Cutting down on amputations: Redesigning care for patients with lower extremity ulcers

From the 2018 HVPAA National Conference

Katherine Neal (Duke University Hospital), Nancy Payne (Duke Univeristy Hospital), Michael Kerzner (Duke Univeristy Hospital), Tom Hopkins (Duke University Hospital), Sharon Olfati (Duke University Health System)


Peripheral vascular disease and diabetes mellitus increase the risk of developing a lower extremity ulcer and rates of both are increasing worldwide. When lower extremity ulcers become infected or ischemic, surgical intervention is warranted, often requiring a lower extremity amputation.


Lower extremity amputation rates in Durham County, North Carolina have been consistently above average, particularly among African Americans. With our higher than average amputation rates and expanding burden of disease, our health system has made a commitment for rethinking how we care for the patient with a lower extremity ulcer.

To improve outcomes of patients with lower extremity ulcers by creating a coordinated and multi-discliplinary approach to care resulting in reduced length stay, reduced readmission rates, and fewer patients requiring multiple amputations.


Our work group formed a multidisciplinary steering committee with representatives from hospital medicine, podiatry/orthopedic surgery, wound care nursing, vascular surgery, and anesthesiology. Using a combination of related ICD-10, MS DRG, and CPT codes, we defined our target population as patients 18 years old or older with a non-traumatic lower extremity wound (including vascular, neuropathic, and diabetic ulcers as well as ulcers with underlying osteomyelitis) admitted to the hospital over the course of one calendar year. After review of baseline data for our patient population, separate work groups developed (1) a standardized work flow and order set for emergency room providers; (2) an order set for admitting providers; (3) a multidisciplinary rounding team; (4) a postoperative order set for patients undergoing surgical debridement or amputation; and (5) enhanced education materials for patients with wound care needs at discharge and those undergoing amputations.


Baseline data for our patient population indicate that 70% of patients had co-existent diabetes and 70% presented to the hospital via the emergency room. At Duke University Hospital, length of stay for patients with lower extremity wounds was 8 days, while length of stay for patients undergoing an amputation was 17.7 days. Time to surgery was 6.5 days in our cohort, and 35% of patients required multiple amputations. The mortality index was 1.26. After complete incorporation of our multidisciplinary protocols, we expect a 5% reduction in length of stay, time to surgery, and reamputations, and a reduction in the mortality index to 1.


Multidisciplinary care delivered by members from hospital medicine, podiatry, orthopedic surgery, vascular surgery, wound care nursing, and anesthesia can provide more efficient and effective care for patients with lower extremity wounds.

Implications for the Patient

Caring for medically complex patients with lower extremity wounds can be more efficient and effective when provided by a coordinated multidisciplinary team. Standardized consult criteria, order sets, and education materials can enhance patient care for the hospitalized patient with a lower extremity wound.

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