The goal of Burke's Amputee Rehabilitation Program is to speed your healing, restore your confidence and provide you with the skills to return home and live as independently as possible after an amputation.
The two-phase program begins immediately following surgery. In the first phase, focus is on pain control, healing, emotional support and preparing the limb for prosthesis. A prosthetist—a professional who assesses, designs, measures, fabricates and fits various types of upper and lower extremity prostheses—is available at Burke through the amputee rehabilitation program. The prosthetist may be involved in the education and training in regarding the use, care and function of the prosthesis during phase II, which can be done on an inpatient or outpatient setting depending on the patient's level of function.
Rehabilitation nursing and access to a physician is available 24 hours a day, seven days a week. Each patient will receive a minimum of 3 hours of therapy a day, 5 days per week, generally Monday through Friday, and a sixth day of therapy, generally Saturday, for 1-2 hours. Once your artificial limb has been constructed and fitted, you will return to Burke for intensive physical and occupational therapy, to ensure maximum mobility and independence in your daily activities.
The interdisciplinary team consists of you, your family or caregiver, physician, nurses, therapists and social worker/case manager. Under the direction of Karen Pechman, M.D., a specialist in physical medicine and rehabilitation, the professionals on the team will assess your medical and rehabilitation needs and work with you to establish your individual goals. In close collaboration, the team designs and implements your treatment program. Throughout your treatment, the entire team meets formally once per week to discuss your progress. Family members and caregivers are encouraged to attend and participate in treatment sessions and patient care as appropriate.
Cultural and religious needs are respected for each patient by the entire team. Accommodations to the patient’s schedule, dietary needs and requests, and the provision of appropriate equipment are provided to enhance the patient’s experience and support full participation in the rehabilitation program. All staff members participate in annual cultural diversity and sensitivity training.
Scope of Services
The Amputee Team is committed to ensuring that each individual’s needs are addressed by:
- Providing rehabilitation through an interdisciplinary approach that emphasizes communication, collaboration and cooperation.
- Lessening limitations of activities by focusing on the individual’s capabilities and utilizing compensatory strategies and devices.
- Providing the highest quality, patient focused rehabilitation.
- Removing or lessening restrictions to participation in life situations to the extent possible.
- Providing counseling to the individual and family and/or caregiver on alternative possibilities for life participation when necessary.
- Preparing the individual, family and/or caregiver to make the transition to the next stage of the rehabilitation process.
In 2014, the Amputee Program:
- Served 11 patients ranging in age from 32 to 93 years old, who suffered from an amputation.
- Discharged 73% of our patients to home to continue receiving therapy at home or in an outpatient facility.
Within the scope of the program, patient evaluation and care planning are designed around traditional medical disablement models. These models assess three levels of dysfunction which stem from the patient’s admitting diagnosis (pathology).
Impairments: Weakening, damage, or deterioration of function within a specific component of the musculoskeletal system, especially as a result of injury or disease.
Examples: Decreases in strength, active range of motion, passive range of motion, cognition, balance, and/or activity tolerance along with increases in pain and/or edema.
Activity Limitations: The inability to perform a specific task as a consequence of the aforementioned impairments.
Examples: Difficulty with ambulation, stair negotiation, dressing grooming or self-care.
Participation Restrictions: The cumulative effect of impairments and activity limitations on the ability of a person to participate in life roles.
Examples: Inability to perform duties as a parent, caregiver, employee or participant in social and leisure activities.
In addition to these medical characteristics identified through the utilization of the disablement model, social barriers to discharge must also be assessed. These factors are societal and environmental by nature and often times they impact the delivery of care and the determination of services rendered upon discharge.
These barriers can include but are not limited to:
- Limited Transportation
- Inaccessible Living Environment
- Limited Caregiver Support
- Insurance Benefits / Finances
The initial assessment performed by each discipline should capture the patient’s most accurate burden of care via Functional Independence Measure (FIM) scoring. Based upon the results of the initial evaluation, each interdisciplinary team member will create a patient specific plan of care designed to meet each patient’s specific goals. The team will formally meet twice weekly to discuss discharge planning and treatment progress.
Discharge planning begins on the first day of the patient stay with the discussion of follow-up services being initiated by social work. The combination of the patient’s medical, physical and social circumstances will dictate the most appropriate discharge environment from the services available.
Upon admission each patient will be evaluated and cared for by members of the interdisciplinary team. The interdisciplinary team make up is determined by patient assessment, medical needs, rehabilitation needs and predicted outcomes. Based upon individual patient needs, the team may be comprised of individuals from, but not limited to, the following disciplines:
Support services available include:
- Medical consultation (Psychiatry, ENT, Dermatology, Podiatry)
- Pastoral services
- Complementary therapy
- Laboratory services
- Prosthetic and orthotic services
- Pharmacy service
- Respiratory therapy
- Driver assessment and education
- Medical nutrition
The ultimate function of this team is to create the most appropriate patient specific plan of care. The team’s goal is to help the patient achieve the highest level of independence while setting in place a discharge plan that keeps the patient progressing within the healthcare continuum. In doing so, the team aims to minimize impairments, reduce activity limitations, lessen participation restrictions and achieve predicted outcomes. The ideal outcome is an independent discharge to the community with follow-up outpatient services concurrently arranged.
The amputee program offers two phases of rehabilitation. The pre-prosthetic training phase or postoperative phase is the period when the patient gains independent mobility and management of the residual limb. During this post-operative healing period, independence is achieved without the use of a prosthesis. The prosthetic training phase occurs once the residual limb has healed and a prosthesis has been fit. The patient receives comprehensive training to achieve independence with the use of a prosthesis for all mobility and activities of daily living.
The following are rehabilitation related admission criteria as set forth by the attending physicians for the amputee population.
Pre-prosthetic Training Phase:
1) Recent amputation (within 4 weeks) of lower extremity. (AKA, BKA, unilateral, bilateral, symmetrical or asymmetrical)
2) The patient has the capacity and potential to become a functional ambulator with prosthesis.
3) The surgical site is clean, dry, intact and without breakdown.
4) No lower extremity contractures.
5) Alert and oriented x 3 without the need for physical or chemical restraints.
6) No active history of drug and alcohol abuse.
Prosthetic Training Phase:
1) Patient must meet all above criteria.
2) Patient must be cleared to progress to prosthetic training by physician with regards to skin integrity, safety and medical status.
3) If one or any of the above criteria are not met, the patient may still be considered for admission. However, admission will require approval of a Burke Rehabilitation Hospital attending physician.
The appropriate disposition following discharge requires planning, preparation and counseling by the interdisciplinary team from the date of admission until return to the community. Upon first contact, social work is to initiate the discussion of follow-up services. The patient is provided general information regarding length of stay for their specific diagnosis as well as the preferred venue for follow-up services upon discharge.
The following are the intended discharge environments in order of preference:
- Home with outpatient services
- Home with home care services
- Sub-Acute (Short-Term) Rehabilitation in a Skilled Nursing Facility
- Long-Term Placement in a Skilled Nursing Facility
Following the evaluation by each discipline, team conferences are held during which each patient is discussed. All members of the interdisciplinary team for that patient are to be present. Following collaborative discussion, the team’s recommended date of discharge and disposition are conveyed to the patient via social work. The patient and family have the right to participate in all discussions regarding discharge and do so at this time. Once the plan is set, the patient is asked to select a provider for follow-up services. The patient is provided the names of agencies along with all necessary contact information.
Prior to discharge, patients will be informed of the durable medical equipment (DME) recommended for discharge. If the patient owns the required equipment they are strongly encouraged to bring it to therapy for adjustment and evaluation. If not, patients are to be educated regarding insurance coverage for DME and all necessary equipment should be ordered. This equipment should be received by therapy, evaluated and adjusted appropriately prior to discharge.
Prior to discharge, a re-evaluation will be performed to capture the patients’ functional status and burden of care again via the FIM instrument. If the patient is to be discharged home and is not independent with the performance of a necessary task, family or caregiver training will be undertaken. This should yield an end result of the patient in combination with caregiver support, being independent with all necessary functional tasks.
Patient and Family/Caregiver
Patient and caregiver education is the first priority and is considered to be ongoing. Each interaction with therapy and social work should serve as educational. In addition to this goal, education classes and materials may be provided. Education will be diagnosis specific with a focus on functional independence, adherence to precautions, progress and well being. Dependent upon need, individual sessions may be dedicated to family training, during which a therapist will train family members in the appropriate provision of care and assistance for mobility, self care or exercise performance.
Educational classes will be held for patients and will be diagnostically exclusive. These sessions will be used to provide educational materials, encourage group discussion, and group problem solving and serve as support sessions.
Staff clinical education will be viewed as being of equal importance. In house interdisciplinary and discipline specific educational in servicing will occur regularly. Staff will be encouraged and afforded the opportunity to attend continuing education
Burke Rehabilitation Hospital utilizes an electronic medical record (EMR) which concurrently displays comprehensive charting from all disciplines. The disciplines that contribute by charting in the EMR include physicians, nursing, social work, physical therapy, occupational therapy, speech therapy, psychology and recreational therapy. In order to ensure that patient related information is current, complete, and compliant with regulatory bodies the following guidelines are in place:
Upon admission, each patient will be seen by nursing and an attending physician. Within 24 hours of admission, the patient will be screened and evaluated by physical therapy, occupational therapy and social work. The initial evaluation documentation should be completed within 24 hours of admission. The initial interdisciplinary evaluations will include FIM scoring, which will be utilized to determine the patient’s case mix group by identifying the highest burden of care demonstrated during the initial 48 hour period. The disciplines that contribute to FIM scoring are nursing, physical therapy and occupational therapy.
Daily charting can include, but is not limited to, recounting patient interactions, therapeutic interventions and patient’s response to treatment, patient progress, pain levels and discharge planning. Documentation supporting these interactions should be completed the day the service is rendered. Any changes or addenda required following the signing of the note in the electronic medical record must be done so according to documentation policy and procedure.
If a patient’s length of stay should exceed 7 days, then a re-evaluation should be performed. Objective data collected on the initial evaluation should be recaptured and achievement of short-term goals should be analyzed. If the patient’s length of stay is expected to exceed another seven days, then new short-term goals should be set. If not, the long term goals will become the target.
Following interdisciplinary rounds the social worker will present the patient with their recommended date and follow up services. The patient is provided with resources and provided individualized education. This information is charted, and is re-charted if the date or discharge disposition changes.
A discharge evaluation will be performed no more than 48 hours prior to discharge, regardless of discharge disposition. Similar to initial and re-evaluations, objective data is collected and achievement of long-term goals is analyzed. Other information to be included is discharge disposition, recommended equipment usage and level of supervision required.
To monitor quality of care and performance, FIM scores are again captured at discharge. In the case of a patient being transferred to an acute care hospital, an interim discharge will be performed. This will capture discharge FIM’s for the patient the day they were transferred. If they return within a 72 hour window they will be re-evaluated and continue the current stay. If the absence is longer than 72 hours, a new stay is begun with a complete set of initial evaluations being performed.
Evidence Based Practice
Evidence based practice (EBP) is an approach which tries to specify the most appropriate care trends and assist the clinician in appropriate decision making. In the health care area, it encourages professionals to use the best evidence possible or the most appropriate information available, to make clinical decisions for individual patients. EBP promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments and facilitate the highest quality of care.
Our Program will utilize various methods to incorporate evidence based practice which include but are not limited to:
- Carefully summarizing research.
- Making research summaries readily accessible.
- Educating professionals in how to understand and apply research findings.
- Encouraging professionals to focus more on available evidence.
The Commission on Accreditation of Rehabilitation Facilities (CARF) has set forth guidelines for specialty and non specialty Amputee programs. In accordance with CARF standards for facilities which provide care to patients post amputation (however do not seek specialty certification), the following services are provided as appropriate. These services are ordered by the physician as necessary and carried out by nursing, occupational therapy, physical therapy, psychology and prosthetics / orthotics.
Education and Support Services
- Limb loss education
- Peer support and Family / Caregiver support
- Prosthetic options and fitting
- Psychological services
- Sexual counseling
- Chemical abuse or dependency counseling
- Smoking cessation
Medical/ Therapeutic Management
- Diabetes management
- Pain management
- Preventive foot and limb care
- Cardiovascular management
- Risk reduction
- Wound care
- Skin care
- Prosthetic and Orthotic services
- Environmental modification
- The provision of and training with DME