Deficiencies in Specialty Referrals Prior to Guillotine Amputation at a Veterans Affairs Hospital

Abstract

Up to one-quarter of below knee amputation patients undergo an open amputation prior to definitive closure. However, the need for a guillotine amputation typically signifies a rapid decline in clinical course. In published studies, guillotine amputations are associated with increased mortality. Therefore, identification of factors that result in these failure to rescue patients prior to the deterioration is vitally important. This study sought to examine the prevalence of time delays and specialty referrals in guillotine amputation patients. All patients who required a major lower extremity guillotine amputation at a single Veterans Affairs Hospital over a 10-year period were retrospectively reviewed. Demographic characteristics, comorbid conditions, and time between wound identification, specialty referrals, and amputation were calculated. We identified 76 patients who underwent an open amputation at or above the ankle level between 2008 and 2019. Ninety-two percent of patients had seen a primary care doctor through the Veterans Affairs system a median of 104 days prior to their amputation. These patients had a median of 30 days between wound identification and amputation. Excluding those without wounds and those who underwent amputation within the same hospital encounter as their wound identification, the median wound duration was 135 days. Fifty-seven percent (29/51) of the patients whose wounds were identified prior to their acute presentation were evaluated by podiatry with an average delay of 20 days (median, 0.5 days). Fifty-one percent of patients were evaluated by vascular within an average of 75 days (median, 11.5 days) from their wound diagnosis. Fifty-nine percent of patients were seen by both services. Sixty patients had diabetes mellitus but only 19 (32%) had been evaluated by an endocrinologist. Average hemoglobin bA1C among diabetics was 8.5 g/dL (range, 4.5-13.7 g/dL). Two-thirds of patients who underwent guillotine amputation had a wound that was identified prior to their acute presentation. However, over 40% of patients were not evaluated by podiatry and one-half were not evaluated by vascular during the course of their wound care. Additionally, nearly 80% of patients had diabetes but only one-third of these patients were followed by endocrinology. This study identifies room for improvement in the provision of appropriate and expedited referrals for comprehensive wound care in veterans.