Development of an Education Material Targeting Patients Undergoing Lower Extremity Amputation due to Severe Limb Ischemia-A Qualitative Study.

INTRODUCTION: Critical limb-threatening ischemia (CLTI) is associated with a high risk of amputation, yet patients undergoing amputation due to CLTI have little knowledge of the amputation process and the rehabilitation that awaits. The aim of the present study was to develop and validate information material for patients undergoing amputation. METHODS: Nine participants were included in the study. Two focus group interviews were performed with seven patients who had undergone lower extremity amputation due to CLTI within the past 2 y. Additionally, two individual interviews were carried out. A semistructured interview guide was used, and the interviews were transcribed verbatim and analysed using qualitative content analysis with a deductive approach. RESULTS: Three themes were identified as essential for the design of the written information: Perspectives on design and formatting, Providing information to enhance participation in care, and Accessibility to information and support. The prototyped information leaflet was perceived as acceptable, useable, relevant, and comprehensible by the participants. CONCLUSIONS: For patients to actively engage in their care, it is vital that their information needs are met and that they are provided with psychosocial support when needed. Written and oral information should be provided by a trusted healthcare professional.

Experiences of Acute Surgical Care During the Coronavirus Disease 2019 Pandemic Among Patients and Their Next of Kin.

INTRODUCTION: Since March 2020, the coronavirus disease 2019 pandemic has affected healthcare systems worldwide. It is largely unknown how acutely ill surgical patients and their next of kin have perceived the hospital care during the ongoing pandemic. Therefore, we aimed to explore their experiences. MATERIAL AND METHODS: We performed 12 interviews with patients who had undergone acute abdominal surgery in a public acute care hospital in Sweden during March to June 2020. In addition, we interviewed 10 of the patients' next of kin. We analyzed the interviews using content analysis. RESULTS: Our analysis resulted in two themes: "Worries about seeking acute care" and "The surgical care worked adequately, even though the system was overloaded." The participants experienced that the hospital maintained its functionality during the ongoing pandemic. Both the patients and their next of kin experienced insufficient information by the hospital, especially during the initial acute phase and at discharge, which led to a perceived loss of control. The implemented ban on visitors was found to have had both positive and negative effects for the patients, whereas the next of kin's experiences focused on the difficulties with not being able to visit. CONCLUSIONS: Our findings indicate that the challenges of communication with patients and their next of kin are exacerbated during a crisis such as a pandemic. In addition, a ban on visitors might have both positive and negative aspects. Therefore, we propose individualized routines for visits to acute surgical patients when possible.

Moral Distress Among Operating Room Personnel During the COVID-19 Pandemic: A Qualitative Study.

INTRODUCTION: The ongoing COVID-19 pandemic has necessitated the reallocation of healthcare resources, and a minimization of elective activities. Healthcare personnel involved in COVID-19 care have been negatively affected by the associated excess stress. The existing COVID-19 research has focused on the experiences among healthcare personnel in general, and not particularly on the operating room team members, who have often been relocated to overburdened workplaces. Therefore, we aimed to explore the experiences in this particular group. METHODS: This study has a qualitative inductive design based on interviews with a strategic sample of 12 operating room team members: surgeons, anesthesiologist, specialist nurses, and nurse assistants. The interviews were analyzed using content analysis. RESULTS: Three themes were identified: "Feeling safe in the familiar and anxiety in the unknown", "To be the ones left behind", and "The possibility for recuperation in a seemingly everlasting situation". The participants described working hard, although their efforts were experienced as not enough according to their moral ideals. We interpreted this as feelings and signs of moral distress, a commonly described concept in previous studies during the COVID-19 pandemic, and a risk for burn out. CONCLUSIONS: The operating room team members emphasized the negative stress of being in the unknown, performing work tasks in an unfamiliar place and situation, and experiencing conflicting feelings of relief and guilt. Organizational strategies toward a functional leadership and support should be emphasized. Such strategies might reduce the risk of psychological consequences such as burn out.

Health-related quality of life and prosthesis use among patients amputated due to peripheral arterial disease - a one-year follow-up.

PURPOSE: A major amputation affects the patients' independence, well-being and HRQoL. However, prosthesis use and the impact on the patient's HRQoL are scarcely described. The aim was to compare HRQoL between walker and non-walker amputees. Secondary aim was to evaluate prosthesis use and habits. METHOD: Ninety-eight patients with a major amputation due to peripheral arterial disease were included during 2014-2018. They were interviewed using EQ-5D-3L (HRQoL), Stanmore Harold Wood mobility grade (prosthesis use) and Houghton scale (prosthesis habits). RESULTS: Seventy-three patients completed the one-year follow-up, out of them 56 got a prosthesis. Twenty-three used it to walk both inside and outside. EQ-5D-3L at follow-up was increased in all patients in comparison to baseline (0.16 versus 0.59, p < 0.001). Patients walking with prosthesis had the largest improvement (0.12 versus 0.78, p < 0.001). A sub-analysis aiming to study the importance of independent movement showed an improved HRQoL at follow-up among those classified as prosthesis-user (p<0.001) and walker (p<0.001), but not among non-prosthesis users (p = 0.245). CONCLUSION: Learning how to use, not exclusively to walk with, a prosthesis after an amputation is important for the patients' HRQoL. At follow-up, patients using their prosthesis to walk or to move to a wheelchair, showed an improved HRQoL compared to baseline.IMPLICATIONS FOR REHABILITATION Walking ability with a prosthesis is important for the patient's perceived HRQoL after an amputation.Rehabilitation of amputees should focus on independence and movability and not only on walking ability.Wider use of prescribing prostheses after an amputation also to those predicted as non-walkers, may increase the number of patients with independence and improved HRQoL.When using their prosthesis for independent movement, patients who were otherwise unable to walk due to their amputation were able to achieve HRQoL comparable to walking amputees.

An Interprofessional E-Learning Resource to Prepare Students for Clinical Practice in the Operating Room-A Mixed Method Study from the Students' Perspective.

The operating room is a challenging learning environment for many students. Preparedness for practice is important as perceived stress and the fear of making mistakes are known to hamper learning. The aim was to evaluate students' perspectives of an e-learning resource for achieving preparedness. A mixed methods design was used. Students (n = 52) from three educational nursing and medical programs were included. A questionnaire was used to explore demographics, student use of the e-learning resource, and how the learning activities had helped them prepare for their clinical placement. Five focus group interviews were conducted as a complement. Most students (79%) stated that the resource prepared them for their clinical placement and helped them to feel more relaxed when attending to the operating room. In total, 93% of the students recommended other students to use the e-learning resource prior to a clinical placement in the operating room. Activities containing films focusing on practical procedures were rated as the most useful. We conclude that an e-learning resource seems to increase students' perceived preparedness for their clinical practice in the operating room. The development of e-learning resources has its challenges, and we recommend student involvement to evaluate the content.

Risk factors for reamputations in patients amputated after revascularization for critical limb-threatening ischemia.

OBJECTIVE: Despite vascular intervention, patients with critical limb-threatening ischemia (CLTI) have a high risk of amputation. Furthermore, this group has a high risk for stump complications and reamputation. The primary aim of this study was to identify risk factors predicting reamputation after a major lower limb amputation in patients revascularized because of CLTI. The secondary aim was to investigate mortality after major lower limb amputation. METHODS: There were 288 patients who underwent a major ipsilateral amputation after revascularization because of CLTI in Stockholm, Sweden, during 2007 to 2013. The main outcome was ipsilateral reamputation. RESULTS: Of 288 patients, 50 patients had a reamputation and 222 died during the 11-year follow-up. Patients with ischemic pain as an indication for primary amputation had nearly four times higher risk for a reamputation compared with those with a nonhealing ulcer (subdistribution hazard ratio, 3.55; confidence interval, 1.55-8.17). Higher age was associated with an increased risk for death in the multivariable analysis (hazard ratio, 1.03; confidence interval, 1.02-1.04). CONCLUSIONS: Patients with ischemic pain as an indication for amputation have an elevated risk of reamputation. Ischemic pain may be indicative of a more extensive and proximal ischemia compared with patients with foot tissue loss. An extended evaluation of the preoperative circulation before amputation may facilitate the choice of amputation level and could lead to a reduction of reamputations.

Risk factors for amputation are influenced by competing risk of death in patients with critical limb ischemia.

OBJECTIVE: Patients with critical limb ischemia (CLI) have a high risk of amputation and death. Death is a competing risk that affects the estimated amputation risk. Our aim was to find the specific risk factors for amputation for patients with CLI using competing risk analyses and compared these results with those from standard Cox regression analysis. METHODS: Patients who had undergone revascularization for CLI (2009-2013, with follow-up data until 2017) in Stockholm were identified from the Swedish National Registry for Vascular Surgery. The main outcome was major amputation. The risk factors for amputation were assessed using competing risk analysis and compared with the risk factors for amputation-free survival identified using Cox proportional hazards regression analysis. RESULTS: Of 855 patients with CLI, 178 had required a major amputation and 415 had died during the 8-year follow-up period. In the competing risk regression, age (subdistribution hazard ratio [sub-HR], 0.98; 95% confidence interval [CI], 0.97-1.00), ambulatory status (independent vs bedridden; sub-HR, 4.10; 95% CI, 2.14-7.86), and ischemic wound vs rest pain (sub-HR, 3.03; 95% CI, 1.72-5.36) were associated with amputation, considering death as a competing risk. In contrast, Cox regression analysis identified female vs male (hazard ratio [HR], 0.77; 95% CI, 0.64-0.94), age (HR, 1.02; 95% CI, 1.01-1.03), renal impairment (HR, 2.08; 95% CI, 1.61-2.67), ambulatory status (independent vs bedridden; HR, 3.45; 95% CI, 2.30-5.18), and ischemic wound vs rest pain (HR, 2.41; 95% CI, 1.78-3.25) as risk factors. CONCLUSIONS: The risk factors associated with amputation differed when analyzing the data using competing risk regression vs Cox regression. The differences between the analyses indicated that a risk exists for biased estimates using standard survival methods when a strong competing risk such as death is present.

An interprofessional initiative aimed at creating a common learning resource for the operating room ward.

Every semester, the operating room (OR) ward receives students from different educational programmes. Although interprofessional knowledge is essential for OR teamwork, students have traditionally been prepared in an uniprofessional manner, with no focus on interprofessional learning outcomes. This report describes the work process of an interprofessional initiative undertaken to create a common learning resource aimed at preparing students for OR practice. With a focus on interprofessional learning, shared and profession-specific learning outcomes, which are needed to prepare for practice, were identified by an interprofessional faculty. To avoid timetabling and geographic barriers, learning outcomes and constructed learning activities were packaged into an e-module and delivered on-line as an adjunct to existing lectures and workshops. A survey was administered to 4th year medical (n = 42) and 1st year OR nurse students (n = 4) to evaluate their perceptions of the e-module. We found that most learning outcomes from the different syllabuses were common for all professions. The overall response rate of the survey was 59% (27 of 46 students). Eighteen of the 27 responding students had used the learning resource, of which 15 students considered it to be of 'high' or 'very high' value. In summary, this interprofessional initiative resulted in a new common learning resource for the OR, which was used and perceived valuable by a majority of the students. The learning outcomes needed to prepare students from different educational programmes for OR practice are, to a great extent, generic and interprofessional and we thus argue that the interprofessional nature of the faculty was essential for the success of the initiative.

The patient's experience of amputation due to peripheral arterial disease.

It is not uncommon that patients with peripheral arterial disease (PAD) need to undergo a lower limb amputation, with or without previous revascularization attempts. Despite that, the patient's experience of the amputation has been scarcely studied. The aim of this qualitative study was to describe the patient's experience of amputation due to PAD. Thirteen interviews were conducted with vascular patients who had undergone a lower limb amputation at tibia, knee, or femoral level. Data were analyzed with content analysis. Our findings of the patient's experiences during the amputation process resulted in three themes with additional time sequences: the decision phase "From irreversible problem to amputation decision", the surgical phase "A feeling of being in a vacuum," and the rehabilitation phase "Adaptation to the new life". One main finding was that the patients felt abandoned during the surgical period. Despite that, most of the participants were satisfied with the decision, some of them even regretted that they had not undergone an amputation earlier in the process. It is important for the patient's well-being to develop a partnership with the surgeon to increase a feeling of being participating in the care. Vascular patients need better information on lower limb amputation, and its consequences so as to be better prepared for the whole process. To increase the patient's quality of life and reduce unnecessary suffering, amputation may be presented earlier in the process as a valuable treatment option.