Fewer than half of leg amputees get good care, national audit reveals

Fewer than half of leg amputees get good care, national audit reveals

This is of particular concern, given the rising number of diabetic patients who require amputation, says the report. The NCEPOD advisors reviewed 596 sets of case notes between October 2012 and March 2013, and found that fewer than half of those (229/519; 44%) requiring leg amputation as a result of vascular disease and/or diabetes were given good care.


Up to 1,000 patients per million of the UK population are thought to have clinically significant peripheral vascular disease. Of these, roughly 1-2% will eventually require leg amputation, although this figure increases to 5% in patients with diabetes. The audit found that early review by a consultant vascular surgeon might have altered the outcome in 18/198 patients, particularly for those admitted under other specialties.


Nearly a quarter (138/598; 23%) of patients who should have had elective amputation underwent emergency surgery instead. And two-thirds of all delays would have been avoided if surgery had been performed on a planned operating list.


Most (87%; 452/516) of amputees did not have a named individual responsible for coordinating discharge planning and rehabilitation. Only 12.8% (41/310) of patients with diabetes were admitted under the care of the diabetes service, and only 58.4% (160/274) were reviewed pre-operatively by a diabetes nurse specialist.


Furthermore, glycaemic control was poor or unacceptable in at least one in seven patients at some point within the surgical pathway. The advisors found that management guidelines already published by the Vascular Society of Great Britain & Ireland (VSGBI), the British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR), and the British Society of Rehabilitation Medicine (BSRM) were not routinely being followed. And the care pathways for leg amputees lacked clarity which adversely affected the quality of care.


Lead report author and consultant vascular surgeon, Professor Michael Gough, commented: “A significant improvement is needed in the care of amputation patients given that fewer than half received good care, and that the mortality rate of 12.4% for the procedure was higher than has been reported in the US (9.6%).


“Having a limb removed is a life changing experience and patients need to be supported by a wide range of health professionals, other than just the surgeon.”


He continued: “Good multidisciplinary care from the outset is required to ensure that these patients, who often have multiple medical problems, receive the best possible treatment, including treatment of diabetes and heart problems, physiotherapy, rehabilitation and a properly planned discharge.”


And he added: “Many amputations are performed in the emergency operating theatre and are often subject to last minute cancellation. These are high-risk patients and they should be given the benefit of surgery in normal working hours where senior doctors can oversee their care.”


Co-author and consultant physician Dr Mark Juniper highlighted the poor diabetes control in this group of patients.


“More than half of the patients in our study had diabetes, and complications from this are a leading cause of leg amputation. Unfortunately, we found that diabetes was not well managed in about 20% of the cases we looked at.


“Routine, early involvement of diabetes specialists would have improved care for these patients, and might even have reduced the number of amputations needed for foot sepsis. The incidence of diabetes is rising, so it is even more important to address this” he emphasised.


“A model of shared care between surgeons and geriatricians reduces mortality in hip fracture patients. We are proposing a similar approach for patients having amputations,” he added.


* Lower Limb Amputation: Working Together. A review of the care received by patients who underwent major lower limb amputation due to vascular disease or diabetes. A report by the National Confidential Enquiry into Patient Outcome and Death (2014)



By Caroline White,

 

 

OnMedica, Monday 17 November 2014

 

 

 

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