title: Quality improvement framework for major amputation: are we getting it right?
abstract: BACKGROUND
  The quality improvement framework for major amputation was developed with the aim of improving outcomes and reducing the perioperartive mortality to less than 5% by 2015. The aim of the study was to assess our compliance with the framework guidelines and look for the reasons for non-compliance.
  
  
  METHODS
  All major amputations performed between 2008 and 2010 were included. The following data were collected: presence of infection ± tissue loss, status of arterial supply, revascularisation attempts, time to surgery, type of amputation, morbidity and mortality.
  
  
  RESULTS
  A total of 81 patients were included (42 BKAs, 39 AKAs). Ninety percentage had formal preoperative arterial investigations and 84% had an attempted revascularisation procedure. Patients who were transferred late from non-vascular units (n = 12) had a 30-day mortality of 50% whereas patients who presented directly to our unit had a 30-day mortality of 7.2%. The number of amputations has decreased over the last 3 years from 34 to 21 per year, coinciding with the doubling of crural revascularisation procedures performed (from 60 to 120 per year). Ten patients underwent a revision from BKA to AKA because of an inadequate profunda femoris artery (PFA), whereas all those with a healed BKA stump either had a good PFA or a named crural vessel.
  
  
  CONCLUSIONS
  The overall number of amputations is decreasing from year to year. By doubling our crural revascularisation procedures we are saving more limbs. Thirty-day mortality is higher than expected, particularly in patients who present late. Expeditious referral may potentially improve the mortality rate among this group of patients.
authors.affiliation: Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK. jokrysa@hotmail.co.uk
authors.forename: J
authors.initials: J
authors.lastname: Krysa
authors.forename: S
authors.initials: S
authors.lastname: Fraser
authors.forename: P
authors.initials: P
authors.lastname: Saha
authors.forename: M
authors.initials: M
authors.lastname: Fuller
authors.forename: R E
authors.initials: RE
authors.lastname: Bell
authors.forename: T W G
authors.initials: TW
authors.lastname: Carrell
authors.forename: B
authors.initials: B
authors.lastname: Modarai
authors.forename: P R
authors.initials: PR
authors.lastname: Taylor
authors.forename: H A
authors.initials: HA
authors.lastname: Zayed
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D015424:Reperfusion / Q000706:statistics & numerical data; D013530:Surgical Wound Infection / Q000209:etiology; D061665:Time-to-Treatment; D016896:Treatment Outcome