wound care is recommended. 31. Question: How long is the cast to say on before moving to a semi-rigid dressing? Answer: Please see previous wound care questions. Further discussion regarding the implementation of this needs to occur. 32. Question: This is a follow up to the question about the facility paying for transport to an SAT clinic if they go to a rehab bed in another city (first bed policy).is there a process or mechanism to change the location of the SAT team they will see to accommodate this? Answer: The challenge with this is the long term care and follow up the patient will require and the difficulty in transferring from one ADP clinic to another. Unless there is an urgent concern that could be helped by getting the opinion of the SAT it is more sensible to wait and have the patient seen in the clinic that they wish to attend once discharged home. The recommendation of prompt referral helps establish a plan and in cases where a patient is discharged to home from acute care, ensures that they remain supported (not lost through the cracks). An inpatient has the support and expertise of that team and therefore waiting for the SAT post discharge is okay. 33. Question: Are transmetacarpal amputations to be included in this pathway? Answer: Upper extremity amputations have not been addressed in this care path. As for partial foot amputations they should be included in the pathway. There are no specialized wound care or shaping techniques required. Wound care is as per wound care best practices. Referral to inpatient rehab, SAT, OP and CCAC follows the pathway.