Quality Improvement Framework for Major Amputation Surgery

Quality Improvement Framework for Major Amputation Surgery

Tuesday, 23 November 2010 11:40

The perioperative mortality rate after major amputation in the UK is unacceptable. Rates of 17% (HES data) and 9% (NVD data) were reported to the VSGBI AGM in 2009. In Feb 2010, VSGBI Council invited a stakeholder group (listed at the end of the document) to discuss a possible QIF for major amputation surgery. A draft version was agreed at Council in May, and circulated to VSGBI membership in the summer. The responses from the membership can be found in a separate document on this website. At the September Council meeting the revised QIF was endorsed and adopted by the Council. The shortened version of the QIF that follows can also be found on this website for dissemination.

 

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Aim to reduce the perioperative mortality rate after major amputation surgery to less than 5% by 2015

Amputation for vascular disease and diabetes should only be undertaken after formal investigation of the arterial system by angiography (DSA, CTA or MRA) or specialist ultrasound imaging, except when the leg is clearly beyond salvage. .

Major amputation is indicated when:

  1. Revascularisation is not a realistic option
  2. Amputation is expected to save or prolong life and/or improve quality of life

After consultation with the membership in May 2010, the Council of the Vascular Society of Great Britain and Ireland endorses the following framework for quality improvement in major limb amputation surgery. Notes at the end of the guidelines will aid surgeons who may need to introduce changes to their vascular practice. The details of the framework are due for review by Council in 2013.

The framework

Preoperative

  • All patients should be assessed and managed by a multidisciplinary vascular specialist team (that regularly undertakes limb amputation)
  • Pain should be controlled, and the pain team involved as needed
  • The agreed decision with the patient to amputate should be timed and recorded in the notes
  • A named individual should be allocated preoperatively to each patient for support, and to co-ordinate care, rehabilitation and discharge planning (1)
  • All patients should have formal clinical assessment (risk assessment) including review by, or in consultation with a consultant anaesthetist
  • Controllable risk factors should be optimised (2)
  • Antithrombotic prophylaxis should be prescribed from admission unless contra-indicated, and continued at least until discharge from hospital
  • Discharge planning and rehabilitation should be considered at this stage, and review by the rehabilitation team encouraged

Perioperative

  • Operation should ideally be undertaken on a planned operating list during normal working hours (target 75% of all major amputations) (3)
  • Patients not booked on a planned list should have their amputation done within 48h of decision to operate, and no patient should have their operation deferred more than once, unless there are new medical contraindications
  • The operation should be undertaken by a trained surgeon who has a regular practice in amputation procedures, and has a knowledge of implications for rehabilitation
  • The anaesthetic must be given by a senior anaesthetist (post FRCA); a trainee should have consultant supervision available
  • Planned amputation should only be undertaken in a facility with ready access to blood products and access to level III critical care
  • The aim should be to undertake below knee amputation (BKA) wherever appropriate - aim to have below knee: above knee ratio > 1, with continuous audit of outcomes and revision rates (4)
  • All patients to have antibiotic prophylaxis, type of antibiotic according to local policy

Postoperative

  • Amputation should only be undertaken in a unit with 24/7 network or local vascular cover, with access to multiprofessional support (cardiac/ renal/respiratory/diabetes)
  • There should be a formal pain management protocol, and access to an acute pain team
  • A protocol for wound and pressure area care should be available on the ward, including management of complications and care of the contralateral leg
  • There should be prompt access to a local amputee rehabilitation team including early mobilisation and physiotherapy
  • There should be continued discharge planning home, or to an appropriate facility
  • There should be formal referral to a specialist amputee rehabilitation team (prosthetics)
  • Optimal medical management and health education should be completed before discharge
  • All vascular amputations should be recorded on the National Vascular Database

Notes

  1. This may be a consultant surgeon, or could be a nurse, or other member of the vascular team
  2. These will be defined by a small working group of the VSGBI and VASGBI and published on the QIP website (www.aaaqip.com)
  3. This may include CEPOD and emergency lists, covering the hours 8am to 8pm
  4. The outcomes from this QIF, including monitoring of submission rates, outcomes and AK:BK ratios will be monitored through the NVD by the QIP team

Vascular teams that cannot meet the requirements of the above framework should engage actively with service managers and commissioners to effect the changes required to develop safe and effective services that meet the local needs of their patients with vascular diseases.
www.vascularsociety.org.uk

The following individuals were members of the original stakeholder group that considered the QIF and agreed the first version. The VSGBI wishes to offer grateful thanks to these individuals for their help and support:

VSGBI Members: Professor Cliff Shearman, President, Mr Jonothan Earnshaw, Honorary Secretary, Mr Peter Lamont, President Elect, Mr Rod Chalmers, Consultant Surgeon, Edinburgh Royal Infirmary, Mr Richard Holdsworth, Consultant Vascular Surgeon, Stirling Royal Infirmary, Mr Keith Jones, Consultant Vascular Surgeon, St George’s Hospital, London, Mr Mike Salter, Consultant Vascular Surgeon, Southend Hospital, Miss Stella Vig, Consultant Vascular Surgeon, Mayday Hospital, Croydon, Mr Ken Woodburn, Consultant Vascular Surgeon, Royal Cornwall Hospital, Mr Waquar Yusuf, Consultant Vascular Surgeon, Brighton, Mr Lasantha Wijesinghe, Consultant Vascular Surgeon, Bournemouth, Mr Peter Holt, Vascular SpR, St George’s Hospital, London, Mr Andy Weale, Vascular SpR, Gloucestershire Royal Hospital, Professor William Jeffcoate, Consultant Physician in Diabetes & Endocrinology, Nottingham City Hospital, Nottingham, Dr Jonathan Thompson, Chairman, Vascular Anaesthetic Society, Dr Gerry Danjoux, Honorary Secretary, Vascular Anaesthetic Society, Dr Tracey Wall, Honorary Secretary Elect, Vascular Anaesthetic Society, Dr Martin Price, Audit Committee Chairman, Vascular Anaesthetic Society, Dr Malcolm Gunning, Audit Committee representative, Vascular Anaesthetic Society, Dr Helen Melsom, SpR observer, Vascular Anaesthetic Society, Dr Claire Myint, British Society of Rehabilitation Medicine, Dr Lal Landham, Consultant in Rehabilitation Medicine at Gillingham, Dr Ashraf Azer, Consultant in Rehabilitation Medicine, Clatterbridge Hospital, Dr Jeff Lindsay, Consultant in Rehabilitation Medicine, Selly Oak Hospital , Mrs Sue Ward, Past President, Society of Vascular NursesMs Penny Broomhead, British Association of Chartered Physiotherapists in Amputee Rehabilitation, Ms Helen Sanderson Vascular Nurse Specialist and Wound Unit Manager, Southend Hospital, Ms Helen Shreeve, Senior Amputation Physiotherapist, Southend Hospitall

In addition the advice of Members of the VSGBI during the review process, contributions from the Vascular Anaesthesia Society of Great Britain and Ireland, and the efforts of VSGBI Council are generously acknowledged.

November 2010

 

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