Major Amputation QIP

A perioperative (in hospital) mortality after major lower limb amputation in the UK of 17% was reported to the VSGBI AGM in 2009.

In Februray 2010 the VSGBI Council invited a stakeholder group to discuss a quality improvement framework (QIF) for major amputation surgery in Feb 2010. The Amputation framework (QIF) was endorsed and adopted by the Council in September 2010.

Quality Improvement Frameworkfor Major Amputation Surgery 2010

Lower limb amputation: Working together

In 2014, an NCEPOD report into the outcomes of lower limb amputation between October 2012 and March 2013 showed mortality was still high, with 30-day postoperative mortality at around 12.4%. The report reiterated many of the VSGBI QIF principles of good practice, and made a number of good practice recommendations:

A ‘best practice’ clinical care pathway, supporting the aims of the Vascular Society’s QIF for Major Amputation Surgery should be developed.
Pathway to include protocols for transfer, the development of a dedicated multidisciplinary team (MDT) for care planning of amputees and access to other medical specialists and health professionals both pre- and post- operatively
Pathways to reflect the standards of the Vascular Society , the British Association of Chartered Physiotherapists in Amputee Rehabilitation and the British Society of Rehabilitation Medicine.
Greater use of dedicated vascular lists for surgery and the use of multidisciplinary records.
All patients with diabetes undergoing lower limb amputation should be reviewed both pre- and post operatively by the specialist diabetes team to optimise control of diabetes and management of co-morbidities.
When patients are admitted to hospital as an emergency with limb-threatening ischaemia, including acute diabetic foot problems, they should be assessed by a relevant consultant within 12 hours of the decision to admit or a maximum of 14 hours from the time of arrival at the hospital, in line with current guidance.
If this is not a consultant vascular surgeon then one should be asked to review the patient within 24 hours of admission.
For patients undergoing major limb amputation, planning for rehabilitation and subsequent discharge should commence as soon as the requirement for amputation is identified. All patients should have access to a suitably qualified amputation/discharge co-ordinator.
As recommended in the QIF for Major Amputation Surgery (VSGBI), amputations should be done on a planned operating list during normal working hours and within 48 hours of the decision to operate. Any case waiting longer than this should be the subject of local case review to identify reasons for delay and improve subsequent organisation of care. (Medical Directors)

Lower limb amputation: Working together

Best Practice Care

The VSGBI has now revised the 2010 Amputation QIF to take into account these recommendations and changes in vascular service provision across the UK since 2010. The National Vascular Registry will provide information as to how well these recommendations are being incorporated in practice through the publication of its annual reports. Aim of the best practice pathway To reduce and maintain the 90-day mortality of major lower limb amputation to 10% or less nationally. Major lower limb amputation is defined as any amputation above the ankle. Forefoot and toe amputations are defined as minor amputations.

Best Practice Care for Major Lower Limb Amputation 2016

BACPAR Guidelines

Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputations 2016

Guidance for the multi disciplinary team on the management of post operative residuum oedema in lower limb amputees

Guideline for the prevention of falls in amputees

Resources

NCEPOD Self Assessment Checklist

Risk to the Conta-lateral Foot of Unilateral Lower Limb amputees