Journal of Rehabilitation Sciences & Research

Lower Limb Amputee patients have comorbidities and risk of complications - Findings from a hospital audit

Document Type : Original Articles

Author

Shyh Poh Teo

1- Older Persons Rehabilitation Services, Hutt Hospital, Lower Hutt, New Zealand. 2- Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Brunei Darussalam.

https://doi.org/10.30476/jrsr.2020.86031.1085
Abstract
Background: Lower limb amputee patients tend to have multiple co-morbidities and are at risk of developing complications during early rehabilitation for lower limb amputees. These complications are associated with worse outcomes and interruption in rehabilitation, requiring a transfer from the rehabilitation ward to acute medical or surgical care. This study aims to describe the circumstances of patients transferred from early lower limb amputee rehabilitation ward to regional hospitals, and identify areas of potential improvement in management.
Methods: The present study is a retrospective study of electronic records for patients admitted or transferred to Hutt Hospital from vascular surgery wards for early lower limb amputee rehabilitation between 1st January 2009 and 31st December 2011. The data collected was identified through a multidisciplinary discussion to determine appropriate standards of care for amputee patients. This included patient demographics, comorbidities, cognitive and physical function, as well as complications during rehabilitation.
Results: There were 42 lower limb amputations with median age of patients 71.5 years. Dysvascularity was the most common cause (57.1%) for amputation. Patient care was inappropriately stepped-down to a rehabilitation ward, including one in six amputees who were not haemodynamically stable, and one-quarter of patients with hypoglycaemia. Handover between allied health staff and comprehensive assessment, particularly of the contralateral limb should be improved. Complications during rehabilitation involved 71.4% patients, the most common non-wound issues were decubitus ulcers, chest infections and delirium. A quarter of the patients, initially living at home were discharged to residential care. The median length of hospital stay was 44.5 days.
Conclusions: Amputee patients have multiple co-morbidities and a high risk of complications. The areas of improvement identified included transfer of care between allied health professionals, appropriateness of step-down transfer to rehabilitation, assessment of the contra-lateral limb and standardisation of care. Education of healthcare professionals and systematic transfer of care should be implemented for patients transferred for early rehabilitation for lower limb amputees.

Keywords

Amputees
Comorbidity
Postoperative Complications
Rehabilitation
Standards of Care
1. Scott H, Patel R, Hebenton J. A survey of the lower limb amputee
population in Scotland 2009. Glasgow: Scottish Physiotherapy
Amputee Research Group; 2011. pp. 1-35.
2. Stineman M, Kwong P, Kurichi J, Prvu-Bettger J, Vogel W, Maislin
G, et al. The effectiveness of inpatient rehabilitation in the acute
postoperative phase of care after transtibial or transfemoral
amputation: Study of an integrated health care delivery system.
Arch Phys Med Rehabil. 2008;89:1863-72.
3. Fleury AM, Salih SA, Peel NM. Rehabilitation of the older
vascular amputee: a review of the literature. Geriatr Gerontol Int.
2013;13(2):264-273.
4. Dillingham T, Pezzin L. Rehabilitation setting and associated
mortality and medical stability among persons with amputations.
Arch Phys Med Rehabil. 2008;89:1038-45.
5. Hershkovitz A, Dudkiewicz I, Brill S. Rehabilitation outcome
of post-acute lower limb geriatric amputees. Disabil Rehabil
.2013;35(3):221-7. doi: 10.3109/09638288.2012.690818
6. Fletcher D, Andrews K, Butters M, Jacobsen S, Rowland C,
Hallett J. Rehabilitation of the geriatric vascular amputee patient: a
population based study. Arch Phys Med Rehabil. 2001;82:776-779.
7. Department of Veterans Affairs, Department of Defense.
Rehabilitation of lower limb amputation. [VA/DoD Clinical
Practice Guidelines] Washington: Department of Veterans
Affairs. [updated 2017 Sep; cited 2020 Apr 5] Available from:
https://www.healthquality.va.gov/guidelines/Rehab/amp/
VADoDLLACPG092817.pdf
8. BSRM Working Party Report. BSRM Amputee and prosthetic
rehabilitation – Standards and guidelines. 3rd Edition. United
Kingdom: British Society of Rehabilitation Medicine. 2018.
[updated 2018; cited 2020 Apr 5] Available from: https://www.
bsrm.org.uk/downloads/prosthetic-amputeerehabilitationstandards-guidelines-3rdedition-webversion.pdf
9. D, Flanagan G. Final report to New Zealand Artificial Limb Board.
Design and implementation of interdisciplinary care guidelines for
hospital management of amputees in Christchurch. Final report to
New Zealand Artificial Limb Board. New Zealand: Artificial Limb
Board. [cited 2020 Apr 5] Available from: https://www.nzals.co.nz/
assets/Utility-Files/DebbieHockleyCareGuidelinesReport1.pdf
10. Meikle B, Devlin M, Garfinkel S. Interruptions to amputee
rehabilitation. Arch Phys Med Rehabil 2002;83(9):1222-8.
11. Vogel TR, Petroski GF, Kurse RL. Impact of amputation level
and comorbidities on functional status of nursing home residents
after lower extremity amputation. J Vasc Surg. 2014;59(5):2014.
12. New Zealand Artificial Limb Centre. 2013-2014 all current amputees.
[Internet]. [cited 2020 Apr 5] Available from: https://www.nzals.
co.nz/assets/Utility-Files/NZALS-Statistics-2013-20141.pdf
13. Thompson NR, Fan Y, Dalton JE, Jehi L, Rosenbaum BP, Vadera
S, et al. A new Elixhauser-based comorbidity summary measure
to predict in-hospital mortality. Med Care. 2015;53(4):374-379.
14. Wong MW-N. Changing dynamics in lower extremity amputation
in China. Arch Phys Med Rehabil. 2005;86:1778-81.
15. Lefebvre K, Chevan J. Sex disparities in level of amputation. Arch
Phys Med Rehabil. 2011;92:118-24.
16. Fyfe N. An audit of amputation levels in patients referred for
prosthetic rehabilitation. Prosthet Orthot Int. 1990;14:67-70.
17. Hordacre B, Birks V, Quinn S, Barr C, Patritti B, Crotty M.
Physiotherapy rehabilitation for individuals with lower limb
amputation: a 15 year clinical series. Physiother Res Int.
2013;18(2):70-80.
18. Leung H, Wong W, Wu F, Guerin J. Perioperative and rehabilitation
outcome after lower limb amputation in elderly Chinese patients
in Hong Kong. J Orthop Surg. 2004;12:102-9.
19. Peng C, Tan S. Perioperative and rehabilitative outcomes after
amputation for ischaemic leg gangrene. Ann Acad Med Singapore.
2000;29:168-72.
20. O’Neill B, Evans J. Memory and executive function predict
mobility rehabilitation outcome after lower limb amputation.
Disabil Rehabil. 2009;31:1083-1091.
21. Desmond D, MacLachlan M. Psychological issues in prosthetic
and orthotic practice: a 25 year review of psychology in Prosthetics
and Orthotics International. Prosthet Orthot Int. 2002;26:182-88.
22. Brett F, Burton C, Duguid M, Brown M, Randell T, Clark K,
et al. Risks to the contra-lateral foot of unilateral lower limb
amputees: a therapist’s guide to identification and management.
United Kingdom: BACPAR. [Cited 2020 Apr 5]. Available from:
http://bacpar.csp.org.uk/publications/risks-contra-lateral-footunilateral-lower-limb-amputees-guideline
23. Ehde D, Czerniecki J, Smith D, Campbell K, Edwards W, Jensen M,
Robinson L. Chronic phantom sensations, phantom pain, residual
limb pain and other regional pain after lower limb amputation.
Arch Phys Med Rehabil. 2000;81:1039-44.
24. Deathe B, Miller W, Speechley M. The status of outcome
measurement in amputee rehabilitation in Canada. Arch Phys
Med Rehabil. 2002;83:912-8.
Journal of Rehabilitation Sciences & Research
Volume 7, Issue 2
June 2020
Pages 60-65

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