Major Lower Limb Amputation: A Review of Current Standards in One Vascular Centre

Abstract

Introduction: There is a need to improve outcomes and care in the perioperative period amongst patients who are having major lower limb amputations. The aim of this audit was to determine adherence to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended standards for the management of patients undergoing major lower limb amputations. Methods: 50 patients requiring major lower limb amputation in a District General Hospital were audited, with further detailed analysis possible in 19 cases where the full records were available. The age range (median) was 49 – 93 (75). 72% were male and 28% were female. The data was collected and analysed using Microsoft Excel 2013 ™. Results: Of the 50 cases audited, 20% (10) of the amputations were performed on a planned operating list and 88% (37) of patients had their operation within normal working hours. A consultant surgeon or trainee with a Certificate of Completion of Training (CCT) performed the operation in 72% (36) of these cases. On detailed review of 19 cases, 68% (13) were reviewed by a consultant within 14 hours of arrival to hospital and 47% (9) were reviewed by a Vascular Consultant within 24 hours of admission. 68% (13) had the amputation within 48 hours and 5% (1) were elective; it is unknown if a local review took place to determine why the rest, 5 cases and all urgent, were not performed within 48 hours. There was multidisciplinary team (MDT) involvement in the decision to operate in 16% (3) of cases. In 26% (5) of the cases were an MDT was not used, this was due to urgency of the operation. There is evidence of discussion with a consultant vascular surgeon in 4 of these cases. However, we were unable to determine whether these 5 cases were reviewed by a consultant Anaesthetist. Discharge planning and rehabilitation was discussed as soon as the need for amputation was identified in 21% (4) of cases. Only 1 case had a named amputation or discharge coordinator. 21% (4) of cases had physiotherapy from the first day post-amputation. A total of 19 (38%) of patients were known to have diabetes pre-operatively. On detailed review of 10 of these patients whose notes were available, the following results were obtained; 50% (5) had both pre-operative and post-operative review, and 30% (3) only had pre-operative review. 7% (7) of the patients had their insulin prescribed according to the National Patient Safety Agency (NPSA) guidelines. It was unclear whether hospital guidelines had been used to manage uncontrolled blood glucose levels in any of these cases. There was an 80% achievement for each of the following standards; nutritional state assessment within 48 hours of hospital admission, pre-operative screening for Methicillin-resistant Staphylococcus aureus (MRSA), pre- and post-operative falls assessment and risk reduction measures. We noted a 30-day post-amputation survival rate of 80%. Conclusion: There are still improvements that need to be made to help improve outcomes for patients undergoing major lower limb amputation. The key areas are early consultant review, involving an extensive MDT in the decision to operate, perioperative optimisation of patients with diabetes, and proactive discharge-planning facilitated by an amputation coordinator.