WoundReference improves clinical decisions
 Choose the role that best describes you
WoundReference logo

Building a Limb Preservation Program: Traditional and Nontraditional Models

Building a Limb Preservation Program: Traditional and Nontraditional Models

0

Building a Limb Preservation Program: Traditional and Nontraditional Models

INTRODUCTION

Overview

This topic provides resources for starting or further developing a limb preservation program. For more on challenges and solutions when building a limb preservation program, watch the interview "Building a Limb Preservation Program: Challenges and Successes".

The scope of the problem

The ultimate goal of limb preservation programs is to restore pulsatile blood flow to an at-risk extremity and prevent major lower extremity amputation. Unfortunately, the literature shows that the vast majority of non-traumatic amputations are preventable.[1] More than 400 non-traumatic lower limb amputations are performed per day in the United States.[1] As many as 50% of those non-traumatic lower extremity limb amputations are associated with diabetes.[2]

There is a broad continuum of care for the limb preservation patient that ranges from limb preservation, limb salvage, wound care, palliative care, to end-of-life care. Throughout the continuum, there are significant differences in the care received for those at risk for limb loss. In fact, patients frequently move from one level of care to another based on the severity of vascular occlusion in the at-risk extremity, complications arising during treatment, and overall health status. These variations in care and outcome are based on many factors that may include access to care, geographic location, and socioeconomic concerns. For instance, among patients with chronic limb threatening ischemia, up to 50% of patients who undergo a major lower extremity amputation never have a thorough vascular assessment in order to evaluate the potential for limb preservation.[2]

In 2017 Neville and Kayssi looked at the role of hospital networks, tertiary care hospitals, and community-based programs in managing limb preservation.[2] These authors described the benefits of limb preservation programs for both patients and medical providers [2]:

  • For patients, benefits include rapid assessment, improved healing, and enhanced revascularization. 
  • For providers, advantages include the ability to efficiently manage complex patients with help from the appropriate specialties (a multi-disciplinary team), an increase in referrals, enhanced identity of the institution, and opportunity to participate in clinical research and therapeutic trials. 

GOALS OF LIMB PRESERVATION

So, what is the primary goal in limb preservation?  

Globally, the healthcare system attempts to deliver the highest quality of care with the best outcome that can be administered in a time-efficient and cost-effective manner. In reality, global healthcare is administered on an individual basis.  As the patient navigates the healthcare system in an effort to “save his/her limb”, access to a multidisciplinary team with expertise and commitment in limb preservation is effective in preventing lower extremity amputation.[3][4] 

More specifically, to meet those needs we must:

  1. Have a dedicated multidisciplinary team focused on limb preservation 
  2. Have access to care that is based on acuity 
  3. Have a broad toolbox that includes both interventional and non-interventional capabilities to manage these patients  

Goal 1. Identify the patient with an at risk limb

The first priority of a limb preservation program is early identification of patients with at-risk limbs. To do so, it is crucial to have a simple and efficient triaging system in place throughout the healthcare system. Classifying a patient's urgency of care may be one way to proceed. A classification of the lower extremity as emergent, urgent or routine care can be utilized when screening patients. Having a clearly defined clinical pathway for each category with appropriate and timely referrals based on the level of acuity is vital. In order to achieve this goal, education of the primary care providers throughout the healthcare system is critical. Follow-up education on an annual basis is also necessary. 

Goal 2. Track, manage and follow up every patient with an at risk limb 

The next step is to establish a way of tracking and following patients. Developing a tracking system to assure appropriate follow up, compliance and identifying any potential delays of care is an imperative. Having an appropriate electronic medical record that can capture the data, then interfacing with an appropriate wound registry is also a high priority.  

So, whether the patient first presents in the emergency department, urgent care center, or primary care physician office, the patient will be treated the same way throughout the healthcare system.

Triaging and tracking in practice

Ideally, a ‘limb preservation hotline’ staffed by a trained, dedicated clinician (e.g,. a nurse), is established and  is available to all departments within the community and healthcare system. Whenever a clinician refers an at-risk patient, the nurse triages and dispatches the case according to the urgency of care. The nurse keeps track and documents all cases and their ultimate disposition. The nurse then can follow up with the patient and referring  provider in order to ensure that the patient is seen in a timely manner. In addition, the record and database of each patient outcome stands as a quality assurance indicator for limb salvage. 

MULTIDISCIPLINARY TEAM AND CARE COORDINATION

A limb preservation program requires the coordinated effort of physicians, nurses, allied health professionals, and healthcare administrators dedicated to the preservation, restoration and salvage of functional limbs. Adoption of a multidisciplinary clinical team has been shown to decrease major amputation rates by more than 50%, decrease wound healing times and to increase wound healing rates.[1][5] The key to a successful program is cooperation and communication among the participants who have a single goal of limb preservation. This process depends on the vision and zeal of a limb salvage champion. This role can be filled by any full-time, trained clinician. In many successful centers, this figure is a podiatrist, vascular surgeon, plastic surgeon, or wound care physician.  Having a limb salvage clinician champion is necessary in order to build a multidisciplinary team. Table 1 illustrates how members of the multidisciplinary clinical team contribute to the limb preservation program. [6]

Table 1. Multidisciplinary approach and full-time wound specialist clinician(s) are needed for a successful wound clinic with a focus on limb salvage program [6]

MemberContribution
AnesthesiologyAnesthesia induction in high-risk patients
EndocrinologyGlucose management
HematologyCoagulopathy assessment and management
Hyperbaric medicineHyperbaric oxygen therapy
Internal medicineAcute inpatient management
Infectious diseaseInfection management
Interventional medicine (radiology, cardiovascular)Assessment and endovascular intervention
NutritionOptimization of healing potential through counseling and supplementation
Orthotics/ ProstheticsOrthotics, prosthetics, bracing
Physical therapyRehabilitation and mobility training
Plastic surgerySoft tissue reconstruction and coverage
PodiatryWound care and surgical biomechanical management
PsychiatryBehavior modification and psychological assessment
RheumatologyVasculitic and autoimmune response
Wound careWound management

Other elements that are beneficial to a limb preservation program include [2]

  • An identifiable physical space
  • A vascular laboratory
  • Hyperbaric oxygen therapy
  • Protocol-driven care involving diagnostic and therapeutic modalities such as endovascular revascularization, open bypass, and soft tissue reconstruction
  • Prosthetic expertise in order to maintain function 
  • Comprehensive foot care and a remission clinic: 
    • Comprehensive foot care, including regular visits with a podiatrist, has been associated with reducing diabetes-related amputations by up to 80% [7]
    • Three critical factors that contribute to reducing amputations are 1) patient education, 2) regular visits with doctor and/or podiatrist, 3) appropriate footwear [7]

Required skills for a successful limb preservation program

Table 2 illustrates eight collective clinical skills that are essential in a limb preservation program.[8] The accompanying list of selected WoundReference premium topics will help members of a limb preservation program build clinical skills. The WoundReference Competency Tool can be leveraged for optimal training and skill building (learn more about the tool).

Table 2. Eight collective clinical skills and selected topics for members of a limb preservation program [8]

Clinical Skills
Selected WoundReference Topics
1. Ability to perform hemodynamic and anatomic vascular assessment with revascularization, as indicated
2. Ability to perform neurologic workup
3. Ability to perform site-appropriate culture technique
4. Ability to perform wound assessment and staging/grading of infection and ischemia
5. Ability to perform site-specific bedside and intra-operative incision and debridement
6. Initiate and modify culture-specific and patient-appropriate antibiotic therapy
7. Provide appropriate postoperative follow up to reduce risks of re-ulceration and infection
8. Provide basic foot care education and referral into (and monitoring of) a home education program
Other: Identify indications for HBOT

OPERATIONS

Traditional models

Ideally, a limb preservation program will have a dedicated multidisciplinary team, and an all-inclusive/equipped clinic with administrative support that offers accessible and affordable care. There are many excellent limb preservation programs throughout the United States. Those programs offer care in a variety of clinical models. Most commonly, these programs are part of larger tertiary care hospitals with administrative support and most, if not all, of the resources mentioned above.

Some of the practices shared by some of these traditional limb preservation programs are listed below.  

Clinical staffing 

  • Wound care centers have an essential role in the program. Ideally, wound care clinics are staffed with at least 1 full-time prescribing provider every day. Having a dedicated clinician present daily shows better outcomes than a ‘platoon’ staffing with multiple providers.

Referral flow patterns

Collaboration between vascular surgery and wound center 
  • Limb preservation programs that are based on the collaboration between a vascular surgery department and a wound center have demonstrated benefits for both parties. 
  • The standard of care on initial evaluation requires an appropriate vascular assessment. An abnormal vascular assessment requires immediate vascular surgical referral.
  • As a result, the implementation of a limb preservation program leads to a medically justified increase in referrals between vascular surgery and wound clinic, which in turn allows both services to identify patients in need of interventions sooner (e.g., infrapopliteal bypass, debridements).[9]

Toe, flow and go model

The toe, flow and go is a model in which someone takes care of the foot medically and surgically, someone takes care of the flow into the foot medically and surgically, and someone manages wounds.[8]

There are four components for a successful program based on this model: foot hotline, wound healing clinic, remission clinic, and screening clinic (see Figure 1).[8]

Figure 1. Four components of a limb preservation program (toe, floe and go)  [8]

Non-traditional models

Although ideal, having a dedicated all-inclusive onsite limb preservation clinic that has Vascular Surgery, Interventional Radiology, Wound Care, Podiatry, Hyperbaric Oxygen Therapy, Vascular Testing, Orthotists, Physiatry, Research requires significant commitment and resources and is not always possible.

An alternative is to offer care in a community based, ambulatory setting.

For communities with no formal limb preservation programs, clinicians can still develop a virtual limb preservation program. In a virtual limb preservation program, a wound center or podiatry clinic can act as a central hub for the management of these patients. Key elements include:

  • Development of a clearly defined relationship with a multidisciplinary team within the community of medical providers and medical resources
  • An appropriate and timely referral pathway to a higher level of care when indicated 
  • Understanding of both quality and safety measures
  • Development of an appropriate mechanism to document and track various metrics of quality of care. 
  • Collecting data that is tracked and monitored in a wound registry is another way to evaluate the quality of an individual program.

For more information on virtual limb preservation programs, watch the interview "Building a Limb Preservation Program: Challenges and Successes".

RESOURCES

Limb Preservation Alliances

Several limb preservation societies and foundations are devoted to the global goal of a standardized approach to limb preservation care (see sample below). Those entities offer a network of resources as well as serve as a vehicle to network amongst colleagues with similar goals, such as conferences and workshops that address concerns and best practice models of limb preservation. 

Resources for Patients

WoundReference Clinical and Reimbursement Decision Support

Wound Reference is an accessible, comprehensive resource with evidence-based, always current information on the role of wound care, hyperbaric oxygen therapy and the multidisciplinary approach to limb preservation. 

SUMMARY

A successful limb preservation program has a visible and identified limb preservation champion. This clinician takes the lead in building a multidisciplinary team that operates with tight guidelines with best-practice care coordination. Another key pillar is administrative support and commitment to building and maintaining such a program. 

Having it all is often a challenge, given common scenarios of limited resources that may result in decreased patient access. This challenge is further intensified during public health emergency situations, such as the one observed in the COVID-19 pandemic.

As medical resources are both vital and limited, it is imperative that at-risk patients are identified and managed along the limb preservation continuum of care, which includes limb preservation, limb salvage, wound care, palliative care and end of life care. Early identification and appropriate management of these patients can reduce morbidity and mortality, and improve  patient outcomes and quality of life. Ambulatory patients have greater longevity than those who lose limbs, and hence, lose mobility. [4]

CURATED ARTICLES


Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association., 2021 Apr 27
Journal: Circulation

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

View on PubMed View on Source
Wound Care and Hyperbaric Medicine Job Board, The Offspring of Sisyphus: Steady Progress in The Decade Since the "Toe and Flow" JAPMA-JVS Special Issue on Limb Preservation., 2021 Mar 17
Journal: Journal of the American Podiatric Medical Association


View on PubMed View on Source
Toward an interdisciplinary approach to diabetic limbs in the era of functional limb preservation: "can we preserve this limb?" meets "should we preserve this limb?", 2021 Mar 17
Journal: Journal of the American Podiatric Medical Association


View on PubMed View on Source
A Limb is a Peninsula- and No Clinician is an Island: Introducing the American Limb Preservation Society (ALPS)., 2021 Mar 29
Journal: Foot & ankle surgery (New York, N.Y.)


View on PubMed View on Source
The impact of the SARS-CoV-2 pandemic on the management of chronic limb-threatening ischemia and wound care., 2021 Oct 29
Journal: Wound Repair and Regeneration

In the wake of the coronavirus pandemic, the critical limb ischemia (CLI) Global Society aims to develop improved clinical guidance that will inform better care standards to reduce tissue loss and amputations during and following the new SARS-CoV-2 era. This will include developing standards of practice, improve gaps in care, and design improved research protocols to study new chronic limb-threatening ischemia treatment and diagnostic options. Following a round table discussion that identified hypotheses and suppositions the wound care community had during the SARS-CoV-2 pandemic, the CLI Global Society undertook a critical review of literature using PubMed to confirm or rebut these hypotheses, identify knowledge gaps, and analyse the findings in terms of what in wound care has changed due to the pandemic and what wound care providers need to do differently as a result of these changes. Evidence was graded using the Oxford Centre for Evidence-Based Medicine scheme. The majority of hypotheses and related suppositions were confirmed, but there is noticeable heterogeneity, so the experiences reported herein are not universal for wound care providers and centres. Moreover, the effects of the dynamic pandemic vary over time in geographic areas. Wound care will unlikely return to prepandemic practices. Importantly, Levels 2-5 evidence reveals a paradigm shift in wound care towards a hybrid telemedicine and home healthcare model to keep patients at home to minimize the number of in-person visits at clinics and hospitalizations, with the exception of severe cases such as chronic limb-threatening ischemia. The use of telemedicine and home care will likely continue and improve in the postpandemic era.

© 2021 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.

View on PubMed View on Source
Official reprint from WoundReference® woundreference.com ©2021 Wound Reference, Inc. All Rights Reserved
Use of WoundReference is subject to the Subscription and License Agreement. ​
NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Creager MA, Matsushita K, Arya S, Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel LP et al. Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association. Circulation. 2021;volume 143(17):e875-e891.
  2. Neville RF, Kayssi A et al. Development of a Limb-Preservation Program. Blood purification. 2017;volume 43(1-3):218-225.
  3. Van Gils CC, Wheeler LA, Mellstrom M, Brinton EA, Mason S, Wheeler CG et al. Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience. Diabetes care. 1999;volume 22(5):678-83.
  4. Eggert JV, Worth ER, Van Gils CC et al. Cost and mortality data of a regional limb salvage and hyperbaric medicine program for Wagner Grade 3 or 4 diabetic foot ulcers. Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, In.... 2016;volume 43(1):1-8.
  5. Chung J, Modrall JG, Ahn C, Lavery LA, Valentine RJ et al. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia. Journal of vascular surgery. 2015;volume 61(1):162-9.
  6. Kim PJ, Evans KK, Steinberg JS, Pollard ME, Attinger CE et al. Critical elements to building an effective wound care center. Journal of vascular surgery. 2013;volume 57(6):1703-9.
  7. . Dignity Health Rehabilitation Hospital in Henderson, NV - Amputee Coalition [Internet] . 2021;.
  8. Khan T, Shin L, Woelfel S, Rowe V, Wilson BL, Armstrong DG et al. Building a scalable diabetic limb preservation program: four steps to success. Diabetic foot & ankle. 2018;volume 9(1):1452513.
  9. . Constructing a Wound Care Center: Does it Make Sense For You. . 2021;.
Topic 1686 Version 1.0