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

Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators Akin Akitola Beckley, Christopher Kevin Wong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4456817/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Implementing evidence-based clinical practice guidelines (CPGs) requiring multidisciplinary efforts for relatively small clinical populations such as people undergoing lower extremity amputations, may present special challenges. People with chronic vascular diseases face wound healing and mobilization challenges that delay rehabilitation and hospital discharge. Lower extremity amputation protocols (LEAP) including postoperative limb dressings and early mobilization improve healing, functional outcomes, and reduce hospital lengths-of-stay—but require multidisciplinary coordination. The purpose of this study was to identify barriers and facilitators to implementing a multidisciplinary evidence-based LEAP for postoperative rehabilitation after amputation. Methods : This cross-sectional organization and provider-level study included a convenience sample of 238 multidisciplinary professionals from an urban medical center. An anonymous survey, developed using the Theoretical Domains Framework, explored barriers and facilitators in the knowledge, clinical skills, and personal/contextual domains. Analysis was descriptive with barriers rank ordered. Results : 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%). Self-rated knowledge was low: 93.3% were unfamiliar with amputation rehabilitation CPGs and 60.9% were unfamiliar with problems delaying hospital discharge. Self-rated clinical competence was low corresponding to minimal reported experience with post-amputation limb wrapping or early mobilization. Potential barriers included unfamiliarity with the evidence, limited clinical training and confidence, insufficient patients, and inadequate interdisciplinary communication and coordination. Facilitators included clinician readiness to change and knowledge of early mobilization evidence. Conclusions : Identifying barriers and facilitators led to provider and organization-level recommendations organized using the behavior change wheel to consider the capability, opportunity, and motivation domain functions. An automated multidisciplinary referral system with standard order set emerged as a proximal strategy to potentially affect all three domains and multiple implementation mechanisms while leveraging clinician attitude may provide a path towards LEAP implementation. Amputation early mobilization wound dressing determinants implementation research Figures Figure 1 Figure 2 Contributions to Literature This study identified determinants to implementing evidence-based practices for smaller clinical populations such as lower extremity amputations. Identifying barriers and facilitators to multidisciplinary postoperative care after vascular amputations, led to a proximal strategy recommended to facilitate implementation of a multidisciplinary lower extremity amputation protocol. This organization and provider-level study was placed in the context of a larger multi-level framework that includes patient and health education systems. Background Implementing established evidence-based practices in rehabilitation settings is difficult despite published Clinical Practice Guidelines (CPGs). 1 Some estimate integrating research evidence into clinical care takes 17 years. 2 Evidence suggests consistent post-amputation residual limb dressing and early mobilization speed wound healing and functional mobility and decrease hospital length-of-stay. 3 , 4 But adopting evidence-based practice for less common clinical populations like people with lower extremity amputations (LEA) may pose special challenges because clinicians may be unfamiliar with the evidence and relevant problems. For instance, while approximately 800x10 3 people in the United States (US) have strokes each year, only a fraction (160x10 3 ) have LEA due to diabetes—the predominant amputation cause. 5 Nevertheless, LEA incidence continues to increase 6 with diabetes the primary predictor of prolonged lengths-of-stay. 7 After LEA, people with chronic vascular conditions face immediate threats and lifelong functional challenges with high first-year mortality and re-amputation rates and five-year incidences for both approximately 50%. 8,9 Healing can be delayed and function limited with approximately half ultimately non-ambulatory after LEA. 9 European and US CPGs describe system-level best practices for peri-operative care. 3 , 4 Post-amputation residual limb dressings promote healing, encourage initial functional mobility, and improve prosthetic walking outcomes. 10 Early postoperative mobilization facilitates rehabilitation and shorten lengths-of-stay. 11 Adopting CPG recommendations including post-amputation limb dressings 12 and early mobilization 13 may improve rehabilitation outcomes and decrease postoperative length-of-stay 14 , 15 as recently piloted in a lower extremity amputation protocol (LEAP) by one institution. 13 One of many challenges that inhibit implementation of evidence-based rehabilitation practice may be that post-amputation care is multidisciplinary by nature. 16 Multiple disciplines play important roles in peri-operative amputation care focused on wound healing, self-care, and mobility. 12 , 17 However, multidisciplinary clinician teams with amputation-specific rehabilitation skills and knowledge are not universally available. 3 , 14 , 15 The hierarchical healthcare culture emphasizes physician knowledge, however staff rotations lead to cycles of training and relationship-building that affects consistent practice and communication. 18 Some disciplines support evidence-based practice with guidelines for systematic new clinician LEA education, but not all disciplines have similar documents. 19 Evidence suggests coordinated multidisciplinary rehabilitation also facilitates rehabilitation and decrease length-of-stay. 15 However, various determinants challenge implementation of evidence-based multidisciplinary rehabilitation practices for LEA. 1 , 20 Exploration of the barriers and facilitators to implementing multidisciplinary evidence-based practices, especially for the less common LEA clinical population, is an important first step to designing implementation strategies that address specific barriers and leverage available facilitators. 21 , 22 The purpose of this study was to determine barriers and facilitators to implementation of a multidisciplinary evidence-based postoperative LEAP aimed at facilitating early rehabilitation and timely hospital discharges. Methods This descriptive cross-sectional study was approved by the Institutional Review Board of the participating major US medical center, which cares for people after LEA in various intensive care and medical units. An anonymous Qualtrics™ (Qualtrics, Provo, UT, USA) survey was sent to a convenience sample of 389 multidisciplinary clinical professionals who could provide postoperative LEAP care, 13 including rehabilitation medicine and vascular surgery physicians, prosthetists, nursing staff, and occupational, physical, and recreational therapy professionals. A 60% response rate was the recommended goal. 23 No identifying personal information (age, sex, email) were captured to preserve respondent anonymity. The survey underwent three developmental steps. First , five prioritized Theoretical Domains Framework domains were selected: knowledge, skills, professional roles and experience, belief in capability, and environment resources. 24 Domains were organized into a 3-part guiding framework: 24 1) Awareness combined knowledge and professional experience, 2) Adoption combined skills and belief in capabilities, 3) Contextual determinants included habitual behavior and communication, motivation and goals, and decision-making and multidisciplinary coordination. Second , corresponding survey questions addressing each domain were developed, modifying Barriers Scale items for multidisciplinary clinicians. 25 Three-level answers were chosen for all questions except clinician self-assessments. Clinician self-assessments used four-level answers (very, somewhat, little, not at all), intentionally merging the last two responses anticipating that clinicians might be reluctant to judge themselves “not at all” knowledgeable, competent, or confident. 26 , 27 Potential barriers were rated on three-levels, with little barrier considered not a barrier anticipating “not a barrier” to be an unlikely response. Third , multidisciplinary professionals reviewed the pilot survey to ensure question understandability and process ease, with feedback guiding minor editorial or procedural changes. Professionals in survey development were excluded from data collection. Analysis was descriptive and characterized participant professional experience, amputation-related clinical experience, knowledge of related evidence, and experience with specific rehabilitation interventions (Appendix 1). Descriptions of clinical experience reduced indirect and direct experience into ratings of “once in a while” and “frequently,” versus “never” meaning no experience. Experience was direct when care was performed; indirect experience included helping or observing. Incomplete response data was anticipated; missing data was not imputed to avoid bias or measurement error. Percent responses were calculated using each survey question’s actual response rate. Quantitative data were analyzed by subgroup. Determinants were rank ordered; items rated by > 80% as very much or somewhat a barrier were considered barriers. 25 Items rated by < 60% as very much or somewhat a barrier were considered facilitators. 25 Qualitative data from written responses to open-ended questions regarding potential barriers and facilitators were used to assess survey internal content validity. Responses were organized using theme analysis identified by consensus of the primary investigators and confirmed by pilot survey recipients. Number of barriers not in the survey indicated internal content validity. Responses were also anticipated to influence implementation planning. Results The multidisciplinary sample included 238 respondents, a 61.2% response rate, representing the medical (17.6%), nursing (16.4%), physical therapy (36.1%), occupational therapy (23.1%), recreational therapy (1.3%), and prosthetics (5.5%) professions. Respondent years of professional experience were categorized as 15 years (30.6%). Respondent experience with amputation rehabilitation, excluding prosthetists, was low with < 9% rating themselves as very experienced and 15.5% having seen no post-amputation patients (Table 1 ). Determinants were rated similarly across professions and experience levels so overall ratings were reported. Table 1 Respondent Experience with Amputation Rehabilitation and Patients After Amputation Seen in Past Year: percent (%) of each profession reported (modes bolded) Respondent Profession Medicine Nursing Prosthetics OT PT RT n n = 42 n = 39 n = 13 n = 55 n = 86 n = 3 Self-reported Experience Level very experienced 2.4 2.8 58.3 5.5 4.8 0.0 Experienced 9.5 22.2 25.0 27.3 15.5 0.0 some experience 35.7 47.2 16.7 30.9 47.6 66.7 little experience 50.0 22.2 0.0 30.9 25.0 0.0 no experience 2.4 5.6 0.0 5.5 7.1 33.3 Patients Seen in Past Year 0 11.9 2.8 0.0 16.4 21.7 33.3 1–5 57.1 33.3 0.0 54.5 45.8 33.3 6–10 26.2 22.2 8.3 20.0 20.5 0.0 11–19 2.4 16.7 8.3 1.8 8.4 33.3 20+ 2.4 25.0 83.3 7.3 3.6 0.0 Abbreviations: OT = Occupational Therapy, PT = Physical Therapy, RT = Recreational Therapy Contextual Determinants Twelve determinants were considered major barriers, > 80% respondents rated the items very or somewhat of a barrier. (Table 2 ) The top two barriers were clinician confidence the using temporary prostheses (86.9%) and postoperative wound dressings (86.3%) techniques. Clinician confidence using temporary prosthesis was considered a major barrier for majorities of all experience levels and professions including prosthetists. Most rehabilitation therapy respondents did not consider knowledge of early mobilization evidence in general a major barrier. Clinician confidence for all experience levels viewed limb dressings as a major barrier. Table 2 Respondent Perception of Degree to which Barriers Exist to Implementation Potential Barriers * major barrier ** facilitator Very or Somewhat a Barrier (%) 1. Clinician comfort & confidence using a temporary prosthesis * 86.9 2. Clinician comfort & confidence in wound dressing * 86.3 3. Timely prosthetic support * 86.0 4. Communication between surgeons/physicians & rehab team * 85.6 5. Insufficient number of amputees for experience * 85.4 6. Clinician training with amputees * 85.1 7. Communication with prosthetic team * 85.0 8. Clinician experience with amputees * 84.7 9. Lack of administrative/institutional directives * 83.7 10. Interdisciplinary coordination * 82.2 11. Access to professional clinical training * 82.2 12. Knowledge of the problem * 81.0 13. Sufficient wound care and prosthetics supplies 78.3 14. Lack of automated referral system 76.4 15. Department productivity demands for clinicians 75.2 16. Knowledge of the evidence supporting wound dressing 74.9 17. Hospital culture 73.8 18. Access to urgent evidence and clinical practice guidelines 72.4 19. Knowledge of evidence supporting temporary prostheses 70.1 20. Documentation system 68.6 21. Knowledge of evidence supporting early mobilization ** 56.5 22. Communication with non-English speaking patients ** 55.7 23. Clinician attitude/readiness to change ** 48.9 Five of the top 12 barriers—interdisciplinary coordination, administration directives, multidisciplinary and team communication and support—related to multidisciplinary coordination and communication. Four related to lack of experience with limb dressings and early mobilization, especially for clinicians with ≤ 15 years-experience: clinical experience, clinician training, access to training, and insufficient post-amputation patients. The twelfth barrier was knowledge of problems delaying discharge post-amputation, especially among clinicians with < 2 years-experience. Productivity demands, reflecting concerns about time, were rated as a barrier by 75.1% and was not classified as a potential major barrier (Table 2 ). Three facilitators were identified. Knowledge regarding early mobilization was no more than a little barrier for all experience level categories. Most clinicians across professions and experience levels rated clinician attitude or readiness to change as no more than a little barrier. Communication with non-English speakers was also only a little barrier for respondent of most experience level categories. Internal Content Validity Survey responses provided detailed context for identified barriers and enhanced planning for targeted educational interventions. Written comments from 102 respondents revealed themes that paralleled survey questions (Appendix 1) without introducing new barrier concepts, supporting internal survey content validity. Recurring barriers included limited clinical experience (n = 44) and knowledge (n = 32), interdisciplinary communication (n = 21); institutional support (n = 19), and the limited number of post-amputation patients (n = 16). Awareness Respondent knowledge of problems encountered post-amputation and related evidence was limited: 60.6% were not or little familiar with problems delaying hospital discharge and 92.8% were unfamiliar with amputation rehabilitation CPG evidence. (Table 3 ) Clinical experience was also limited with 43.2% unfamiliar with semirigid/rigid postoperative dressings and 70.1% having no direct experience applying semirigid/rigid dressings. Conversely, > 80% were very or somewhat familiar with post-amputation soft limb dressings and 75% reported at least indirect experience. Across professions, most clinicians also had direct early mobilization experience as soon as postoperative day one, but 88.5% of non-prosthetists lacked any experience with temporary prostheses. (Appendix 2) Table 3 Self-Reported Knowledge by Years of Experience (% of all respondents, modes bolded) Knowledge of 15y Total % Clinical Practice Guidelines 1 Familiar with both 0.5 0.0 0.5 0.0 0.5 1.4 Familiar with one 0.9 0.0 0.9 0.5 3.6 5.9 Not familiar with either 14.9 26.2 14.9 11.3 25.7 92.8 Problems of Delayed Discharge 2 Very familiar 0.4 0.9 2.7 0.9 4.5 9.4 Somewhat familiar 4.5 7.2 3.6 3.6 11.2 30.0 Not or little familiar 11.2 17.9 9.8 7.2 14.3 60.6 Amputation Rehabilitation Interventions Soft dressing for limb wrapping 3 Very familiar 2.3 5.4 4.1 2.7 9.9 24.3 Somewhat familiar 11.7 15.3 7.7 6.3 15.3 56.3 Not or little familiar 2.3 5.4 4.5 2.7 4.5 19.4 Semirigid/rigid dressings for limb wrapping Very familiar 1.8 2.3 2.7 1.8 4.5 13.1 Somewhat familiar 8.6 14.0 5.0 3.2 13.1 43.7 Not or little familiar 5.9 9.9 8.6 6.8 12.2 43.2 Early mobilization on Day 1 4 Very familiar 5.4 8.1 4.1 4.1 11.7 33.3 Somewhat familiar 9.0 14.4 8.6 7.2 12.2 51.4 Not or little familiar 1.8 3.6 3.6 0.5 5.9 15.3 Temporary "bypass" prosthesis use 5 Very familiar 0.9 0.9 1.4 0.0 2.3 5.5 Somewhat familiar 4.1 8.2 5.0 3.2 11.4 31.8 Not or little familiar 11.4 17.3 10.0 8.6 15.5 62.7 Note: some totals do not add up to 100.0% due to rounding. 1 92.8% not familiar 2 60.6% not or little familiar 3 80.6% very or somewhat familiar 4 84.7% very or somewhat familiar 5 62.7% not familiar Adoption Competence in applying soft post-amputation limb dressings was no more than little for most respondents, but confidence to adopt soft limb dressings into daily practice was higher with the overall majority very or somewhat confident. Conversely, majorities across disciplines and experience levels were not or little competent with semirigid/rigid dressings and the majority overall were not or little confident to adopt semirigid/rigid dressings. Confidence to adopt early mobilization into practice post-amputation (very or somewhat confident) was higher than self-rated competence (not or little competent). Few respondents were competent or confident using temporary prostheses with 93.4% reporting no or little competence across non-prosthetist clinicians and all experience levels. (Appendix 2) Discussion This study exposed challenges to implementing an evidence-based LEAP for multidisciplinary post-amputation rehabilitation. Top ranked barriers included clinician confidence with specific interventions, lack of clinical LEA experience and clinical training; interdisciplinary coordination and communication; and knowledge of problems delaying hospital discharge. Top barriers reflected multidisciplinary limited self-rated knowledge, clinical experience and competence in specific rehabilitation interventions. Variations across disciplines and experience levels suggest implementing multidisciplinary evidence-based practices could be facilitated with interventions tailored for specific disciplines’ needs. Broad unfamiliarity with CPG evidence may be because the LEA population is relatively small. Since clinical experience, competence, confidence, and training were top barriers, one recommendation was to increase referrals, and thus LEA patients with whom to gain experience, using an automated multidisciplinary referral system with standard order set to improve referral consistency while facilitating interdisciplinary communication and coordination. Adopting a proximal strategy to potentially affect most mechanisms and distal outcomes may be a useful approach. The capability, opportunity, and motivation domains of behavior change (COM-B) were used to organize recommended implementation interventions, recognizing that intended behavior change may arise from multiple factors and that proposed interventions may affect multiple behavioral change functions. 28 Capability domain recommendations included education addressing knowledge and clinical skills gaps, experienced champions to provide clinical support, and an automated referral system with standard order set to enable multidisciplinary clinicians to provide their specialized care that rotating physicians in training may not be oriented to or unwittingly restrict through the absence of specific orders. 18 An automated referral order set with corresponding electronic documentation system would also have an opportunity domain function by expanding opportunities for clinician LEA experience in this relatively small clinical population by reducing the number of LEA patients lost to oversight and removing restrictions multidisciplinary providers may perceive or self-impose based on cultural medical hierarchy. 28 Motivation domain interventions have been less emphasized than capability and opportunity domain interventions in a Theoretical Domains Framework systematic review, though professional role and identity were frequently noted issues. 29 The automated multidisciplinary LEAP referral system may empower disciplines not recognized for their contributions 30 and motivate others disciplines via coercion of perceived requisite action and incentivism of potential cost savings associated with shorter lengths-of-stay. 28 Together with interdisciplinary education and training and support from multidisciplinary champions, the LEAP automated referral system may foster a sense of team and group purpose while tapping into the propensity to mimic others. 28 An automated referral system could be a single intervention that affects all three COM-B domains. Identifying barriers and facilitators aids development of implementation strategies to facilitate the mechanisms required to implement new evidence-based practice protocols. 31 This study was consistent with a systematic review identifying lack of clinician awareness of the relevant research as a top personal barrier for implementing research in practice. 25 Insufficient knowledge leads to lower confidence 29 thus education regarding CPG evidence and the problems of delayed rehabilitation appears foundational to implementing a multidisciplinary LEAP. 32 Limited clinical experience and competence varied among disciplines, perhaps explaining why interdisciplinary communication and coordination were perceived barriers. Multidisciplinary variations helped identify champion clinicians to support educational training matching specific professional needs—such as postoperative limb dressings and early mobilization. 32 Specific protocol elements for which multiple professions across experience levels lacked experience, competence, and confidence (semirigid/rigid dressings, temporary prostheses), could not be recommended. One commonly reported barrier, insufficient time to implement evidence-based practices, 25 , 29 was not a major concern in this study, and clinician attitude was a facilitator, supported in self-rated confidence to adopt evidence-based limb dressings and early mobilization practices that exceeded self-rated clinical competence. This study identified determinants leading to recommended strategies along a causal pathway that could plausibly lead to measurable implementation outcomes as recommended for effective change enactment. 33 (Fig. 1 ) The identified barriers may not be isolated to one institution; others have attempted to initiate a postoperative LEAP at the institutional level. 13 , 34 This study fits within a multi-level process (Fig. 2 ) in which system level efforts have already been enacted including post-amputation rehabilitation CPGs 3 , 4 and the American Physical Therapy Association limb loss educational curricular guideline. 19 At the organizational level (Fig. 2 ), the recommended automated multidisciplinary referral system would address institutional barriers such as insufficient patients with which to gain experience and multidisciplinary communication or coordination. 13 , 34 This single recommendation could have multiple downstream effects. All professions could be automatically alerted to their roles to optimize multidisciplinary communication and coordination, all clinicians would have access to relevant outcome measures through the electronic documentation system, and more people with LEA would be referred, taking advantage of the fact that productivity was not a major barrier. At the practitioner level (Fig. 2 ), results prompt recommendations addressing barriers and facilitators. 31 Accessible educational programming and in-person training were recommended to address knowledge gaps regarding post-amputation problems delaying discharge and limited CPG awareness. Education interventions tailored for targeted professional groups can be supported by recruiting champions, capitalizing on clinician readiness to change. While long-term impact is the ultimate goal, implementing evidence-based practices can take years to enact as many factors influence health outcomes, 2 , 33 thus improving patient level outcomes remains for future research. This study was constrained to identifying determinants to assist strategic planning for LEAP implementation. Limitations include sample size which exceeded the 60% response rate, 23 but could limit the scope of barriers in written responses. While piloted for understanding and response levels chosen anticipating clinician reluctance to acknowledge lack of competence, 26 survey response and recall bias are still possible. Finally, analysis of respondent characteristics was impossible because identifying data was not recorded to ensure anonymity. Conclusions This study identified barriers and facilitators to implementing an evidence-based multidisciplinary LEAP for postoperative amputation rehabilitation at the provider and organizational levels. 24 Primary barriers included limited knowledge of the evidence-base, clinical experience, and self-reported clinical competence and confidence. Personal and organizational level barriers included insufficient clinical training and multidisciplinary communication and coordination. Identifying barriers and facilitators can lead to strategies such as an automated referral with standard order set that could affect all COM-B domains to facilitate LEAP implementation. Abbreviations COM-B = Capability Opportunity Motivation - Behavior CPGs = Clinical Practice Guideline(s) LEA = Lower extremity Amputation LEAP = Lower extremity Amputation Protocol US = United States Declarations Ethics approval: This study was conducted with approval of the participating major urban US university medical center Institutional Review Board #XXXX-XXXX. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This study had no funding. Authors’ contributions: All authors approved the final manuscript. AAB contributed substantially to the study concept, and the acquisition, analysis, and interpreted of the data. CKW contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript. 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Madsen UR, Hommel A, Berthelsen CB, Bååth C. Systematic review describing the effect of early mobilisation after dysvascular major lower limb amputations. J Clin Nurs. 2017;26:3286-97. Supplementary Files APPENDIXFile.docx ImplementationLEAPSTROBEchecklistcrosssectional.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4456817","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316961996,"identity":"1a3055d4-d320-4118-b854-052bb185c177","order_by":0,"name":"Akin Akitola Beckley","email":"","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Akin","middleName":"Akitola","lastName":"Beckley","suffix":""},{"id":316961997,"identity":"b010cd71-1342-4d23-b769-981ec5971d39","order_by":1,"name":"Christopher Kevin Wong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACHgb2Hx9gnAcMDAlsEFG8WhgkZ8A4CcRqkYYrSAAjAlr4e84YGNvUHI7mb2B++CCxbVseH/sBxgdv23BrkTjbY5Ccc+xw7owDbMYGiW23i9l4EpgN5+LRYsDPu+FwbsPh3A0MPGwSQC2JbUDvSPPi17Kx2RJFC/8D9t94tfD2bmZmRNEikcDGjE+LxJnz3xh7jqXnzjgM9EvCOaBfJB42S845h1sLf09aGsOPGuvc/vbmhw8+lN3Ok+9PPvjhTRluLQjADGcxNhCjfhSMglEwCkYBHgAADptPHEKGToYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-5041-527X","institution":"Columbia University Irving Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Christopher","middleName":"Kevin","lastName":"Wong","suffix":""}],"badges":[],"createdAt":"2024-05-21 19:35:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4456817/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4456817/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60614685,"identity":"ffdb0b5a-2c65-494b-b228-709513ad447c","added_by":"auto","created_at":"2024-07-18 20:04:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":571579,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImplementation Causal Pathway of the LEAP—Lower Extremity Amputation Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA causal pathway was developed that addressed the identified barriers (-) and facilitators (+) to implementation with recommended potential strategies, considering preconditions and moderators for success, to activate the mechanisms by which measurable implementation outcomes could be achieved at both provider and organization levels.\u003csup\u003e20,33\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4456817/v1/42544a3c9be7260f6018f249.jpg"},{"id":60616412,"identity":"c163f9f5-9ab6-4fb4-9d5e-19a1c7543b83","added_by":"auto","created_at":"2024-07-18 20:20:29","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":459635,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverarching Multilevel Implementation Theoretical Model\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis study focuses on the organization and provider levels of a 4-level implementation framework\u003csup\u003e20\u003c/sup\u003e that includes evidence informed educational curricula\u003csup\u003e19\u003c/sup\u003e and clinical practice guidelines\u003csup\u003e3,4\u003c/sup\u003e (CPGs) at the system level, LEAP implementation\u003csup\u003e13\u003c/sup\u003e at the organizational level, and ultimately prosthetic fitting and mobility\u003csup\u003e14\u003c/sup\u003e at the patient level.\u003c/p\u003e","description":"","filename":"floatimage2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4456817/v1/8e8b8d2e6850f9b73302bb81.jpg"},{"id":65551383,"identity":"20694313-dd3b-48c1-a733-bed62ad31bb2","added_by":"auto","created_at":"2024-09-30 00:58:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1791250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4456817/v1/04c6ce81-3d8f-4fd5-8122-dd62f5b3e9a2.pdf"},{"id":60614684,"identity":"2d730331-4cf6-44ab-92f1-80be38d66912","added_by":"auto","created_at":"2024-07-18 20:04:29","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25382,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4456817/v1/542b3239ae8a2627a2572510.docx"},{"id":60615473,"identity":"350567a7-d1fb-4d2f-8bee-bb97eb0724b5","added_by":"auto","created_at":"2024-07-18 20:12:29","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":33287,"visible":true,"origin":"","legend":"","description":"","filename":"ImplementationLEAPSTROBEchecklistcrosssectional.docx","url":"https://assets-eu.researchsquare.com/files/rs-4456817/v1/57f4cc6a77ec460230da5d30.docx"}],"financialInterests":"","formattedTitle":"Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators","fulltext":[{"header":"Contributions to Literature ","content":"\u003cul\u003e\n \u003cli\u003eThis study identified determinants to implementing evidence-based practices for smaller clinical populations such as lower extremity amputations.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIdentifying barriers and facilitators to multidisciplinary postoperative care after vascular amputations, led to a proximal strategy recommended to facilitate implementation of a multidisciplinary lower extremity amputation protocol.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis organization and provider-level study was placed in the context of a larger multi-level framework that includes patient and health education systems.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eImplementing established evidence-based practices in rehabilitation settings is difficult despite published Clinical Practice Guidelines (CPGs).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Some estimate integrating research evidence into clinical care takes 17 years.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Evidence suggests consistent post-amputation residual limb dressing and early mobilization speed wound healing and functional mobility and decrease hospital length-of-stay.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e But adopting evidence-based practice for less common clinical populations like people with lower extremity amputations (LEA) may pose special challenges because clinicians may be unfamiliar with the evidence and relevant problems. For instance, while approximately 800x10\u003csup\u003e3\u003c/sup\u003e people in the United States (US) have strokes each year, only a fraction (160x10\u003csup\u003e3\u003c/sup\u003e) have LEA due to diabetes\u0026mdash;the predominant amputation cause.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Nevertheless, LEA incidence continues to increase\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e with diabetes the primary predictor of prolonged lengths-of-stay.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAfter LEA, people with chronic vascular conditions face immediate threats and lifelong functional challenges with high first-year mortality and re-amputation rates and five-year incidences for both approximately 50%.\u003csup\u003e8,9\u003c/sup\u003e Healing can be delayed and function limited with approximately half ultimately non-ambulatory after LEA.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e European and US CPGs describe system-level best practices for peri-operative care.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Post-amputation residual limb dressings promote healing, encourage initial functional mobility, and improve prosthetic walking outcomes.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Early postoperative mobilization facilitates rehabilitation and shorten lengths-of-stay.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Adopting CPG recommendations including post-amputation limb dressings\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e and early mobilization\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e may improve rehabilitation outcomes and decrease postoperative length-of-stay\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e as recently piloted in a lower extremity amputation protocol (LEAP) by one institution.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOne of many challenges that inhibit implementation of evidence-based rehabilitation practice may be that post-amputation care is multidisciplinary by nature.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Multiple disciplines play important roles in peri-operative amputation care focused on wound healing, self-care, and mobility.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, multidisciplinary clinician teams with amputation-specific rehabilitation skills and knowledge are not universally available.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The hierarchical healthcare culture emphasizes physician knowledge, however staff rotations lead to cycles of training and relationship-building that affects consistent practice and communication.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Some disciplines support evidence-based practice with guidelines for systematic new clinician LEA education, but not all disciplines have similar documents.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Evidence suggests coordinated multidisciplinary rehabilitation also facilitates rehabilitation and decrease length-of-stay.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e However, various determinants challenge implementation of evidence-based multidisciplinary rehabilitation practices for LEA.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eExploration of the barriers and facilitators to implementing multidisciplinary evidence-based practices, especially for the less common LEA clinical population, is an important first step to designing implementation strategies that address specific barriers and leverage available facilitators.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The purpose of this study was to determine barriers and facilitators to implementation of a multidisciplinary evidence-based postoperative LEAP aimed at facilitating early rehabilitation and timely hospital discharges.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This descriptive cross-sectional study was approved by the Institutional Review Board of the participating major US medical center, which cares for people after LEA in various intensive care and medical units. An anonymous Qualtrics\u0026trade; (Qualtrics, Provo, UT, USA) survey was sent to a convenience sample of 389 multidisciplinary clinical professionals who could provide postoperative LEAP care,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e including rehabilitation medicine and vascular surgery physicians, prosthetists, nursing staff, and occupational, physical, and recreational therapy professionals. A 60% response rate was the recommended goal.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e No identifying personal information (age, sex, email) were captured to preserve respondent anonymity.\u003c/p\u003e \u003cp\u003eThe survey underwent three developmental steps. \u003cem\u003eFirst\u003c/em\u003e, five prioritized Theoretical Domains Framework domains were selected: knowledge, skills, professional roles and experience, belief in capability, and environment resources.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Domains were organized into a 3-part guiding framework:\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e 1) Awareness combined knowledge and professional experience, 2) Adoption combined skills and belief in capabilities, 3) Contextual determinants included habitual behavior and communication, motivation and goals, and decision-making and multidisciplinary coordination. \u003cem\u003eSecond\u003c/em\u003e, corresponding survey questions addressing each domain were developed, modifying Barriers Scale items for multidisciplinary clinicians.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Three-level answers were chosen for all questions except clinician self-assessments. Clinician self-assessments used four-level answers (very, somewhat, little, not at all), intentionally merging the last two responses anticipating that clinicians might be reluctant to judge themselves \u0026ldquo;not at all\u0026rdquo; knowledgeable, competent, or confident.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Potential barriers were rated on three-levels, with little barrier considered not a barrier anticipating \u0026ldquo;not a barrier\u0026rdquo; to be an unlikely response. \u003cem\u003eThird\u003c/em\u003e, multidisciplinary professionals reviewed the pilot survey to ensure question understandability and process ease, with feedback guiding minor editorial or procedural changes. Professionals in survey development were excluded from data collection.\u003c/p\u003e \u003cp\u003eAnalysis was descriptive and characterized participant professional experience, amputation-related clinical experience, knowledge of related evidence, and experience with specific rehabilitation interventions (Appendix 1). Descriptions of clinical experience reduced indirect and direct experience into ratings of \u0026ldquo;once in a while\u0026rdquo; and \u0026ldquo;frequently,\u0026rdquo; versus \u0026ldquo;never\u0026rdquo; meaning no experience. Experience was direct when care was performed; indirect experience included helping or observing. Incomplete response data was anticipated; missing data was not imputed to avoid bias or measurement error. Percent responses were calculated using each survey question\u0026rsquo;s actual response rate. Quantitative data were analyzed by subgroup. Determinants were rank ordered; items rated by \u0026gt;\u0026thinsp;80% as very much or somewhat a barrier were considered barriers.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Items rated by \u0026lt;\u0026thinsp;60% as very much or somewhat a barrier were considered facilitators.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eQualitative data from written responses to open-ended questions regarding potential barriers and facilitators were used to assess survey internal content validity. Responses were organized using theme analysis identified by consensus of the primary investigators and confirmed by pilot survey recipients. Number of barriers not in the survey indicated internal content validity. Responses were also anticipated to influence implementation planning.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe multidisciplinary sample included 238 respondents, a 61.2% response rate, representing the medical (17.6%), nursing (16.4%), physical therapy (36.1%), occupational therapy (23.1%), recreational therapy (1.3%), and prosthetics (5.5%) professions. Respondent years of professional experience were categorized as \u0026lt;\u0026thinsp;2 (15.9%), 2\u0026ndash;5 (25.4%), 6\u0026ndash;10 (16.4%), 11\u0026ndash;15 (11.6%), and \u0026gt;\u0026thinsp;15 years (30.6%). Respondent experience with amputation rehabilitation, excluding prosthetists, was low with \u0026lt;\u0026thinsp;9% rating themselves as very experienced and 15.5% having seen no post-amputation patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Determinants were rated similarly across professions and experience levels so overall ratings were reported.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondent Experience with Amputation Rehabilitation and Patients After Amputation Seen in Past Year: percent (%) of each profession reported (modes bolded)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespondent Profession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedicine\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProsthetics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRT\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported Experience Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003every experienced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e58.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperienced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esome experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e47.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e30.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e47.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e66.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elittle experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e50.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e30.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients Seen in Past Year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e57.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e33.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e54.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e45.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e83.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAbbreviations: OT\u0026thinsp;=\u0026thinsp;Occupational Therapy, PT\u0026thinsp;=\u0026thinsp;Physical Therapy, RT\u0026thinsp;=\u0026thinsp;Recreational Therapy\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eContextual Determinants\u003c/h2\u003e \u003cp\u003eTwelve determinants were considered major barriers, \u0026gt;\u0026thinsp;80% respondents rated the items very or somewhat of a barrier. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) The top two barriers were clinician confidence the using temporary prostheses (86.9%) and postoperative wound dressings (86.3%) techniques. Clinician confidence using temporary prosthesis was considered a major barrier for majorities of all experience levels and professions including prosthetists. Most rehabilitation therapy respondents did not consider knowledge of early mobilization evidence in general a major barrier. Clinician confidence for all experience levels viewed limb dressings as a major barrier.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondent Perception of Degree to which Barriers Exist to Implementation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotential Barriers\u003c/p\u003e \u003cp\u003e* major barrier ** facilitator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery or Somewhat a Barrier \u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Clinician comfort \u0026amp; confidence using a temporary prosthesis *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Clinician comfort \u0026amp; confidence in wound dressing *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Timely prosthetic support *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Communication between surgeons/physicians \u0026amp; rehab team *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Insufficient number of amputees for experience *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Clinician training with amputees *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Communication with prosthetic team *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Clinician experience with amputees *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Lack of administrative/institutional directives *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Interdisciplinary coordination *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Access to professional clinical training *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Knowledge of the problem *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Sufficient wound care and prosthetics supplies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Lack of automated referral system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Department productivity demands for clinicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Knowledge of the evidence supporting wound dressing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Hospital culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Access to urgent evidence and clinical practice guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Knowledge of evidence supporting temporary prostheses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. Documentation system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21. Knowledge of evidence supporting early mobilization **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22. Communication with non-English speaking patients **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23. Clinician attitude/readiness to change **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFive of the top 12 barriers\u0026mdash;interdisciplinary coordination, administration directives, multidisciplinary and team communication and support\u0026mdash;related to multidisciplinary coordination and communication. Four related to lack of experience with limb dressings and early mobilization, especially for clinicians with \u0026le;\u0026thinsp;15 years-experience: clinical experience, clinician training, access to training, and insufficient post-amputation patients. The twelfth barrier was knowledge of problems delaying discharge post-amputation, especially among clinicians with \u0026lt;\u0026thinsp;2 years-experience. Productivity demands, reflecting concerns about time, were rated as a barrier by 75.1% and was not classified as a potential major barrier (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThree facilitators were identified. Knowledge regarding early mobilization was no more than a little barrier for all experience level categories. Most clinicians across professions and experience levels rated clinician attitude or readiness to change as no more than a little barrier. Communication with non-English speakers was also only a little barrier for respondent of most experience level categories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInternal Content Validity\u003c/h2\u003e \u003cp\u003eSurvey responses provided detailed context for identified barriers and enhanced planning for targeted educational interventions. Written comments from 102 respondents revealed themes that paralleled survey questions (Appendix 1) without introducing new barrier concepts, supporting internal survey content validity. Recurring barriers included limited clinical experience (n\u0026thinsp;=\u0026thinsp;44) and knowledge (n\u0026thinsp;=\u0026thinsp;32), interdisciplinary communication (n\u0026thinsp;=\u0026thinsp;21); institutional support (n\u0026thinsp;=\u0026thinsp;19), and the limited number of post-amputation patients (n\u0026thinsp;=\u0026thinsp;16).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAwareness\u003c/h2\u003e \u003cp\u003eRespondent knowledge of problems encountered post-amputation and related evidence was limited: 60.6% were not or little familiar with problems delaying hospital discharge and 92.8% were unfamiliar with amputation rehabilitation CPG evidence. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) Clinical experience was also limited with 43.2% unfamiliar with semirigid/rigid postoperative dressings and 70.1% having no direct experience applying semirigid/rigid dressings. Conversely, \u0026gt;\u0026thinsp;80% were very or somewhat familiar with post-amputation soft limb dressings and 75% reported at least indirect experience. Across professions, most clinicians also had direct early mobilization experience as soon as postoperative day one, but 88.5% of non-prosthetists lacked any experience with temporary prostheses. (Appendix 2)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-Reported Knowledge by Years of Experience (% of all respondents, modes bolded)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge of\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2-5y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6-10y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11-15y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Practice Guidelines \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamiliar with both\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamiliar with one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot familiar with either\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e14.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e26.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e14.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e11.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e25.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e92.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProblems of Delayed Discharge\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e11.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot or little familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e11.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e17.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e9.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e60.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmputation Rehabilitation Interventions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSoft dressing for limb wrapping\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e11.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e15.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e7.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e6.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e15.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e56.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot or little familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSemirigid/rigid dressings for limb wrapping\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e8.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e14.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e13.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e43.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot or little familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e8.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e6.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e43.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEarly mobilization on Day 1\u003c/b\u003e \u003csup\u003e\u003cb\u003e4\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e9.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e14.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e8.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e12.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e51.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot or little familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTemporary \"bypass\" prosthesis use\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot or little familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e11.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e17.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e10.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e8.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e15.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e62.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: some totals do not add up to 100.0% due to rounding.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e1 92.8% not familiar\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e2 60.6% not or little familiar\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e3 80.6% very or somewhat familiar\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e4 84.7% very or somewhat familiar\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e5 62.7% not familiar\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAdoption\u003c/h2\u003e \u003cp\u003eCompetence in applying soft post-amputation limb dressings was no more than little for most respondents, but confidence to adopt soft limb dressings into daily practice was higher with the overall majority very or somewhat confident. Conversely, majorities across disciplines and experience levels were not or little competent with semirigid/rigid dressings and the majority overall were not or little confident to adopt semirigid/rigid dressings. Confidence to adopt early mobilization into practice post-amputation (very or somewhat confident) was higher than self-rated competence (not or little competent). Few respondents were competent or confident using temporary prostheses with 93.4% reporting no or little competence across non-prosthetist clinicians and all experience levels. (Appendix 2)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study exposed challenges to implementing an evidence-based LEAP for multidisciplinary post-amputation rehabilitation. Top ranked barriers included clinician confidence with specific interventions, lack of clinical LEA experience and clinical training; interdisciplinary coordination and communication; and knowledge of problems delaying hospital discharge. Top barriers reflected multidisciplinary limited self-rated knowledge, clinical experience and competence in specific rehabilitation interventions. Variations across disciplines and experience levels suggest implementing multidisciplinary evidence-based practices could be facilitated with interventions tailored for specific disciplines\u0026rsquo; needs. Broad unfamiliarity with CPG evidence may be because the LEA population is relatively small. Since clinical experience, competence, confidence, and training were top barriers, one recommendation was to increase referrals, and thus LEA patients with whom to gain experience, using an automated multidisciplinary referral system with standard order set to improve referral consistency while facilitating interdisciplinary communication and coordination. Adopting a proximal strategy to potentially affect most mechanisms and distal outcomes may be a useful approach.\u003c/p\u003e \u003cp\u003eThe capability, opportunity, and motivation domains of behavior change (COM-B) were used to organize recommended implementation interventions, recognizing that intended behavior change may arise from multiple factors and that proposed interventions may affect multiple behavioral change functions.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Capability domain recommendations included education addressing knowledge and clinical skills gaps, experienced champions to provide clinical support, and an automated referral system with standard order set to enable multidisciplinary clinicians to provide their specialized care that rotating physicians in training may not be oriented to or unwittingly restrict through the absence of specific orders.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e An automated referral order set with corresponding electronic documentation system would also have an opportunity domain function by expanding opportunities for clinician LEA experience in this relatively small clinical population by reducing the number of LEA patients lost to oversight and removing restrictions multidisciplinary providers may perceive or self-impose based on cultural medical hierarchy.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Motivation domain interventions have been less emphasized than capability and opportunity domain interventions in a Theoretical Domains Framework systematic review, though professional role and identity were frequently noted issues.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e The automated multidisciplinary LEAP referral system may empower disciplines not recognized for their contributions\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e and motivate others disciplines via coercion of perceived requisite action and incentivism of potential cost savings associated with shorter lengths-of-stay.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Together with interdisciplinary education and training and support from multidisciplinary champions, the LEAP automated referral system may foster a sense of team and group purpose while tapping into the propensity to mimic others.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e An automated referral system could be a single intervention that affects all three COM-B domains.\u003c/p\u003e \u003cp\u003eIdentifying barriers and facilitators aids development of implementation strategies to facilitate the mechanisms required to implement new evidence-based practice protocols.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e This study was consistent with a systematic review identifying lack of clinician awareness of the relevant research as a top personal barrier for implementing research in practice.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Insufficient knowledge leads to lower confidence\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e thus education regarding CPG evidence and the problems of delayed rehabilitation appears foundational to implementing a multidisciplinary LEAP.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Limited clinical experience and competence varied among disciplines, perhaps explaining why interdisciplinary communication and coordination were perceived barriers. Multidisciplinary variations helped identify champion clinicians to support educational training matching specific professional needs\u0026mdash;such as postoperative limb dressings and early mobilization.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Specific protocol elements for which multiple professions across experience levels lacked experience, competence, and confidence (semirigid/rigid dressings, temporary prostheses), could not be recommended. One commonly reported barrier, insufficient \u003cem\u003etime\u003c/em\u003e to implement evidence-based practices,\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e was not a major concern in this study, and clinician attitude was a facilitator, supported in self-rated confidence to adopt evidence-based limb dressings and early mobilization practices that exceeded self-rated clinical competence.\u003c/p\u003e \u003cp\u003eThis study identified determinants leading to recommended strategies along a causal pathway that could plausibly lead to measurable implementation outcomes as recommended for effective change enactment.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e) The identified barriers may not be isolated to one institution; others have attempted to initiate a postoperative LEAP at the institutional level.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e This study fits within a multi-level process (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e) in which system level efforts have already been enacted including post-amputation rehabilitation CPGs\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and the American Physical Therapy Association limb loss educational curricular guideline.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAt the organizational level (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the recommended automated multidisciplinary referral system would address institutional barriers such as insufficient patients with which to gain experience and multidisciplinary communication or coordination.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e This single recommendation could have multiple downstream effects. All professions could be automatically alerted to their roles to optimize multidisciplinary communication and coordination, all clinicians would have access to relevant outcome measures through the electronic documentation system, and more people with LEA would be referred, taking advantage of the fact that productivity was not a major barrier.\u003c/p\u003e \u003cp\u003eAt the practitioner level (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e), results prompt recommendations addressing barriers and facilitators.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Accessible educational programming and in-person training were recommended to address knowledge gaps regarding post-amputation problems delaying discharge and limited CPG awareness. Education interventions tailored for targeted professional groups can be supported by recruiting champions, capitalizing on clinician readiness to change. While long-term impact is the ultimate goal, implementing evidence-based practices can take years to enact as many factors influence health outcomes,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e thus improving patient level outcomes remains for future research. This study was constrained to identifying determinants to assist strategic planning for LEAP implementation.\u003c/p\u003e \u003cp\u003eLimitations include sample size which exceeded the 60% response rate,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e but could limit the scope of barriers in written responses. While piloted for understanding and response levels chosen anticipating clinician reluctance to acknowledge lack of competence,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e survey response and recall bias are still possible. Finally, analysis of respondent characteristics was impossible because identifying data was not recorded to ensure anonymity.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study identified barriers and facilitators to implementing an evidence-based multidisciplinary LEAP for postoperative amputation rehabilitation at the provider and organizational levels.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Primary barriers included limited knowledge of the evidence-base, clinical experience, and self-reported clinical competence and confidence. Personal and organizational level barriers included insufficient clinical training and multidisciplinary communication and coordination. Identifying barriers and facilitators can lead to strategies such as an automated referral with standard order set that could affect all COM-B domains to facilitate LEAP implementation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOM-B = Capability Opportunity Motivation - Behavior\u003c/p\u003e\n\u003cp\u003eCPGs = Clinical Practice Guideline(s)\u003c/p\u003e\n\u003cp\u003eLEA = Lower extremity Amputation\u003c/p\u003e\n\u003cp\u003eLEAP = Lower extremity Amputation Protocol\u003c/p\u003e\n\u003cp\u003eUS = United States\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThis study was conducted with approval of the participating major urban US university medical center Institutional Review Board #XXXX-XXXX.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study had no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e All authors approved the final manuscript. AAB contributed substantially to the study concept, and the acquisition, analysis, and interpreted of the data. CKW contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKinney AR, Stearns-Yoder KA, Hoffberg AS, Middleton A, Weaver JA, Roseen EJ, et al. Barriers and facilitators to the adoption of evidence-based interventions for adults within occupational and physical therapy practice settings: a systematic review. Arch Phys Med Rehabil. 2023;104:1132-51.\u003c/li\u003e\n\u003cli\u003eGreen LW, Ottoson JM, Garc\u0026iacute;a C, Hiatt RA. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Ann Rev Public Health. 2009;30:151-74.\u003c/li\u003e\n\u003cli\u003eWebster JB, Crunkhorn A, Sall J, Highsmith MJ, Pruziner A, Randolph BJ. Clinical Practice Guidelines for the rehabilitation of lower limb amputation: an update from the Department of Veterans Affairs and Department of Defense. Am J Phys Med Rehabil. 2019;98:820-9. \u003c/li\u003e\n\u003cli\u003eGeertzen J, van der Linde H, Rosenbrand K, Conradi M, Deckers J, Koning J, et al. Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: amputation surgery and postoperative management. Part 1. Prosthet Orthot Int 2014,39:351-60.\u003c/li\u003e\n\u003cli\u003eCDC National Center for Health Statistics. Accessed May 16, 2024. Available at https://cdc.gov.\u003c/li\u003e\n\u003cli\u003eCai M, Xie Y, Bowe B, Gibson AK, Zayed MA, Li T, et al. Temporal trends in incidence rates of lower extremity amputation and associated risk factors among patients using Veterans Health Administration services from 2008 to 2018. JAMA Netw Open. 2021;4(1):e2033953.\u003c/li\u003e\n\u003cli\u003eEssien SK, Zucker-Levin A. Factors associated with prolonged post-operative acute care length of stay in limb amputation patients in Saskatchewan, Canada. BMC Health Serv Res. 2021;21:1128. \u003c/li\u003e\n\u003cli\u003eRathnayake A, Saboo A, Malabu UH, Falhammar H. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. World J Diabetes. 2020;11:391-9. \u003c/li\u003e\n\u003cli\u003eNehler MR, Coll JR, Hiatt WR, Regensteiner JG, Schnickel GT, Klenke WA, et al. Functional outcome in a contemporary series of major lower extremity amputations. J Vasc Surg. 2003;38:7-14. \u003c/li\u003e\n\u003cli\u003eKwah LK, Webb MT, Goh L, Harvey LA. Rigid dressings versus soft dressings for transtibial amputations. Cochrane Database Syst Rev. 2019;6:CD012427.\u003c/li\u003e\n\u003cli\u003eWong CK, Rosati J, Forbes K, Feng S, Donohue A, Beckley A. A scoping review of postoperative early rehabilitation programs after dysvascular-related amputations. Prosthet Orthot Int. ePub 2024 May 21: doi: 10.1097/PXR.0000000000000361. \u003c/li\u003e\n\u003cli\u003eReichmann JP, Stevens PM, Rheinstein J, Kreulen CD. Removable rigid dressings for postoperative management of transtibial amputations: a review of published evidence. PM R. 2018;10:516-23. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Banion LA, Qumsiyeh Y, Matheny H, Siada SS, Yan Y, Hiramoto JS, et al. Lower extremity amputation protocol: a pilot enhanced recovery pathway for vascular amputees. J Vasc Surg Cases Innov Tech 2022;8:740-7.\u003c/li\u003e\n\u003cli\u003eStineman MG, Kwong PL, Xie D, Kurichi JE, Ripley DC, Brooks DM, et al. Prognostic differences for functional recovery after major lower limb amputation: effects of the timing and type of inpatient rehabilitation services in the Veterans Health Administration. PM R 2010;2:232-43. \u003c/li\u003e\n\u003cli\u003eDuarte A, Bojke C, Cayton W, Salawu A, Case B, Bojke L, et al. Impact of specialist rehabilitation services on hospital length of stay and associated costs. Eur J Health Econ. 2018;19:1027-34.\u003c/li\u003e\n\u003cli\u003eKwah LK, Green J, Butler J, Lam L. Quality of clinical practice guidelines for management of limb amputations: a systematic review. Phys Ther. 2019;99:577-90.\u003c/li\u003e\n\u003cli\u003eSauter CN, Pezzin LE, Dillingham TR. Functional outcomes of persons who underwent dysvascular lower extremity amputations: effect of postacute rehabilitation setting. Am J Phys Med Rehabil. 2013;92:287-96. \u003c/li\u003e\n\u003cli\u003eRogers L, De Br\u0026uacute;n A, McAuliffe E. Exploring healthcare staff narratives to gain an in-depth understanding of changing multidisciplinary team power dynamics during the COVID-19 pandemic. BMC Health Serv Res. 2023;23:419. \u003c/li\u003e\n\u003cli\u003eAPTA Academy of Acute Care Physical Therapy. Amputation and limb difference curricular guideline for entry-level doctoral of physical therapy professional degree programs. Accessed Jan 10, 2024. Available at https://www.aptaacutecare.org/store/viewproduct.aspx?id=18270303\u003c/li\u003e\n\u003cli\u003eKrause J, Van Lieshout J, Klomp R, Huntink E, Aakhus E, Flottorp S, et al. Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods. Implement Sci. 2014;9:102. \u003c/li\u003e\n\u003cli\u003eJones CA, Roop SC, Pohar SL, Albrecht L, Scott SD. Translating knowledge in rehabilitation: systematic review. Phys Ther. 2015;95:663-77.\u003c/li\u003e\n\u003cli\u003eMurrel JE, Pisegna JL, Juckett LA. Implementation strategies and outcomes for occupational therapy in adult stroke rehabilitation: a scoping review. Implement Sci. 2021;16:105. \u003c/li\u003e\n\u003cli\u003eFincham JE. Response rates and responsiveness for surveys, standards, and the Journal. Am J Pharm Educ. 2008;72:43. \u003c/li\u003e\n\u003cli\u003eAtkins L, Francis J, Islam R, O\u0026rsquo;Connor D, Patey A, Ivers N, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77. \u003c/li\u003e\n\u003cli\u003eKajermo KN, Bostr\u0026ouml;m AM, Thompson DS, Hutchinson AM, Estabrooks CA, Wallin L. The BARRIERS scale\u0026mdash;the barriers to research utilization scale: a systematic review. Implement Sci. 2010;5:32.\u003c/li\u003e\n\u003cli\u003eRosenman R, Tennekoon V, Hill LG. Measuring bias in self-reported data. Int J Behav Healthc Res. 2011;2:320-32. \u003c/li\u003e\n\u003cli\u003eKreitchmann RS, Abad FJ, Ponsoda V, Nieto MD, Morillo D. Controlling for response biases in self-report scales: forced choice vs psychometric modelling of Likert items. Front Psych. 2019;10:2309.\u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Sci. 2011;6:42. \u003c/li\u003e\n\u003cli\u003eMather M, Pettigrew LM, Navaratnam S. Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel. Syst Rev. 2022;11;180.\u003c/li\u003e\n\u003cli\u003eFernandopulle N. To what extent does hierarchical leadership affect health care outcomes? Med J Islam Repub Iran. 2021;14(35):117. \u003c/li\u003e\n\u003cli\u003eWaltz TJ, Powell BJ, FernandezME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci 2019;14:1-15.\u003c/li\u003e\n\u003cli\u003ePantoja AF, Britton JR. An evidence-based, multidisciplinary process for implementation of potentially better practices using a computerized medical model. Int J Qual Health Care. 2011;23:309-16. \u003c/li\u003e\n\u003cli\u003eLewis CC, Klasnja P, Lyon AR, Powell BJ, Lengnick-Hall R, Buchanan G, et al. The mechanics of implementation strategies and measures: advancing the study of implementation mechanisms. Implement Sci Commun. 2022;3:114. \u003c/li\u003e\n\u003cli\u003eMadsen UR, Hommel A, Berthelsen CB, B\u0026aring;\u0026aring;th C. Systematic review describing the effect of early mobilisation after dysvascular major lower limb amputations. J Clin Nurs. 2017;26:3286-97. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Amputation, early mobilization, wound dressing, determinants, implementation research","lastPublishedDoi":"10.21203/rs.3.rs-4456817/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4456817/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Implementing\u003cstrong\u003e \u003c/strong\u003eevidence-based clinical practice guidelines (CPGs) requiring multidisciplinary efforts for relatively small clinical populations such as people undergoing lower extremity amputations, may present special challenges. People with chronic vascular diseases face wound healing and mobilization challenges that delay rehabilitation and hospital discharge. Lower extremity amputation protocols (LEAP) including postoperative limb dressings and early mobilization improve healing, functional outcomes, and reduce hospital lengths-of-stay—but require multidisciplinary coordination. The purpose of this study was to identify barriers and facilitators to implementing a multidisciplinary evidence-based LEAP for postoperative rehabilitation after amputation. \u003cbr\u003e\n \u003cstrong\u003eMethods\u003c/strong\u003e: This cross-sectional organization and provider-level study included a convenience sample of 238 multidisciplinary professionals from an urban medical center. An anonymous survey, developed using the Theoretical Domains Framework, explored barriers and facilitators in the knowledge, clinical skills, and personal/contextual domains. Analysis was descriptive with barriers rank ordered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 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%). Self-rated knowledge was low: 93.3% were unfamiliar with amputation rehabilitation CPGs and 60.9% were unfamiliar with problems delaying hospital discharge. Self-rated clinical competence was low corresponding to minimal reported experience with post-amputation limb wrapping or early mobilization. Potential barriers included unfamiliarity with the evidence, limited clinical training and confidence, insufficient patients, and inadequate interdisciplinary communication and coordination. Facilitators included clinician readiness to change and knowledge of early mobilization evidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Identifying barriers and facilitators led to provider and organization-level recommendations organized using the behavior change wheel to consider the capability, opportunity, and motivation domain functions. An automated multidisciplinary referral system with standard order set emerged as a proximal strategy to potentially affect all three domains and multiple implementation mechanisms while leveraging clinician attitude may provide a path towards LEAP implementation.\u003c/p\u003e","manuscriptTitle":"Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers and facilitators","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:04:25","doi":"10.21203/rs.3.rs-4456817/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d2969ab-a992-4b27-99a1-6c3602eeb3dc","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T00:50:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:04:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4456817","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4456817","identity":"rs-4456817","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}