Implementing a multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators

Research Objectives: To determine barriers and facilitators to implementation of a multidisciplinary early mobilization post-operative lower extremity amputation protocol (LEAP).

Design: The descriptive implementation survey study was guided by established Implementation Theoretical Frameworks leading to a framework exploring relevant knowledge, clinical skills, implementation issues such as professional interactions, and contextual factors such as hospital culture. Survey questions were developed and tested by multidisciplinary professionals uninvolved in hospital care.

Setting: Urban academic medical center

Participants: Convenience sample of 225 healthcare professionals

Interventions: None

Main Outcome Measures: Descriptive participant and survey data

Results: Respondents from medicine (17.3%), nursing (16.0%), physical therapy (36.0%), occupational therapy (24.0%), other therapy (0.9%), and prosthetics (5.8%) reported median 6-10 years professional experience. 70.2% reported little-some amputation rehabilitation experience; 45.5% saw 1-5 amputees per year but 15.0% reported seeing none.
Knowledge of the problems delaying discharge after amputation and evidence-base was low: 60.9% were a little or unfamiliar with factors delaying discharge and 93.3% were unaware of amputation-rehabilitation clinical practice guidelines (CPGs). Competence in clinical skills was low: 40.3-69.7% had no direct/indirect experience with wound dressings or early mobilization after amputation.
Personal barriers included limited knowledge of the problem (80.6%), wound dressings evidence (74.9%), and CPGs (73.0%); and limited clinical training and confidence (84.8-87.2%). Institutional barriers included insufficient amputee patients (85.6%), interdisciplinary communication and coordination (81.8-85.2%), inadequate institutional directives (83.2%) and referral systems (75.9%); and insufficient supplies (77.0%). Facilitators included clinician attitude/readiness to change (50.6%), knowledge of early mobilization evidence (43.4%), and communication with non-English speakers (44.2%).

Conclusions: Identified implementation barriers to early mobilization after amputation included knowledge; skill; professional interactions; and hospital context. Implementation interventions targeting each domain can include educational modules to address limited knowledge, multidisciplinary clinical training to address skills competence, and an institutional clinical pathway with automated referral system to facilitate multidisciplinary communication and coordination.

Author(s) Disclosures: None