6287 Steps and Missed Steps: It took a Team

Nancy Payne, RN, MSN, CWCN, CFCN, Duke University Health System, Limb Loss CNS, Durham, NC, Jan Johnson, MSN, ANP-BC, CWOCN, Duke University Hospital Wound Management Treatment Facility, Nurse Practitioner, Zebulon, ND and Stephanie Yates, MSN, ANP, CWOCN, ANP-BC, Duke University Wound Management Institute, Adult Nurse Practitioner, Cary, NC
Topic:  Clinical pathways are designed to provide guidance for efficient care; however patients with complex mental, physical and social needs often fall off the “path.”  A patient with parasitic infection and resulting chronic lymphedema presented a complex challenge when he chose amputation to improve his quality of life.  Additional challenges were limited social support and poor living situation complicated the situation.  Nurse practitioners (CWOCNs) were able to heal the lower leg ulcer using dressings and compression wraps, but the extremely large and heavy leg continued to limit his mobility and lifestyle. Due to the complexity of this patient, extreme coordination of care was required.

Purpose:  To describe the care coordination by the Limb Loss CNS (CWCN) to expediently support this patient through a lower extremity amputation – pre-operatively through rehabilitation.

Objective:  To engage a team of healthcare professionals to support a patient with complex needs through life changing surgery.

Outcomes:  The first admission failed; not fully prepared and declined surgery.  For success, APRN’s collaborated to create a contract with explanations of the surgical consent and a simple, but inclusive timeline expected in the hospital, including discharge, future prosthetic fitting and gait training.  The primary internal medicine physician confirmed this patient was mentally ready for the surgery. Stress management provided relaxation therapy in the pre operative holding area. Occupational therapy provided immediate lymph wrapping of the residual limb post operatively.  His social worker created an agreeable discharge plan.  Other services included daily physical therapy, compressive garment applied by his prosthetist, peer visit from an amputee and daily visits from the Limb Loss CNS to reinforce plan.  Coordination by CNS likely reduced LOS, readmissions, clinic and emergency room visits.  The Limb Loss CNS continues to assist with such challenges as redundant skin, prosthetic fitting and correcting four years of poor gait.