Draft NSW Health Guidelines for Amputee Care January 2006

NSWPAR AND BACPAR AMPUTEE CARE GUIDELINES REVIEW

NOVEMBER 2008

References:

Draft NSW Health Guidelines for Amputee Care January 2006
Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation, BACPAR 2006
Evidence based on clinical guidelines for the physiotherapy management of adults with lower limb prostheses, BACPAR 2003

The purpose of this document is to inform physiotherapists in amputee rehabilitation of the components of the above documents and to provide a self assessment tool for existing services.

Overall Service provision

Guideline / Source / Achieved
1.1 / The Area Health Service (AHS) must:

provide access to a specialist amputee service for all amputees.
make provision for the rehabilitation of those amputees that are not suitable for prosthetic rehabilitation.
make provision for those patients whose needs are unable to be managed adequately within the phases of care currently available within the patient’s local area. Where gaps exist in the phases of care the AHS must ensure that patients gain timely access to services. This may involve referral to another AHS to ensure access to appropriate specialist amputee services.
ensure equity of access for all, irrespective of age, disability or cultural background.

/ A
1.2 / Each phase of the amputee service must

be governed by appropriate policies and procedures consistent with those of the AHS.
have oversight from a suitably experienced clinician in amputee management.
reflect a staffing mix appropriate to the level of service being provided.
have an established complaints procedure.

/ A
1.6 / Service users within any AHS must have access to appropriate rehabilitation services that aim to maximize physical, psychosocial and cognitive wellbeing. / A
1.7 / All patients must be given access to relevant information about lifestyle opportunities when living with an amputation. / A
1.9 / Clinical input must be sought in any decision-making regarding the amputee service. / A
1.11 / All users of the service must have adequate access to relevant information in an appropriate format, including a choice of language, ie Arabic, Vietnamese, Hindi, large print, etc / A
1.12 / The amputee service must have access to appropriate prosthetic services. / A
1.13 / Every health facility within the service must participate in an appropriate accreditation process, such as Australian Council of Healthcare Standards (ACHS), NSW Artificial Limb Service (ALS) accreditation. / A
1.16 / The management of the patient, including transfer and /or discharge of patients must be supported with appropriate documentation to assist in ongoing health provision and care. / A
1.17 / Each phase of the amputee service should

be responsible for data collection in line with NSW Health and ALS requirements and for the purpose of accreditation.
have established performance indicators and outcome measures for quality assurance purposes. Please refer to Appendix 1 for recommendations of suitable tools.

/ A
1.18 / Patients and carers should be provided with opportunities to input into service planning and review processes. / A
1.20 / The medical director of the amputee clinic (or their nominated delegate) should be the official representative of the service with the ALS. / A
1.21 / Out patient and day rehabilitation should be supported by adequate transport systems to ensure equity of access to services. / A
1.22 / Access to community support for those unable to travel to a rehabilitation centre, or for whom rehabilitation is more appropriately conducted in the context of their normal home environment, should be made available. / A
1.23 / Where possible funding opportunities should be explored by the AHS to assist in the provision of peer support to people with amputation. / A

Subtotal______

Role of the Physiotherapist within the multidisciplinary team

Guideline / Source / Achieved
1.1 / As a member of the MDT, the Physiotherapist should be specialized in amputee rehabilitation / B
1.2 / Communication between the physiotherapist and the MDT should be formally established to co-ordinate care of the patient. / B
1.3 / Within the MDT, the role of the physiotherapist includes exercise and compression therapy. / B, C
1.4 / The physiotherapist, in conjunction with the MDT, should contribute to:

protocols for amputee care
discharge planning from inpatient care
the management of residual and contralateral wound healing, pressure care and pain
decisions regarding prosthetic limb manufacture, such as predicted use, timing and componentry
the patient's psychological adjustment following amputation

/ B
1.5 / As a member of the MDT, the physiotherapist should be able to directly refer patients to:

clinical psychologists or counselors
amputee peer support
podiatrists

/ B
1.6 / The physiotherapist should contribute to MDT:

outcome measure selection and data collection
audits
research
education

/ B

Subtotal______

Subtotal_____

Pre-operative

Guideline / Source / Achieved
2.1 / Facilities where planned amputations occur must have

access to a specialised team including rehabilitation physician, prosthetist, nurse, occupational therapist and physiotherapist.
consultation with rehabilitation specialist team involved in post-operative rehabilitation.
Access to information regarding local peer support and/or amputee association
where appropriate, assessment and education on post-operative mobility, exercise and the rehabilitation process
respiratory assessment and management as indicated

/ A

Subtotal______

Surgical

Guideline / Source / Achieved
3.1 / Each hospital where planned amputations are performed must have access to a Consultant Surgeon with special responsibility for amputation surgery. / A
3.2 / An amputation must be performed or supervised by a suitably experienced surgeon using currently recognised operative techniques. All surgical interventions must take into consideration future rehabilitation potential and prosthetic use, except in cases of extreme urgency. / A
3.3 / The surgical team must

ensure that the patient has adequate peri-operative pain control, including use of pre-operative techniques such as epidural analgesia.
liaise with the rehabilitation service to ensure continuity of care.

/ A
3.5 / Rigid dressings should be applied according to NSW Health Department’s guidelines. Please refer to Appendix II. / A

Subtotal______

Post Surgical

Guideline / Source / Achieved
4.1 / All amputees must be referred for assessment by the rehabilitation team. / A
4.2 / All relevant clinical information, incorporating any special needs, must be made available to the rehabilitation team at the point of referral. / A
4.3 / All patients must be assessed by the appropriate members of the multi-disciplinary team to assist in the ongoing management and care. / A
4.4 / All patients must be informed about the outcome of assessments and their ongoing health care plan. / A

______

Care of remaining and residual limbs

Guideline / Source / Achieved
4.1.1 / Vascular and diabetic patients and their carers should be made aware of the risks to their remaining limb and educated in risk reduction. / B
5.6.5 / Physiotherapists should establish links with their local podiatry services for treatment of the patient and education of carers / C
Ongoing advice and warnings should be given to the patient/carer about wound healing, the use of compression therapies and methods to manage scar adhesions.
Fluctuations in residual limb volume and its management should be explained. When using compression therapy to reduce limb volume, compression socks should be used in preference to elastic bandaging.
Appropriate advice, education and treatment should be given for phantom limb sensation/pain.
Education should be given on skin care and good hygiene for the residual limb
Patients and carers should be given instruction on achieveing correct socket fit, considering pressure tolerant and pressure sensitive areas of the residual limb.

Early Rehabilitation

Treatment must be given after adequate analgesia ahs been supplied
The physiotherapy program, post-operatively, should be relevant to patient goals and should include:

Respiratory care where appropriate
Bed mobility, sitting and standing balance, and transfer training as appropriate
Contracture prevention through stretching, splinting and positioning
Exercises for hip extensors, flexors and abductors, and ankle plantarflexors
Wheelchair and mobility aid(s) training as appropriate

The physiotherapist should:

be familiar with use and provision of equipment that can facilitate daily living, including aids and wheelchairs
participate in home visits where appropriate

Patient Journey

Guideline / Source / Achieved
4.1.1 / Patients / carers should be informed:

about the expected stages and location of the rehabilitation programme suited to their individual circumstance.
that the level of amputation, co-morbidities and previous mobility affects the expected level of function and mobility.
that the energy cost of prosthetic walking is related to the amputation level.
of the possible psychological effects following amputation and how and where to seek advice and support.
that the risk of falling is increased following lower limb amputation.
about the prosthetic process and show demonstration limbs to those patients likely to be referred for a prosthesis.

/ B
5.6.5 / Information on the following should be made available.
National and local amputee support and user groups
Health promotion
Sporting and leisure activities
Driving after amputation
Employment/ training / C

Subtotal_____

Rehabilitation

Guideline / Source / Achieved
5.1 / All amputees must be provided with an opportunity to participate in a rehabilitation program in accordance with the policies and procedures of the treating facility. Furthermore, referrals to rehabilitation must be acknowledged and followed up in a timely manner. / A
5.2 / All patients undertaking rehabilitation must:

assessed and realistic rehabilitation goals established in conjunction with the patient and /or carers.
Have goals documented, including reasons for inability to achieve those goals
Be able to participate in a program which is responsive to changes in their lifestyle, occupational and health.
Have access to all members of the specialist team as required
Have referral and access to couselling and vocational support services where required
Have their GP and other relevant agencies updated regularly on progress and discharge planning.

/ A
5.6 / When a prosthesis is not prescribed, reasons for the decision must be clearly documented and alternative rehabilitation plans implemented. Outcomes must be reported back to referring agencies and the patient/carer. / A
5.7 / At the time of discharge, patients must be provided with suitable arrangements and follow-up services appropriate to their individual goals. This should include maintenance of their details on a servive database, with offers for routine/follow-up as requested. / A

Subtotal______

Rehabilitation with prosthesis

Guideline / Source / Achieved
6.1 / Prosthetists must follow the manufacturers’ instructions and guidelines on risk management and any deviations from standard practice must be fully documented. / A
6.2 / When the patient abandons limb use reasons must be documented and the treating physician informed. / A
6.3 / If prosthetic rehabilitation is planned, the prosthesis should be prescribed in consultation with relevant members of the multi-disciplinary team. / A
6.4 / A mechanical interim prosthesis manufactured by a prosthetist should be made available to all amputees. / A
6.5 / The amputee service should have a written and agreed policy for the provision of prosthetic limbs such as cosmesis, leisure limbs, and water activity limbs. / A
6.6 / Facilities for the design and supply of custom made/ one off appliances required for amputees, especially for work related activities, should be available and managed within the policies and procedures of the treating facility. / A

Subtotal______

Prosthetic Rehabilitation Program

Guideline / Source / Achieved
4.1 / Prosthetic rehabilitation should aim to establish an energy efficient gait based on normal physiological walking patterns, the level of amputation and medical and social history, / C
3.4 / The physiotherapist should record the prosthetic componentry, type of socket and method of suspension. / C
4.10 / Walking aids should be provided to ensure that prosthetic users, where possible, progress to being fully weight bearing through their prosthesis. / C
4.11 / Functional skills progressing in complexity should be taught within the patients’ limits and integrated with activities of daily living. / C
6.6.2 / Rehabilitation programmes should include education on preventing falls and coping strategies should a fall occur. / B, C
4.13 / The physiotherapist should train the patient in a range of functional tasks or part of that functional task relevant to the goals set with that individual. These may include:
Getting on and off the floor
Getting in and out of a car
Going up and down stairs, kerbs, ramps and slopes
Walking in a crowded environment
Carrying an object whilst walking
Walking over uneven ground outdoors
Changing speed and direction
Picking up objects from the floor
Opening and closing a door
The use of public transport
The use of escalators / C
4.14 / Prosthetic users should be encouraged and assisted to resume hobbies, sports, social activities, driving and return to work. / C
6.6 / If prosthetic use is discontinued during the rehabilitation programme the reasons should be documented. / C
6.1 / A summary of the patient’s function and mobility at transfer or discharge from active rehabilitation should be documented in the treatment notes. / C

Subtotal _____

Lifelong management

Guideline / Source / Achieved
7.1 / All service facilities must have a written policy and procedure on patient follow up. / A
7.2 / To meet the changing needs of individual patients, the amputee service must offer the patient access to the rehabilitation team for the purpose of review. / A
7.3 / Feedback to the treating physician and any other relevant services should be provided on follow-up when clinically indicated. / A

Subtotal______

Staff Development

Guideline / Source / Achieved
8.1 / Systems must be in place in each service facility for quality assurance and clinical governance and be linked to the appropriate accreditation procedure. This includes:

regular appraisal for all staff
written policy on staff training and professional development
updates on current best practice in amputee care
quality improvement activities

/ A
8.5 / Professional development should be encouraged through:

attendance at educational forums, including national and international conferences
access to current health literature
multi-disciplinary and inter-agency education and training, including the involvement of patients in the management of their disability and the raising of awareness of amputation.

/ A

Subtotal______

Specialist subsection – Upper limb

Guideline / Source / Achieved
9.1 / All upper limb amputations must be carried out by an appropriately experienced upper limb surgeon using currently recognised upper limb amputation techniques with due consideration of future rehabilitation potential including prosthetic use, except in cases of extreme urgency. / A
9.2 / Experienced clinical counseling and psychological support must be made available to all patients to assist with issues such as adjustment and pain management. / A
9.3 / During pre-amputation consultation for upper limb amputees’ particular emphasis should be placed on the likely function with or without a prosthesis. / A

Subtotal______

Specialist subsection – Children with Congenital Limb Deficiencies

Guideline / Source / Achieved
10.1 / Parents/ guardians must be made aware of general and detailed expert advice on all relevant treatment options (including the advisability or otherwise of prosthetic and surgical management). / A
10.2 / The multi-disciplinary team must provide ongoing care for the child and parents/guardians with appropriate and documented follow-up plan. / A
10.3 / Prosthetists experienced in congenital limb deficiency must be involved in the management and treatment of all children. / A
10.4 / A therapist experienced in management of limb deficiency must be available to all children with Congenital Limb Deficiency. / A
10.5 / If a limb deficiency is detected during pregnancy, an antenatal referral to a Limb Deficiency Clinic should be offered. / A
10.6 / The Paediatrician should refer to the Consultant in Rehabilitation Medicine specialising in Congenital Limb Deficiency as soon as possible but not later than one month of birth. / A
10.7 / Where appropriate (for example where there are major joint abnormalities) the Paediatrician / Rehabilitation Consultant should , in consultation with parents/ guardians, refer the child to a specialist orthopaedic surgeon. / A
10.8 / The child and parent/ guardians should be seen in a Specialist Limb Deficiency Clinic within 3 months of birth. / A
10.9 / Expert orthotic advice and treatment should be readily available. / A

Subtotal______

Total______