Discharge management of the amputee

Original Editor - Barbara RAU

Top Contributors - Sheik Abdul Khadir, Admin, Kim Jackson, 127.0.0.1, Tony Lowe, Tarina van der Stockt, Simisola Ajeyalemi and Karen Wilson  

Introduction

Successful rehabilitation post-amputationrelies on the patient’s achievement of goals that were pre-determined by a multidisciplinary team (Multidisciplinary_management_of_the_amputee) and assessed through specific outcome measures (Outcome_measures_for_amputees). Successful rehabilitation is therefore intrinsicallylinked to effective discharge,which allows a patient to function optimally in his/her environment withthe necessary tools for proper management and self-care at home, inherent to the quality of life and empowerment of the patient. Because one can expect prosthetic usage to be altered or health status to change over time, timely re-evaluation of aforementioned outcome measures should be performed. However, there is currently no clear evidence in the literature supporting the optimal process for patients’ discharge following an amputation, or suggesting determinants for the management of patients post-discharge to maintain their independence through regular follow-up.

Discharge Determinants: WHO ICF Model

The patients’ expected level of functional independence will not only be influenced by their physical and psychological presentation, but by their social environment as well.

In fact, the WHO developed an international standard used to describe and measure health and function: the International Classification of Functioning, Disability and Health, commonly known as the ICF (International Classification of Functioning, Disability and Health (ICF)). Instead of focusing on a patient’s diagnosis or disability, the ICF encourages health care professionals to adopt a holistic approach through a biopsychosocial model that considers all aspects present in someone’s life (health condition, environmental and personal factors) as interacting bodies that are determinant to the three level of functioning (body structure and functions, activity, and participation).

In accordance with the ICF model, Rommers et al. (1997) describe how “parameters such as physical condition, social factors, age and co-morbidity are influencing factors in determining the discharge destination” . It is indeed by considering the patients’ activity and participation that the health care team can effectively direct patients towards the gradual resumption of roles within a community, whether it is practicing a sport or returning to work (International Classification of Functioning, Disability and Health (ICF)).

Prior to discharge, occupational and physical therapists also need to conduct a detailed interview with the patients pertaining to environmental factors. For instance, positively reinforcing the importance of the patients’ social network reintegration is paramount to their recovery and should not be over looked by the rehabilitation team  Together with the patient and his family, the rehabilitation team also determines the need for modifications around their home, alterations ofactivities of daily living, or relocation to a residence that provides assistance. Indeed, functional outcomes in amputees has been shown to be improved by modification of their physical environment .
Personal factors such as coping mechanisms in the face of bereavement or overall behavioral patternsequally need to be taken into consideration to ensure the well-being of patients during and following the maintenance phase once they are at home.

An Amputation Core Set following the ICF model
The use of the ICF in clinical practice and research is facilitated by Core Sets that serve as short lists of ICF categories, focusing on specific aspects of function typically associated with a particular disability  They can help guide the rehabilitation management process as described by the Swiss Paraplegic Centre (SPC), Nottwil, Switzerland (Www.icf-casestudies.org), or serve for the documentation of functioning and health in clinical studies. They are agreed upon according to specific conditions or for different health care contexts. Kohler et al integrated four preparatory studies towards the conception of a Core Set for persons following amputation. As he states in his paper, the “classification, measurement and comparison of the consequences of amputations has been impeded by the limited availability of internationally, multi-culturally, standardized instruments in the amputee setting.”  Once it is finalized, the Core Set for amputation will provide health care professional with a standard path to assess patients for expected outcomes, and ultimately a more specific description of the individual who underwent an amputation that will not only take into account medical conditions, but activities and participation, along with environmental and personal factors.