The loss of a limb has a devastating impact on individuals and can be a death sentence in some parts of the world. Treating patients with complex medical needs is challenging though, and clinicians are most likely to successfully prevent amputation and its repercussions by working as part of a multidisciplinary team. In this Q&A, Richard Neville, MD, FACS, discusses how to set up or join such a team. Dr Neville is Associate Director at the Inova Heart and Vascular Institute in Falls Church, Virginia. He is also a Guest Course Director for the International Symposium on Endovascular Therapy (ISET), February 3-7, 2018 in Hollywood, Florida. Dr Neville will be presenting on several topics at ISET, including wound care for limb preservation.
What is the benefit of a multidisciplinary approach to saving limbs?
Clinical data shows that when people lose a limb, they have a significant risk of losing another limb in 2 years, as well as an increased mortality risk. Patients who lose a limb have increased mortality, as high as 30% to 50%, due to pneumonia, heart disease, bed sores, infection, etc. Thus, we’re doing more than just saving a leg when we treat these patients. We’re prolonging life, and we’re prolonging quality of life.
In addition to increased mortality among patients, the loss of a limb leads to significant cost for the health care system. Billions of dollars are spent on foot problems related to diabetes, including amputations and subsequent rehabilitation. The number of people with diabetes is increasing, as are the related problems and costs.
Proper treatment of these patients, including prevention of amputation, obtaining functional limbs, and promoting good healing, is markedly enhanced through the care of a multidisciplinary team. Individual healthcare providers may attempt to treat these patients, but it’s much harder to do alone, and the outcomes for patients are poorer. I’ve spent my whole career advocating for and trying to refine and construct these teams.
What resources/personnel are needed to create one of these teams?
The first key element is a physician champion(s) for the cause. It’s preferable if one of the physician champions is a vascular-oriented specialist such as a vascular surgeon, interventional radiologist, or interventional cardiologist; oriented towards the blood supply, perfusion, and circulation. Another physician may be focused on the soft tissue piece—a podiatrist or a plastic surgeon.
Under the physician champions, leaders, who have a passion for the cause, you will need to draw on a whole cadre of staff and other physicians to treat these patients properly – endocrinologists, infectious disease experts, cardiologists, nephrologists, orthopedists, rehabilitation medicine physicians, and prosthetists. You’ll need support staff dedicated to the cause—wound nurses and nurse practitioners.
The patients we treat often have complex medical issues and limited mobility. By putting together a multidisciplinary team to treat them, we can offer better and more streamlined care. The benefits of such care extend beyond better medical outcomes to better patient satisfaction and QOL. Patients with limited mobility can be more rapidly treated with less need for different appointments in different places.
To create a multidisciplinary team, you’ll need an identifiable space, in addition to the staff (physician champions, physician staff, and support staff). You need space either in the hospital or in an outpatient facility recognized and dedicated to specifically treating this problem. For example, patients are aware that cancer centers exist—we need the same level of awareness and availability for amputation prevention centers.
In this dedicated space, you’ll need to have diagnostic equipment—ultrasound equipment first, but also access to CT scans and MRIs. In our center, we still do a lot of angiography or arteriography, which vascular surgeons, interventional radiologists, and interventional cardiologists perform. We also must offer all the forms of revascularization techniques, including both endovascular or catheter-based techniques. And the ability to do open surgical bypass for these certain patients. In our practice, approximately 25% of these patients are best treated with surgical bypass optimize blood flow, thereby enhancing the ability to save the leg, and heal. However, this percentage may decrease as additional endovascular procedures and technologies advance, such as drug-coated balloons, drug-eluting stents, and absorbable stents. Nonetheless, as we sit here today, about 75% of patients are best treated with endovascular-based or catheter-based therapy, and about 25% are best treated with open or surgical techniques.
What are some key points to keep in mind when treating these patients?
It’s important that once you establish perfusion, you focus on the soft tissue. One of the most frustrating situations to encounter is limb loss due to infection or the inability to close or restore the functional tissue, even after a successful revascularization. To avoid this situation, a good podiatric or plastic surgery team is essential to help with the advanced techniques to put the soft tissue back together after circulation is restored. That’s one of the key messages I want to deliver to ISET this year through the wound symposium.
ISET gives outstanding lectures on how to restore perfusion with advanced, cutting-edge endovascular techniques, but in the past, we haven’t focused the audience on the next steps. What do you do after you do the angioplasty?
Most interventional radiologists or interventional cardiologists will need to align or work with a podiatrist or plastic surgeon. That way, after the IR or IC establishes the blood supply, the podiatrist or plastic surgeon can complete the process by healing the wound, debriding, rotating soft tissue flaps—doing whatever it takes to save that limb and optimize the function of that limb.
After restoring soft tissue with the help of appropriate specialists, what’s the next step?
You can’t forget the importance of rehabilitation, prosthetics, and postoperative care. If you do, you may have a patient lose a limb even after all the previous steps have been successful. For example, let’s say you’ve completed a successful bypass or angioplasty, circulation is restored, and the podiatrist does a great job. Then, then infectious disease expert stops the infection, debrides the tissue, and closes the tissue. The patient walks out the door, and everyone is pleased with the outcome. However, 6 months later, the patient returns with a large ulcer on his foot because of ill-fitting shoes, and now the patient is in trouble again.
Thus, the postoperative rehabilitation piece and follow-up is critical. No one person can undertake all of these parts of care. To treat these patients successfully, you need to put together a team of people that have the passion for it, and then get the support of your health system to give you the resources to get this started.
Is it difficult to secure the resources necessary to create a multidisciplinary team?
I would argue that if you make the up-front investment to get something like this started, it will pay off in the long run, both in terms of the health of the patients and also financially. There’s no question that these teams are a financially advantageous entity for the hospital and the health system.
More importantly, it’s also better care for the patients. If we can keep people walking and ambulating with a functional limb, we can keep them out of nursing homes and they can live independently. It’s less of a burden on their family. They’re happier. It’s a win-win for everyone, and as I said earlier, saving a limb extends patients’ lifespan and increases the chance of them keeping their other leg.
What are physicians doing now to treat patients if a team is not in place?
In many places, the care can be fragmented. A patient will see their endocrinologist, who will identify a wound on the patient’s foot. Or a patient will go to the wound center, and the wound center will try to treat it for a little while. If the patient is not getting better, the wound center might refer the patient to an interventional radiologist, an interventional cardiologist, or a vascular surgeon. Those practitioners will focus on the blood supply, and then the patient will make their way to someone else. The fragmented care is frustrating, and it results in longer time to treatment and worse outcomes.
What if, for example, you’re an interventional radiologist who agrees with the team approach but doesn’t have the bandwidth to be the founding member and team lead? What should he/she do to treat these patients?
I would argue that you should be a part of a team or not treat these patients. However, you don’t have to be the physician champion. You can still be a part of the team. If someone else has set up the team, and they include you on the team to focus on your area of specialty, then that role can be straightforward. It’s better to function on a team than to do this in a vacuum on your own.
Is it hard to find and join a team?
I am from Washington, DC and have always been told that “All politics is local.” It depends on who’s starting the team in your center and the relationships you have with that person. If you hear of a team like this starting, seek the people out and ask to be involved. Be proactive, not passive.
Is it difficult to identify which patients will need this complex treatment?
It can be. That question is often asked in the wound center setting. Sometimes they have to determine which patients they can continue treating with wound care and which patients need to be treated in an advanced program.
In my experience, 15% to 20% treated in our wound center system need this advanced, multidisciplinary care. Identifying those patients can be difficult. We try to do this with noninvasive vascular lab testing using ultrasound, and other diagnostic techniques. Sometimes the identification happens when the patient simply isn’t healing over time.
I think the difficulty in identifying these patients further supports treatment within the confines of the team. In this scenario, the wound center functions as part of the team—they wouldn’t send every patient to a multidisciplinary amputation prevention center, but if the lines of communication are open (eg, joint conferences and interactive education sessions) then the appropriate patients will get to the appropriate place more efficiently.
How might setting up or joining a team align with future models of health care delivery?
Our health care system is changing, and we won’t be rewarded and measured the same as in the past. We’ll be rewarded on quality, outcomes, and cost. Functioning in a team will optimize those metrics, which will make it more advantageous to work in this model. In the future, we may not treat every patient as in the past – but we will hopefully optimize expertise and interest and the outcomes will be better.
Can you recommend any resources for individuals interested in learning more about multidisciplinary amputation prevention teams?
A wealth of literature has arisen around this topic. The Society of Vascular Surgery and the American Podiatric Society have published an important joint paper,1 and I along with others have published on our experiences on how to put together a multidisciplinary team.2-4
1. Sumpio BE, Armstrong DG, Lavery LA, Andros G, SVS/APMA writing group. The role of interdisciplinary team approach in the management of the diabetic foot: A Joint Statement from the Society for Vascular Surgery and the American Podiatric Medical Association. J Vasc Surg. 51(6):1504-1506.
2. Neville RF, Kayssi A. Development of a limb preservation program. Blood Purif. 2017;43:218-225;(DOI: 10.1159/000452746)
3. Neville RF. Role of surgical bypass in a limb preservation practice. Endo Today. 2015;6:5-11.
4. Neville RF. Invited commentary: Importance of post-procedural wound, ischemia, and foot infection(WIFi) restaging in predicting limb salvage. J Vasc Surg. 2017; in press.