Considerations to Guide Clinical Decision Making in the Management of Amputees in Acute Care: A Pre-Clinical Learning Module for DPT Students
By Terra D. Osmon, SPT
♦ Background
I was initially exposed to working with amputee patients while in my former acute cardiopulmonary clinical rotation. Following the completion of my first year, I realized that there were gaps in my knowledge that presented new challenges with respect to special populations such as amputees within the Acute Care setting, despite having acute care content in our curriculum. Some of those disparities include: when to select appropriate outcome measures, how to critically assess all the determinants affecting patient outcomes, where to integrate those factors when making clinical judgments for discharge planning, and what the longitudinal impact on patient health will be.
♦ Statement of Need
During my former Acute Care rotation, the clinical instructor expressed that there was a common trend amongst DPT students in which there was a lack of exposure to the aforementioned concepts, especially for in the early stages of their curriculum. A cross-sectional study shows that Physical Therapists perceptions of acute care concluded with the belief that there is inadequate training with respect to discharge planning and the hospital discharge processes in the setting1. In addition, there is currently a lack of high quality evidence indicating the validity and reliability of outcome measures specific to amputees in the acute/post-operative stage of rehabilitation 2. The ability to select appropriate outcome measures tailored to physical therapy patients is important in providing objective data to support and validate the clinical judgments and when discharge recommendations are made. Furthermore, because discharge planning is a core competency skill that is expected of entry level physical therapy students, this skill should have larger emphasis3. Literature suggests that when PT recommendations are followed, there is favorable impact on patient health outcomes4. This further supports the vital role of PTs in patient discharge processes. Collectively, these are grounds to encourage students to learn and master these core concepts.
♦ Project Overview
This capstone project will help to ‘bridge-the-gaps’ in knowledge amongst DPT students and better prepare students for an acute care clinical rotation with a focus on amputee management. DPT students will integrate their current knowledge about the Acute Care setting with amputee-specific information and other concepts of relevance that have not yet been covered in the curriculum, all of which are integral parts in advancing skills in one’s physical therapy practice. My intended audience for my capstone is DPT student learners. I have produced a presentation which is available online and designed to be used as self-study. I have also provided resources/articles which will contain relevant evidence and content which may benefit students as future references.
Capstone Materials:
♦ Relevant Content
Various content in the curriculum and prior work/projects are relevant to my capstone. During my clinical rotation in acute care cardiopulmonary unit, I developed and presented an in-service presentation to CMC Employees in the Therapy Department titled: “Outcome Measures for the Acute Cardiovascular Patient.” As the title indicates, this presentation emphasized and considered selecting appropriate outcome measures for general population of acute cardiovascular patients. It also acknowledged and provided amputee-specific outcome information given the high volume of amputee patients in our unit.
During Evidence Based Practice II, my Critically Appraised Topic (CAT) focused on the clinical question: “For a community-dwelling older adult (geriatric) with acute Transtibial below knee amputation and pre-prosthetic surgery, does a fall prevention program decrease future fall occurrences?”
Furthermore, the Social Determinants of Health5 discussed in my capstone are concepts which were covered in the Health and Wellness Course in the third year of UNC’s DPT Program.
I have modified and/or utilized the results of these prior projects to be integrated into my final capstone project. Primary emphasis on additional review of literature has included evidence on appropriate amputee-specific outcome measures for acute setting, the socio-economic and social barriers evidenced to impact the healthcare of amputees, and the statistics and data on amputee readmissions and the impact on national healthcare costs.
♦ Reflection
In designing my presentation, I utilized various resources such as “Death by PowerPoint” for avoiding common mistakes in designing slides. These suggestions helped me understand the importance of being simple when integrating content and formatting in order for students to consume and digest key concepts. In the future, I would like to construct a way to integrate this material into a course. I think a voice-thread could be especially beneficial for explaining the social determinants independently and could be utilized in a course such as Health and Wellness. Also, presenting in front of a class would be beneficial for students by providing an opportunity to critically discuss concepts for better facilitation of learning.
♦ Acknowledgements
I have been fortunate to have wonderful Clinical Instructors throughout my Doctor of Physical Therapy Education at UNC Chapel Hill. I want to say a most sincere thank you to Daniel Friedlander, DPT, Alison Balmat, DPT, and David Sutton, DPT. Thank you for sharing your knowledge, investing your time to my education, and challenging me during my clinical learning experiences. Each of you have been integral in my development of the foundational clinical skills that I will continue to build upon, and I am better prepared to be a physical therapist because of your guidance. In your own respective ways, you have influenced my perspective of physical therapy practice, and helped me develop into a more mindful, and holistic person so that I can effectively care for my future patients. I appreciate you and I thank you.
♦ References
1. Matmari L, Uyeno J, Heck CS. Physiotherapists’ perceptions of and experiences with the discharge planning process in acute-care general internal medicine units in ontario. Physiother Can 2014;66(3):254-263. doi:10.3138/ptc.2013-12.
2. Cole MJ, Cumming J, Golland N, et al. BACPAR Toolbox of Outcome Measures. BRITISH ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN AMPUTEE REHABILITATION 2014;Version 2.
3. Greenwood, PT, DPT, MS, GCS K, Stewart, PT, DPT E, Milton, PT, DPT, NCS E, Hake, PT, DPT, NCS M, Mitchell, PT, DPT L, Sanders, PT, DPT, MS, FAPTA B. Core Competencies for Entry-Level Practice in Acute Care Physical Therapy. Academy of Acute Care Physical Therapy 2015;First Edition. Available at: http://c.ymcdn.com/sites/www.acutept.org/resource/resmgr/Core_Competencies_of_Entry-L.pdf.
4. Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther 2010;90(5):693-703. doi:10.2522/ptj.20090164.
5. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health 2011;32:381-398. doi:10.1146/annurev-publhealth-031210-101218.
5 Responses to “Considerations to Guide Clinical Decision Making in the Management of Amputees in Acute Care: A Pre-Clinical Learning Module for DPT Students”
anne hammonds
Terra, you obviously learned a lot about the acute amputee patient during your clinical rotation. Your slide presentation really touched on a lot of points that many students may not be aware of when they are completing their clinical rotations. I appreciate the thoroughness and thoughtfulness of your discussion of the social determinants associated with patients with amputation.
I work with a significant number of patients in the sub-acute phase of their medical care following amputation surgery. The SNF that I work at is associated with a regional VA Medical Center. One of the topics of health behavior that you touched upon is instrumental in being successful in the use of a prosthetic limb. That behavior is cognition. In my own research, I have found that cognition is a component of the vascular disease that caused the patient to lose their limb in the first place. The vascular changes that affected the lower limb affect the brain as well. If the patient is unable to perform executive function tasks (memory, sequencing, judgement), then they will require some assistance from a family member for donning the px, managing volume control, walking safely, etc.
Additionally, your discussion about the social determinants of health can be translated to any patient with just about any diagnosis. The patient’s social support and the housing environment is very important in determining the DC plan. You mentioned a very simple, yet often overlooked concept in your presentation – if the patient can not get into the house, they can not go home safely. It is our job to ask/investigate what are the pertinent equipment needs that each patient needs to be safe and successful at home (regardless of their diagnosis – amputee, CVA, PD, hip fracture).
Finally, I appreciate the outcome measures you found to be valid and reliable for the patient with LE amputation. They are certainly appropriate for the patient when they begin gait training. However for the acute patient, the AMPnoPro show good reliability and validity without the use of the prosthesis and helping to determine the rehab potential for gait training and K-levels. If you are interest in more information regarding gait training, Dr Bob Gailey is a great resource in gait training patients with prosthetics.
The students that come through my clinic are very eager to learn about treating patients following amputation and gait training. From your presentation, it appears your clinical has given you the advantage of exposure and working with this inspiring population.
Nice work! Congratulations!
Dan Steele
Terra, what a thorough job you did exploring a topic that, as you mentioned, we don’t get an extensive amount of training in prior to our first clinical rotation. I especially appreciated you going into depth regarding the socioeconomic factors associated with higher prevalence of amputations. During my inpatient rehab rotation I was in Pinehurst, which is not an underserved area but Moore Regional Hospital definitely serves outlying communities which have a far lower average income level. While we saw mostly patients recovering from stroke, there were also a significant number of recent amputees and I very much enjoyed working with them. However, it was repeatedly disheartening to get into their subjective histories and find that they frequently lived alone, without family or reliable transportation, in single wide trailers with multiple steps to enter, and a whole host of other barriers which did not bode well for their eventual return to independent living in their prior situation. Many of them smoked, were obese, and had type 2 diabetes, which not only bodes poorly for exercise tolerance, physical conditioning, and wound healing, but are also well known to be more prevalent among lower-income, lower education-level populations. Your slide on the WHO criteria for health care equality really resonated with me as the disconnect between the ideal, utopian intervention plans and resource distribution we learn in school and the practical reality many of our real-world patients face has come into clear focus.
I feel that working in the IRF did a lot to help me as a student gain a better grasp on the discharge planning concepts you covered, due to the fact that we met regularly as an interdisciplinary team. Hearing input from the MD, nurses, and OT’s really helped me see a fuller picture of each patient’s recovery course and the specific concerns raised by each discipline. There were also times when I strongly felt a patient still had crucial progress to make and should not be discharged early, and had to justify that assessment to the attending MD. I know that not every student has the opportunity to do a full rotation in an IRF. While the IPE experience provided during geriatrics class was very informative, just having those 2 sessions as part of our mandatory coursework does not seem to be adequate to prepare us as clinicians for confident interdisciplinary communication. Your slides relating to the importance of confidently delivering our professional recommendations, and that data support the importance of those recommendations will give the students learning from your presentation more confidence to present themselves as valuable and authoritative components of a patient’s course of recovery following an amputation. Great job!
Amanda Doty
Hi Terra,
Great job on your capstone! I can tell you worked very hard on this and I completely agree that discharge planning can be difficult, especially for this patient population. My final rotation is going to be in inpatient rehab and I will likely be working with amputees. I really appreciate your project in helping to “bridge the gaps” in knowledge and help me to feel better prepared for discharge planning with this patient population.
I enjoyed your presentation. I think that making it into a voicethread would make it even better. It is difficult for me to read the notes at the bottom without getting lost in the text. Making it into a voicethread may help the learner to stay more engaged throughout the presentation. However, I think you did a great job with your organization of the materials and the visuals are great! Again, great job on your presentation!
Brennan Visser
Terra,
Great job! Your presentation is very well done and as a visual learner, I greatly appreciated all of the graphs and figures that laid out the data in a much more exciting and learner-friendly way than simply listing out statistics. I agree that presenting in front of students or providing a Voicethread instead of having the text underneath the slides would be more effective, as listening to someone speak about something is usually more engaging than reading large amounts of text after also looking at the slides.
Thank you for also including information on social determinants of health. You did a great job of relating it specifically to the amputee patient population with literature to back up your statements. Your inclusion of outcome measures for amputees in the acute setting was very helpful, as outcome measures can be forgotten in a setting with such a short length of stay. You did a great job including outcome measures with different levels of difficulty to allow for use across various patients. I am excited to utilize this information in my upcoming inpatient pediatric clinical rotation at Wake Forest Baptist Medical Center. While these children’s amputations will likely be due to trauma or cancer, as opposed to PAD or diabetes, it will still be important to utilize appropriate outcome measures and pay attention to their social determinants of health in order to provide the best care.
Congratulations!
Brennan
Amanda Friedline Weber
Hi Terra,
Great job on your capstone project! I agree with you the need for this presentation. My first clinical rotation was acute care and I was on the trauma floor. We had not had course curriculum on amputations yet, but I ended up working with several individuals who sustained traumatic amputations I struggled dealing with the complexity of these cases and making appropriate discharge planning recommendations. Knowing which outcome measures to use for this specific patient population would have been a beneficial “tool in my tool belt” to aid in making these recommendations, though as you mentioned, unfortunately there is limited evidence focusing on the acute setting for this population.
I appreciate the way you organized the presentation. I think starting with the “big picture” and statistics helps draw the audience in and show the need for the information you are about to discuss. I also really enjoyed your slides. The graphics and layout you used is professional and grabs the audience’s attention. The overall inclusion of the social determinants of health, specifically to individuals who have suffered amputations, further emphasized to me the vital importance for PTs to see the whole person/situation and how this can lead to better patient outcomes.
I agree with you, that converting this presentation to a voicethread would enhance the material delivery and allow for more in-depth comprehension. If you did, you could also create a short survey for the audience to take pre and post presentation to determine confidence in identifying barriers, utilizing outcome measures, and making informed clinical decisions. I also think, adding videos of patients completing the discussed outcome measures may help the learner better understand and visualize the measure so that they may remember to use it clinically. Great job and congrats on finishing the capstone process!