Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP):...

People undergoing lower extremity amputations are often overlooked in healthcare. Limited clinician knowledge and skills challenge implementation of evidence-based clinical practice guidelines. Multidisciplinary lower extremity amputation protocols (LEAP) piloted in community and regional settings have improved outcomes and reduced hospital length-of-stay-but remain untested in larger settings. The purpose of this study was to identify barriers, facilitators, and strategies for implementing a multidisciplinary evidence-based LEAP for postoperative rehabilitation in a large urban quaternary medical center.

The planning phase study used the Theoretical Domain Framework (TDF) to develop and administer an anonymous survey. A purposive sample of 238 multidisciplinary professionals from a large urban medical center responded. The TDF and Capability-Opportunity-Motivation for Behavior Change (COM-B) framework-with its 3 components aligned with 6 behavior sources in 8 domains with further construct-level detail-were used for data analysis. Analysis was descriptive with barriers rank-ordered, facilitators identified by theme analysis, and strategies derived from written comments.

Clinicians responded from medicine (17.3%), nursing (16.0%), prosthetics (5.8%), physical therapy (36.0%), occupational therapy (24.0%), and recreational therapy (0.9%). Primary barriers fell within the knowledge, skill, and belief-in-capability capability-domains; and the professional role and environmental context opportunity-domains. Four capability and opportunity component facilitators emerged with corresponding strategies: education via short multimedia resources, hands-on clinical training, clinical support via champion mentors, and interdisciplinary coordination via automated multidisciplinary order set.

Identifying barriers and facilitators led to provider- and organization-level strategies that address capability and opportunity TDF components. Capability strategies included didactic education and clinical training supported by mentors. An automated multidisciplinary order set referral system emerged as the principal opportunity strategy. The order set aimed to improve communication regarding professional roles, enhance clinical training opportunities, and coordinate interdisciplinary care in the teaching hospital context of rotating multidisciplinary clinicians of a large urban quaternary medical center.