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Part 1:
Introduction"She heard that you were going to be here today. We drove all day to get here. They said that they would cut off her leg, that there was nothing else to do. Doctor, isn’t there something that you can do?"
This translation from native tongue is from a recent Operation Desert Foot screening clinic held on the Navajo Reservation in Window Rock, Arizona. The patient was over 80 years old, although no one was really sure of her exact age, and had been told that her swollen leg needed amputation. Her daughter had driven all day in the blistering sun to bring her mother to our screening clinic.
After a careful history, examination and vascular testing, utilizing the UMA oscillometer to detect arterial blood flow, the diagnosis was narrowed down to severe degenerative joint disease, treatable through a combination of surgical and medical intervention. She was not a candidate for amputation and was spared the operation, for which her family smiled and thanked us.
From our point of view, the two days spent in the hot Arizona sun examining patients on our hands and knees, having unbathed feet in our laps for examination, with some of the screeners suffering from gastrointestinal distress from the local food, was suddenly worth it. We had made a difference!
This excerpt is from a journal detailing the type of community outreach inherent in the Operation Desert Foot Program (ODF) which is based at the Carl T. Hayden Veterans Administration (VA) Hospital in Phoenix, Arizona.
ODF has undertaken six mass patient screenings, in a variety of patient populations, since November 1994. ODF clinicians will screen anyone wishing to access services and are willing to go almost anywhere to screen and train people in ODF processes and ideas.
A programme like this raises many questions, which people constantly ask:
- What is Operation Desert Foot?
- Why does it exist?
- Why should I care about amputations?
- Why do you do this?
This article aims to address some of these questions.
Background: Operation Desert Foot
What is Operation Desert Foot?
Operation Desert Foot (ODF) is a multidisciplinary collaborative process for the identification of and intervention in lower extremity amputation. Through the involvement of different disciplines in our hospital, we are able to provide a truly holistic approach to the devastating problems surrounding major amputation.
A major factor contributing to amputation is lack of awareness. If you don’t know that you have a problem, you cannot fix it.
This is the underlying premise behind the Desert Foot process. The identification, intervention and ongoing care and education of the high risk population is the primary concern.
The short and long term goals of the ODF process include:Identification of those patients who are recognized as being at high risk for amputation:(algorithm available)
- protocol for screening triage
staff and patient education in our screening methodologies provision of screening clinics (in hospital) along with mass community and outpatient screenings. Development of a treatment regime for intervention and maintenance of the high risk patient:
- High Risk Foot Clinic - joint vascular and podiatric clinic
- vascular reconstructive surgery - distal bypass and limb salvage procedures
- podiatric reconstructive surgery and outpatient clinic maintenance
- easy referral process for high risk patients and potential high risk patients.
Development of statistical evaluation processes:
- database for hospital-wide identification of the high risk patient
- epidemiological studies (ongoing)
- continuous evaluation of process.
Development and maintenance of communication tools to be used for staff and patient education in diabetes and the problems associated with amputation:
- staff and patient newsletters - communication tool
- national training programme for amputation prevention.
Psychological and rehabilitative support:
- development of Amputee Support Team - medical psychology, surgery, prosthetics and rehabilitation medicine;
- Amputee Support Group - initiated and maintained by Price Locke, PhD;
- medical psychology - initial preoperative evaluation and postoperative evaluation available for new and prior amputees.
Why Care About Amputations?
Several co-morbidity factors have been identified in relation to major amputation. Diabetes has long been recognised as a major contributing factor. Most people know someone who has diabetes or a family history of diabetes and one of the major contributing factors or complications such as amputation. Depending upon where you live and your ethnic background you, or someone you know or love, may be prone to developing diabetes and the risk of amputation.
Within five years of a major amputation, 50% of individuals have died, not to mention the tremendous impact on the physical, psychological, social and functional capacities of these people and their families and loved ones.
Fifty percent of lower extremity amputations performed in the United States are for the complications of diabetes.
Some of the other risk factors that we are currently researching with the statistical assistance of Marty Mellstrom, PhD. in the Office of Organizational Performance Improvement at the Phoenix VA, are personal or family history of cardiac disease, renal failure, cancer and smoking (current or past history).Preliminary data from four of our mass screenings:
Total patients screened 775 Diabetes (personal) 12% Diabetes (family history) 26% Smoking (current history) 56% Cardiac disease (personal) 14% Cardiac disease (family history) 26% Screening results : at risk status for amputation ***
*** AT RISK status determined by ODF protocol using the UMA oscillometer measuring arterial blood flow
Ischaemic (high risk) 11% Low normal (moderate risk) 28% Normal (minimal risk) 58% High normal (aneurysmal) 3% All patients screened received copies of their screening forms to take with them. All were advised to show these results to their next health care providers and to have copies placed into their charts.
Patients with ischaemic and low normal risk status were advised to seek medical intervention with recommendations for treatment and intervention procedures stated on their screening forms.
Contact telephone numbers were listed on the bottom of the screening forms as reference for the participants’ health care providers.
One participant from a screening in August 1995 returned in June 1996 to show the excellent results from vascular surgery performed as a result of her high risk status which was discovered during the screening. If left untreated, she would have gone on to amputation.
How Do I Get Started?
Through the ODF process, we have discovered a simple, cost-effective and viable approach that can be undertaken by virtually any health care or community outreach facility with minimal expense, and utilising staff already in place. The main factors contributing to the success of this and any programme are the identification of willing and able workers and the development of a viable, realistic programme time frame.
Why Do We Go To All Of The Trouble For Just A Few?
The answer lies in the reason why anyone becomes involved in health care. It is because we want to be able to make a difference and somewhere along the way we all have this desire. You may be first aware of it during a clinical experience, sitting up with a sick or dying loved one or hearing a child whimpering in the night. If we can make a difference, in even one person, that is enough.
Part 2:
Introduction
This Operation Desert Foot Program (ODF) sounds interesting. I would like to have something like this at my facility. Where do I begin? Can it be taken out into rural areas with direct application to the people? Can it run out of a clinic setting or does it need to be based out of a hospital setting? What kind of organisation is needed to run it? Can nurses/nurse practitioners run it? What kind of back-up support is required? How do I get everyone to work together? Where do I start first?
Getting Started
It is best to start at the beginning. Short term and long term goals that are realistic in both timeframe and resource utilisation need to be identified and set. Several basic components need to be addressed during the goal-setting phase:
- identification and tracking the high risk for amputation patient - screening programmes, patient database;
- intervention strategies - treatment modalities (feasible with your current resources and staff) and speciality referral bases;
- communication and ongoing education - staff and patient education and communication tools (newsletters, classes);
- systematic data collection and statistical analysis for programme evaluation.
Ingredients for Success
What makes the programme work?
- attitudes?
- skills?
- relationships?
- resources?
All of these factors are important throughout the evolution of your programme. Select colleagues who you can work with and who are willing to work. You must be highly motivated, even passionate about your programme. You must believe in what you are doing to convince others to join your team. Your team members need good clinical skills and access to appropriate resources including medical supplies, manpower and referral bases. Collaborative multidisciplinary teams that can function well together are an option. Beware of the tendency to spread goal-setting too broadly. Start small. Be satisfied with small victories. Establishing your core team of workers within one to three months is an excellent initial short term goal. Do not try to do everything yourself. Learn how to delegate responsibility. Above all, remember that you can do this. It will work.
Understanding the Problem
How can you plan intervention if you are unsure about the causes and implications of the disease process(es) which you are targeting? It is imperative to have a basic grounding in the underlying disease processes and their complications that contribute to amputation. The long term effects of diabetes (neuropathy and accelerated arteriosclerosis, podiatric deformities such as hammer toes, ulcers and open foot lesions, peripheral vascular disease resulting in ischaemic lower extremity circulation) are some of the underlying causes of amputation. Unfortunately, detailed study of some of these diseases and their symptomatic sequelae is often lacking in training programmes.
Differentiation between venous and arterial ulcers and the importance of this distinction as an integral part of a patient’s treatment plan is often omitted from training programmes. In order to provide a more adequate baseline knowledge of these contributory disease processes, it would be necessary to discuss them in length which is not possible in this article. However, I will endeavour to provide this information in a third article in this series at a later date.
Suffice to say that a basic understanding of the contributing factors in lower extremity amputation is a prerequisite before planning how to proceed with your programme.
Identifying Your Resources
The areas of personnel, physical plant (facility location), feasibility mini-study, access to estimated resources (medical equipment) and proposed costs need to be identified. Can the programme be taken out into rural areas with direct application to the people? Can it run out of a clinic setting or does it need to be based out of a hospital setting?
With respect to facility location, your programme does not have to be based out of a hospital setting. It can be run out of a rural health care facility, a clinic or even a physician’s office, provided that you have adequate staffing and treatment space to support your intervention modalities. A bare minimum that your programme will require is:
- a location where a co-ordinator can run the programme and maintain a continuing database of patients;
- a location for clinic - office patient visits/treatments;
- access to surgical interventions - if you are in a rural clinic setting, you may need to collaborate with outside resources that can provide the surgical interventions.
ODF is run out of the Phoenix Veterans Administration (VA) Hospital. Some advantages of basing this type of programme in a hospital setting are:
- availability of clinic space;
- availability of patient scheduling staff via main scheduling system;
- access to vascular and podiatric surgery and residency programmes;
- access to physical space for the co-ordinator’s office;
- multidisciplinary involvement in programme development and implementation;
- a patient population accustomed to accessing the VA system for health care.
Your programme does not have to be this involved. Remember that this is your programme; you can make it whatever you want it to be.
What kind of organisation is needed to run a programme? A health care management organisation (HMO)? The programme can be based in an HMO setting as long as the HMO will provide ’ease-of-access’ to any ancillary services you deem necessary for your programme.
Can nurses/nurse practitioners run the programme? My answer to this question is both "yes" and "no". Yes, nurses/nurse practitioners can co-ordinate and ’run’ the program, provided that adequate physician back-up is readily available. I can envisage such a programme based in a rural setting, for example a remote location in New Zealand which provides services to some of the local people in that area. Following along the lines of the ’barefoot doctors’ programmes, nurses can be provided with additional training in triage of the high risk for amputation patient. Once patients have been triaged, they can be relegated to pre-established treatment modalities sanctioned by the health care organisation underwriting these services. There are certain clinical situations where the nurse will need to consult with physicians immediately during the triage process. Thought needs to be given to this problem before the nurse is out in the field and faced with an emergency or questionable situation.
Know where your referral bases are and how to use them. This is where ’networking’ comes in. Every day you are in contact with numerous people and resources who you can call on for assistance. Learn the best way to approach them, the best time to approach them and what you can expect. Multidisciplinary staffing is an advantage. Not all staff need to be clinically based. A clerk/receptionist can maintain the database of patients identified as high risk. Volunteers can help in the clinics, make telephone calls and provide secretarial services. Most hospitals and HMOs have nursing staff who are on ’light-duty’ because of illness or accident. These nurses can be used to help in data collection, chart review or data input for the high risk patient database.
Treatment Intervention Strategies
What are you going to do once high risk patients have been identified? Firstly, you need to identify those patients who are at risk for amputation. Some physicians use neuropathy testing to screen out neuropathic patients. The most common form of neuropathy which contributes to amputation is from diabetes resulting in loss of normal nerve sensation, generally in the feet. Monofilament testing is a standard screening method for neuropathy. However, it cannot be used on non-communicative or comatose patients or those with spinal cord injury. At ODF, we advocate a combination vascular-podiatric screen utilising the oscillometer which measures the pulsatile wave flow form of each systolic contraction of the heart, and a careful podiatric visual and tactile examination of the feet and lower legs. This screening method is portable, rapid (five to 20 minutes per examination), cost-effective and can be used in a mass patient screen setting.
Once you have identified those patients at risk for amputation, you will need to track them in a database and develop some means of identifying them to other providers. In our hospital, anyone who has been identified as being at high risk for amputation has a ’flag’ on the computer stating "WARNING! THIS PATIENT IS AT HIGH RISK FOR AMPUTATION!" We do this to notify other health care providers of this patient’s condition.
What are you going to do once high risk patients have been identified? How can you access these services if you cannot provide them yourself? You must decide what treatment modalities you will provide:
- wound care clinic?
- referral to podiatric clinic?
- what will you need to refer out?
Each programme will be individualised according to availability of staffing and resources.
Communication and Ongoing Education
Public relations and advertising play a role here. Providers and patients cannot make use of your programme if they are unaware of its existence. Supplement existing patient education programmes with diabetic and non-diabetic risk stratification. Initiate patient education programmes if needed. Clinical training in risk stratification for patient identification may be warranted as well as accessibility to your clinic area. Education in your programme goals can be worked into established staff education programmes. Let staff members know how they can help you. Let them know that they are a very important part of the success of your programme. Frequent recognition and thanks for patient referral will be required to keep up the momentum. Everyone likes to be praised for their efforts.
Summary
In summary, be clear about short term and long term goals. Know and understand the disease processes you are working with. Become comfortable in your risk triage methods and treatment interventions. Be pleased to start small and work up to your ’ideal’ programme. If you are motivated enough to start such a programme, you will be successful. We at Desert Foot started with four team members from four different disciplines in November 1994. It has taken us almost two years to progress to the current stage. We have been happy with each small victory, be it at someone’s toe, foot, or innocent-looking blister. This is your programme. Make it what you want it to be.
