Leading Change Following the Publication of the NCEPOD ... · NCEPOD -NCEPOD Guideline 20- A...

Leading Change Following the

Publication of the NCEPOD

Guidelines

Felicity Williams

Alice Vallance

Objectives

• Reviewing the Previous Service at UHB (2014)

• Comparing the UHB (2014) Service to NCEPOD

Guidelines

• Leading Change and the Implementation of NCEPOD

Guidelines into the UHB Physiotherapy Vascular Service

(2015)

• Success of Change

• Onward Plan- Short and Long Term Plan

Reviewing a Service to Allow Change

Requirements

Resources

ConstructingImplementation

Outcomes and Success

Requirements- Comparing a Service to

NCEPOD

Requirements

Resources



-NCEPOD Guideline 9- Elective patients should be seen

in a pre-assessment

-NCEPOD Guideline 4- The decision to undertake a

major amputation should be made by a multidisciplinary

team (MDT)

-NCEPOD Guideline 20- The physiotherapist should be

consulted in the decision making process regarding the

most functional level of amputation for the individual

-NCEPOD Guideline 20- Physiotherapy commences from day 1 and to including

exercise, oedema management and use of early walking aids

-NCEPOD Guideline 1- Involvement in producing protocols followed by the MDT

Requirements- Comparing a Service to

NCEPOD -NCEPOD Guideline 20- A structured exercise

regime

- NCEPOD 20- Within the MDT the role of the

Physiotherapist involves compression therapy

-NCEPOD Guideline 20- Prompt access to a local

amputee rehabilitation team

-NCEPOD Guideline 19- Falls and coping strategies

-NCEPOD Guideline 10- Forward planning regarding rehab and discharge

-NCEPOD Guideline 3- There should be a continued discharge planning

home, or to an appropriate facility

Requirements

Resources



Resources

-Access to data

-NCEPOD Guidelines and expectations of

a major amputee service

-Access to MDT

-Financial Director for the Vascular

Service

Requirements

Resources



-Departmental level support

-Access to Local Prosthetic Rehabilitation

Centre’s

Constructing

-Improving the Physiotherapy Profile

-Education Sessions

- Consultant Presentation

-Departmental Lead and Financial Divisional

Director Support

-MDT based Focus Groups

Requirements

Resources



-Local Visits to Prosthetic Limb Centre’s

-Insight into local Amputee Hubs and

Prosthetic Limb Centre’s Services

Implementation- Leading Change Amber

“Elective patients should be seen in a pre-assessment amputation to

optimise medical co-morbidities and to plan post operative rehabilitation”

Requirements

Resources

Constructing Implementation


Converted to Green by:

-Stronger Links with Prosthetic Limb

Centre’s

-Wheelchair provision

-Pre-op Occupational Therapy

-Improved relationships with consultants

-Insight into rehabilitation potential

Implementation- Leading Change Red

“The decision to undertake a major amputation should be made by a

multidisciplinary team (MDT)”

“When it is possible to choose the level of amputation, the physiotherapist should

be consulted in the decision making process regarding the most functional level of

amputation for the individual”

Requirements

Resources



Converted to Amber by:

-Improved Physiotherapy Profile

-Daily Ward Rounds

-Visit to Local Prosthetic Limb Centre’s

Implementation- Leading Change

Red

“Involvement in producing protocols followed by the MDT”


-Focus Groups and New Amputee Pathway

-Financial Director for Vascular- sourced

Compression Socks

-Day 1 Referral to Local Prosthetic Limb

Centre’s

Requirements

Resources



Implementation- Leading Change Green

“Physiotherapy commences from day 1 and to including exercise, oedema

management and use of early walking aids”

Amber

“A structured exercise regime should be started as early as possible”

“Within the MDT the role of the Physiotherapist involves compression therapy”

Requirements

Resources




-Physiotherapy Review Day 1

-Daily Exercise Therapy and Vascular

Exercise Class once Weekly

-Ward based Compression Therapy


“Rehabilitation programmes should include education on preventing falls

and coping strategies”

Green

“There should be prompt access to a local amputee rehabilitation team

including early mobilisation and physiotherapy”

Requirements

Resources




-Education Falls Classes

-Regular Risk Assessments

-Routine on/off floor practice

-Built stronger links with local prosthetic limb

centre’s


“For patients undergoing major limb amputation, planning for rehabilitation

and subsequent discharge should commence as soon as the requirement

for amputation is identified”

“There should be a continued discharge planning home, or to an appropriate

facility”

Requirements

Resources




-Visited Local Prosthetic Limb Centre’s

-Education with Vascular Doctors

-Education to patients regarding realistic

expectations and goals


Requirements

Resources


Outcomes and

Success

-Demonstrates the reduction in length of stay and improved TCI admission

following the implementation of NCEPOD guidelines to UHB Service

S O N D J F Mar Ap M Ju Jul Au S


Requirements

Resources


Outcomes and

Success

-Reduction in complaints

-Improved patient satisfaction and

recommendations of the service

-Improved moral and staff satisfaction

-Business Case: Recent Success and

Formation of Potential Band 7, 6 and 3

Positions

Onward Plan- What next?

Short Term:

-Ongoing development and improving links

with local in-patient amputee centre’s

-Improve volume of therapy classes during

week to improve functional outcomes

-Continue to build on physiotherapy profile to

ensure that all elective amputee patients level

of amputation are discussed prior to surgery

Long Term: -Business case to secure a Permanent Team Lead in Vascular, Full Time

Senior and Assistant at UHB

-Amputee Co-coordinator

-Ongoing development into intermittent claudication and exercise therapy

Conclusion

-Demonstrated how a service can be reviewed

-Change can be implemented with patience and close MDT working

-Demonstrated improved patient experience and outcome

-Impacts an improved service can have on length of stay

Key Message:

The Therapy Vascular Service at UHB are proud of what has been achieved

and are proof that it can be done without any additional staff, funding or

resources

Although additional staff is always helpful, a service can be changed with a

little bit of innovation, time and patience!

References Johannesson, A., Larsson, G.U., Ramstrand, N., Lauge-Pedersen, H., Wagner, P. and Atroshi, I. (2010) Outcomes of a

standardized surgical and rehabilitation program in transtibial amputation for peripheral vascular disease: a prospective

cohort study. American Journal of Physical Medicine and Rehabilitation, 89(4)

Nawijn, S.E., Van Der Linde, H., Emmelot, C.H. and Hofstad, C.J. (2005) Stump management after trans-tibial amputation: a

systematic review. Prosthetics and Orthotics International, 29(1), 13-26

NCEPOD, (2014) National Confidential Enquiry Into Patient Death and Outcome. Retrieved from

http://www.ncepod.org.uk/2014report2/downloads/Working%20Together_FullReport.pdf

NICE, (2012), Lower limb peripheral arterial disease. NICE clinical guideline

NICE. (2015). Lower limb peripheral arterial disease overview. Retrieved from file:///D:/Users/Student/Downloads/lower-limb-

peripheral-arterial-disease-lower-limb-peripheral-arterial-disease-overview.pdf

Norgren, L., Hiatt, WR., Dormandy, JA, Nehler, MR, Harris, KA and Fowkes FGR on behalf of the TASC II Working Group

(2007), Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II), Journal of Vascular Surgery,

45 (1) S5A – S66A

Van Velzen, A.D., Nederhand, M.J., Emmelot, C.H. and Ijzerman, M.J. (2005) Early treatment of trans-tibial amputees: a

retrospective analysis of early fitting and elastic bandaging. Prosthetics and Orthotics International, 29(1)

Wong, C.K. and Edelstein, J.E. (2000) Unna and elastic postoperative dressings: comparison of their effects on function of

adults with amputation and vascular disease. Archives Of Physical Medicine And Rehabilitation, 81(9), 1191-1198

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