Evidence-Based Post-Operative Care
Evidenced-based medicine (EBM) is becoming an essential component of O&P practice. In simplest terms, EBM is discontinuing practices that medical evidence demonstrates do not improve clinical outcomes, and conversely, consistently incorporating into practice interventions that are proven to enhance patient outcomes.
EBM was introduced in the 1990s and defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient. Medical evidence demonstrates that four overarching factors influence successful outcomes following lower-limb amputations. They are surgical technique; post-operative care; site of discharge; and amount, intensity, and duration of physical therapy. Two clinically important components of post-operative care are peer support and post-operative dressing choice.
An integrative review was published this year in the Journal of Vascular Nursing that examined the extant body of evidence regarding the value of peer support for people with major limb amputations. Researchers assembled ten peer-reviewed studies published from 1977 to 2009 on amputee peer support, including one level III retrospective case-controlled trial, two level IV case series, and seven level V expert opinions. They found that all the studies demonstrated or described improved outcomes as a result of a peer support visit. In fact, 92 percent of patients surveyed responded favorably to a peer visit and claimed it substantially improved their amputation outlook after surgery. Over 50 percent of patients would have liked an additional peer visit during their rehabilitation, and 66 percent of patients older than 65 and 70 percent of people with bilateral amputations said they desired even more peer visits. The authors of the review concluded that, although the research designs of the various studies were not particularly robust, the totality of the evidence is one directional. Peer support intervention is low cost and low risk. The resulting evidence-based clinical practice recommendation is that all individuals undergoing major limb amputations should be offered peer visits as a post-operative component of the rehabilitation process.
Hospital falls gained increased attention when Medicare decided to financially penalize hospitals for avoidable falls. Patients who have undergone amputation surgery represent the subset of patients who are most likely to experience an inpatient fall. Twenty percent of amputees fall in an acute care institution, i.e. the hospital or inpatient rehabilitation center; more than the 17 percent of stroke patients who fall in the same setting. Three percent of people with lower-limb amputations experience a fall that requires a revision surgery. Tragically, almost half of patients who require a revision surgery experience a transfemoral amputation as a final outcome. Evidence demonstrates that falls requiring a return for revision surgery are eliminated when patients are wearing a properly fitted.
Outcomes measurement is a critical step necessary to effectively practice EBM. Fortunately, in prosthetics, the outcome to collect is fairly obvious—mobility. But exactly how to measure mobility may not be quite so clear. A strong positive correlation between mobility and quality of life and general satisfaction is unsurprising. Using goal attainment scaling (GAS), researchers have previously determined that mobility is the primary concern of people with a lower-limb amputation, so it seems reasonable to measure mobility. It is also generally accepted that rising, sitting down, and climbing stairs can be particularly challenging for this population. Since mobility is of great concern for people with lower-limb loss and important to recovery, the timely, consistent, and accurate measurement of mobility becomes paramount in the practice of EBM and management of the rehabilitation process.
Contact Teter Orthotics & Prosthetics for any evidence-based post-operative care questions or prosthetic needs. We’ve been providing expert prosthetic and orthotic services in Michigan since 1955 and have grown to more than 20 locations, including Traverse City, Alpena, Greenville, Mantisee and visit our new location in St. Joseph opening soon!