Benefits of an Enhanced Recovery Pathway (ERP) for Lower Extremity Amputation Patients
Angela Sickels, Kory Dees, Charles A Banks, Zdenek Novak, Adam W Beck, Emily Spangler
University of Alabama at Birmingham, Birmingham, AL
BackgroundVascular patients undergoing major lower extremity amputation (LEA) have multiple comorbid conditions, putting them at high risk for postoperative complications. Here we sought to evaluate early outcomes after implementation of an Enhanced Recovery Pathway (ERP) for major (above and below-knee) amputation.
MethodsThe LEA ERP was implemented in February 2022 and included early structured patient education with physical medicine and rehabilitation team involvement, regional anesthesia, and early postoperative physical therapy. ERP patients (Feb 2022-July 2023) were compared to a recent historic cohort (non-ERP care Jan 2020-Feb 2022) and a retrospective analysis was conducted. Outcomes of interest included length of stay (LOS), mortality, revisions, and readmissions. Complication was defined as any medical or surgical deviation from the expected postoperative course. Stratified analyses were conducted by staged vs unstaged operation and amputation level. Results220 patients were in the non-ERP group and 152 patients received the ERP. The cohorts were similar in comorbidity rates. Surgical indication in the non-ERP group included: infection (45%), tissue loss (TL) (31.4%), acute limb ischemia (ALI) (13.2%), and rest pain (CLTI) (10.5%) while indications in the ERP group were: infection (25.2%), TL (28.5%), ALI (9.3%) and CLTI (37.1%), p<0.001. Rates of perioperative regional anesthesia utilization were similar (63.6% vs 64.9%, p=0.8). Complication rates were similar in both non-ERP and ERP patients (53.7% vs 52.3%, p=0.79).
Indications for patients undergoing a staged operation included: infection (52.5%), TL (17%), ALI (15.6%), and CLTI (14.9%) while indications for unstaged patients included: infection (27.8%), TL (37.9%), ALI (9.3%), and CLTI (25.1%), p<0.001. Staged ERP patients had lower rates of readmission and complications than staged non-ERP patients at 90 days. Staged ERP patients trended toward lower rates of revision to higher amputation, though this was not statistically significant. These differences between non-ERP and ERP care were not observed among unstaged amputation patients (Table 1). Examining below (BKA) and above knee amputations (AKA), ERP patients undergoing BKA had lower 90-day mortality than non-ERP patients. ERP patients undergoing AKA had a shorter postoperative LOS than non-ERP patients, otherwise no significant differences were observed (Table 2).
ConclusionAmong amputees presenting with a multitude of indications, urgencies, and levels of amputation required, we saw benefit from the implementation of an ERP among patients with staged amputations with reductions in complications and readmissions. Among AKA patients, a shorter postoperative LOS was observed with ERP utilization, and among BKA patients a lower 90-day mortality rate observed with ERP utilization. While effects of this ERP implementation were more heterogeneous compared to ERPs for other vascular procedures, ERP patients tended toward improved outcomes in multiple categories. The high complication rates across cohorts highlight the severity of illness affecting these patients and underscores the importance of perioperative optimization efforts.
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