Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators

Abstract

Background: Implementing evidence-based clinical practice guidelines (CPGs) requiring multidisciplinary efforts for relatively small clinical populations such as people undergoing lower extremity amputations, may present special challenges. People with chronic vascular diseases face wound healing and mobilization challenges that delay rehabilitation and hospital discharge. Lower extremity amputation protocols (LEAP) including postoperative limb dressings and early mobilization improve healing, functional outcomes, and reduce hospital lengths-of-stay—but require multidisciplinary coordination. The purpose of this study was to identify barriers and facilitators to implementing a multidisciplinary evidence-based LEAP for postoperative rehabilitation after amputation. Methods: This cross-sectional organization and provider-level study included a convenience sample of 238 multidisciplinary professionals from an urban medical center. An anonymous survey, developed using the Theoretical Domains Framework, explored barriers and facilitators in the knowledge, clinical skills, and personal/contextual domains. Analysis was descriptive with barriers rank ordered. Results: Clinicians responded from medicine (17.3%), nursing (16.0%), prosthetics (5.8%), physical therapy (36.0%), occupational therapy (24.0%), and recreational therapy (0.9%). Self-rated knowledge was low: 93.3% were unfamiliar with amputation rehabilitation CPGs and 60.9% were unfamiliar with problems delaying hospital discharge. Self-rated clinical competence was low corresponding to minimal reported experience with post-amputation limb wrapping or early mobilization. Potential barriers included unfamiliarity with the evidence, limited clinical training and confidence, insufficient patients, and inadequate interdisciplinary communication and coordination. Facilitators included clinician readiness to change and knowledge of early mobilization evidence. Conclusions: Identifying barriers and facilitators led to provider and organization-level recommendations organized using the behavior change wheel to consider the capability, opportunity, and motivation domain functions. An automated multidisciplinary referral system with standard order set emerged as a proximal strategy to potentially affect all three domains and multiple implementation mechanisms while leveraging clinician attitude may provide a path towards LEAP implementation.