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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
ConstructingImplementation
Outcomes and Success
-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
ConstructingImplementation
Outcomes and Success
Resources
-Access to data
-NCEPOD Guidelines and expectations of
a major amputee service
-Access to MDT
-Financial Director for the Vascular
Service
Requirements
Resources
ConstructingImplementation
Outcomes and Success
-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
ConstructingImplementation
Outcomes and Success
-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
Outcomes and Success
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
Constructing Implementation
Outcomes and Success
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”
Converted to Green by:
-Focus Groups and New Amputee Pathway
-Financial Director for Vascular- sourced
Compression Socks
-Day 1 Referral to Local Prosthetic Limb
Centre’s
Requirements
Resources
Constructing Implementation
Outcomes and Success
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
Constructing Implementation
Outcomes and Success
Converted to Green by:
-Physiotherapy Review Day 1
-Daily Exercise Therapy and Vascular
Exercise Class once Weekly
-Ward based Compression Therapy
Implementation- Leading Change Amber
“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
Constructing Implementation
Outcomes and Success
Converted to Green by:
-Education Falls Classes
-Regular Risk Assessments
-Routine on/off floor practice
-Built stronger links with local prosthetic limb
centre’s
Implementation- Leading Change Amber
“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
Constructing Implementation
Outcomes and Success
Converted to Green by:
-Visited Local Prosthetic Limb Centre’s
-Education with Vascular Doctors
-Education to patients regarding realistic
expectations and goals
Outcomes and Success
Requirements
Resources
Constructing Implementation
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
Outcomes and Success
Requirements
Resources
Constructing Implementation
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