Clinician codesign of cognitive function screening pathways for amputation care

<p dir="ltr"><b>Background:</b> Vascular conditions, including infection, peripheral vascular disease and diabetes are the primary causes of amputation globally. In Australia, approximately 8,000 lower limb amputations occur annually, with 5,300 amputations attributed to diabetes, a growing health concern.</p><p dir="ltr">Assessing cognitive function in individuals undergoing amputation is crucial for several reasons. As the ageing population grows, age-related cognitive changes become more prevalent. Also, research suggests that individuals with diabetes may experience cognitive function alterations like mild cognitive impairment. These challenges are particularly relevant when patients adapt to new prostheses post-surgery. The Agency for Clinical Innovation (ACI), the lead agency for innovation in clinical care in New South Wales, Australia, recognises the importance of comprehensive and collaborative care, and recommends cognitive assessment be integrated into the care plan as part of a holistic approach to post-amputation.</p><p dir="ltr"><b>Aim:</b> To determine the utility of cognitive screening for vascular lower limb prosthetic rehabilitation and discharge planning. To test this, three research objectives were identified:</p><ul><li>Phase 1: To determine the level of adherence to cognitive screening component of the ACI minimum care standards.</li><li>Phase 2: To understand the factors clinicians consider when prescribing prosthetic rehabilitation, as well as to understand the clinicians’ views on the role of cognition in prosthetic rehabilitation.</li><li>Phase 3: To codesign a process that facilitates routine cognitive screening into the inpatient journey of persons with an amputation (PWA).</li></ul><p dir="ltr"><b>Methods:</b> This research used an action orientated research methodology, underpinned by a pragmatic worldview. The integrated Promoting Action on Research Implementation in Health Services translational research model, and the Knowledge to Action cycle were the guiding frameworks that underpinned this research. Staff involved in the hospital journey of a PWA i.e. vascular surgeons, rehabilitation physicians, physiotherapists, occupational therapists, podiatrists and psychologists engaged in three action research cycles to meet the objectives.</p><p dir="ltr">Phase one was a retrospective notes audit to determine the current rate of cognitive screening within one local Australian health district to establish a baseline snapshot for the practice of cognitive screening for PWAs. Phase two involved interviews, focus groups and survey methods to understand the factors that are considered when prescribing prosthetic rehabilitation, as well as to understand the clinicians’ views on the role of cognition in prosthetic rehabilitation. Phase three involved all clinicians relevant to the PWA journey to explore whether it was possible to codesign a pathway to routinely complete cognitive screening for PWA within the local health district. Quantitative data were analysed using descriptive statistics, while qualitative data were analysed using thematic analysis.</p><p dir="ltr"><b>Findings:</b> Phase one found that over a 2-year period, 178 episodes of amputation care were completed. Of these, a typical PWA was male aged over 60 years. Only 21.9% of episodes of care recorded a cognitive screen during their inpatient admission. This provided a strong driver to move into phase two. Phase two demonstrated there were several considerations when prescribing prosthetic rehabilitation (e.g. cognition, patients’ goals, and medical history). Despite differences in who clinicians believed should undergo prosthetic rehabilitation, they were unanimous that cognition played a role in prosthetic rehabilitation, paving the way for phase three. Phase three illustrated that it was possible to codesign a pathway that added cognitive screening to the journey, with the establishment of an inpatient and outpatient pathway.</p><p dir="ltr"><b>Conclusion:</b> This research demonstrated that within the health district is that minimal cognitive screening is completed with the PWA population, that clinicians believe that cognitive screening is important for prosthetic rehabilitation and discharge, and that there is an appetite for, and plan to engage in routine cognitive screening with PWAs moving forward. Inpatient and outpatient cognitive screening pathways were generated. Implications for practice, policy and research exist from these findings. From a practice perspective, factors such as patient goals, medical history, quality of life, cognition and support on discharge should inform prosthetic rehabilitation prescription. From a research standpoint future study could look to broaden the scope and assess the validity of cognitive screening in other surgical populations. When considering policy, there needs to be discussion beyond state based ACI guidelines to ensure that PWA nationwide are receiving cognitive screening routinely as part of best practice care. Understanding patients’ cognitive profile is vital for effective prosthetic rehabilitation and discharge planning.</p>