Introduction of RRD and INTERIM programs Tony Fitzsimons NSWPAR Meeting 13/3/09 ISSUES AND SOLUTIONS

RRDs & INTERIMS  Summary - Main Issues  Surgeon resistance  Split service – expertise off main campus  (moved at the same time we were trying to start the RRD protocol)  No specialist amputee physio position  Prosthetists come up from Port Kembla twice a month (extra visits for casting / fitting interims can be negotiated).

1. Pre-op Consults  Physio: 2/9 amputations done at Nepean.  Solutions:  Review of surgical lists  Raise profile with vascular team (see section 3)

2. Surgeon Resistance  Why:  Perceived loss of control over decision making  Previous bad experiences, mainly with RRD ’ s.  Did not like being told “ apply RRD or your patients do not qualify for interims ”.  Outcomes:  Are we getting full buy-in?  Not informed pre-operatively.  RD ’ s not generally applied in theatre  ?effectiveness.

2. Surgeon Resistance  Solutions (so far … ):  Reinforce - decision making by surgeon.  Recruitment of multiple allies: Rehab Specialists, Network Directors, ALS, approach surgeons from Westmead.  Use RD rather than RRD until t/f to rehab:  Orthopaedic senior to apply.  Previous bad experience was with RRD ’ s.  Less need for staff education on acute wards on monitoring & fit

2. Surgeon Resistance  Solutions (still to go … ):  Provide data / evidence of effectiveness.  Raise profile of physio dept with vascular team.

3. RD / RRD Program  Problems:  Not applied in theatre (3/7 TTA) – not informed, last on list, surgeon preference, etc.  Rehab / amputee staff off main campus.  Poor understanding of goals of RD/RRD program.  Inconsistent technique of application – several RD ’ s have fallen off!  Few staff have skills / knowledge to make RRD ’ s – delays in conversion.  Inability to apply RRD ’ s properly on ward – patient and nurses  Incomplete data collection on acute side – data not showing what we know in practice is happening  Outcomes:  Lack of evidence of effectiveness.  Leads to problems with interim fit due to poor management of oedema

3. RD / RRD Program  Solutions (so far … ):  Ortho senior applies majority of RD ’ s in absence of rehab team (superior plastering skills).  Update inservices for PT ’ s who are doing RD ’ s on the main campus.  Posters / file inserts for ward.  Copy of our stump measurement sheets sent to main campus.  Update of Quality data collection sheet – increase focus on early management & variations from ideal.

3. RD / RRD Program  Solutions (still to go … ):  Review manufacture protocols (more pictures, clearer instructions).  Nurses encouraged to call PT ’ s to the Rehab ward for advice / checking application of RRD ’ s.  Increase patient education / shift responsibility for donning to the patient, away from staff.  Further regular inservices to maintain staff manufacturing skills, and stop “ Chinese whispers ”  Regular inservices to nurses (eg each time an RRD is used).  Education to each new vascular registrar.  Create careplans and pathways for variations / troubleshooting (including bandaging techniques for early end of RRD program).  Physio on rehab ward rounds for increased input on wound / stump management / RRD program.

3. RD / RRD Program  Solutions (long term … i.e. when we move back):  Rehab physio to take over acute management  Physio ’ s with the skills & knowledge manage the full episode of care: acute  rehab.  Better / earlier troubleshooting and progression  Removes burden from ward PT ’ s who have other priorities.  Increased consistency of information / communication  Familiar faces  Raise profile – “ Amputee Physio team ”  Team expanded to include CNC and OT

4. Stump Management  Problems:  RD / RRD program  Varying levels of experience / skills in bandaging.  Late referrals to outpatient physio – some external referrals go to clinic, not to physio  delays, minimal time for us to get our hands on the patients.  Varying level of skills / knowledge / confidence to initiate oedema and scar management, manual or EPA modalities.

4. Stump Management  Outcomes:  Delays in interim fitting.  Formation of adhesions.  Oedema poorly controlled before casting for interim.  Interim socket quickly becomes uncomfortable and cannot be quickly replaced.

4. Stump Management  Solutions (so far … )  RD / RRD actions.  Solutions (still to go … ):  Increased staff education on stump management.  Raise physio profile with vascular team.  Amputee clinic referrals also forwarded to physio to screen for need for input prior to clinic appt.  Inservices to nurses, and encouraged to call for Physio to assist / demonstrate bandaging each time an amputee is admitted to Rehab ward.

4. Stump Management  Solutions (long term … ):  Rehab Physio to take over acute care – specialist team.  Increase Physio input at amputee clinics.  Increase skill base of grade 1 physio ’ s – at present not much skill base outside rehab senior staff  extend rotation in rehab

5. Interim Program  Problems:  Sometimes minimal stump / oedema management before casting (eg external referrals to clinic).  Delays in time from “ healed ” to fitting (temps = 3 days, interims = 11 days).  Specialist not always on site to write scripts for OP ’ s when not on clinic days.  Prosthetist located a couple of hours away.  Client ability to stand, tolerate socket pressures, or amount of oedema on day of fit can quickly change by day 2-3  interim needs socket and alignment changes.

5. Interim Program  Outcomes:  Can have an interim that requires modification (socket and alignment) but can take up to 2 weeks until next Prosthetist clinic to get adjustments made (no “ extra-clinic ” visits to turn an Allen key).  Interim socket cannot be replaced in short term – stuck with an uncomfortable socket until “ time ” has passed (3 months).

5. Interim Program  Solutions (so far … ):  Informal agreement – some physio ’ s can make minor alignment adjustments (has unresolved legal and TGA issues).  RD / RRD actions.

5. Interim Program  Solutions (still to come … ):  Education to Physio ’ s on how “ healed ” a stump needs to be in order to be ready (incl written guidelines).  Increased team input into wound status – prediction and agreement on timing of casting – plan ahead for “ extra-clinic ” visits by prosthetist.  Amputee case conference prior to clinic.  Interim scripts written in advance.  Tray a minimum period of physio involvement to manage oedema & wound / scar before casting.  Reinforce need to take stump measurements on acute side.  Formalise agreement on Physio ’ s ability to modify an interim, resolve legal issues.

5. Interim Program  Side effects?  Inability to trial components prior to prescription.  If management of interim prosthetic fit and alignment is completely removed from the physio, will there be a loss of skills and knowledge on monitoring and troubleshooting prosthetic problems by the Physio ’ s?  Less emphasis on prosthetic causes of gait abnormalities  Perseverance on attempting to fix patient causes, when a tweak to the alignment might fix the problem.  Less referral to prosthetist for adjustments, as issues not recognised.  Delays or wasted appointments as problems not identified and solutions take time to implement.  Risk to patient?

6. Ideal Interim Program  Reasonable period of stump / oedema management prior to casting.  Time from “ healed ” to casting minimised.  Time from casting to fit minimised  What is a reasonable time?  Who can do it – can accredited physio ’ s fit the interim?  Minimal time between identification of prosthetic problems and fixes:  What is a reasonable time?  Who can make fixes – packing, alignment?

6. Ideal Interim Program  If stump size changes significantly (beyond ability to pack it), quick replacement of socket  If stump shape is changing quickly because of use of the prosthesis, is it reasonable to have them off the prosthesis for 1-2 weeks again, while a replacement is made – turnaround time for replacement sockets?  Is there a minimum time before replacement allowed?  Should amputee be disadvantaged by having an ill- fitting (or no) socket for a period of time because of early management or service delivery problems?

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