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

Abstract

Background

People undergoing lower extremity amputations are often overlooked in healthcare. Limited clinician knowledge and skills challenge implementation of evidence-based clinical practice guidelines. Multidisciplinary lower extremity amputation protocols (LEAP) piloted in community and regional settings have improved outcomes and reduced hospital length-of-stay—but remain untested in larger settings. The purpose of this study was to identify barriers, facilitators, and strategies for implementing a multidisciplinary evidence-based LEAP for postoperative rehabilitation in a large urban quaternary medical center.

Methods

The planning phase study used the Theoretical Domain Framework (TDF) to develop and administer an anonymous survey. A purposive sample of 238 multidisciplinary professionals from a large urban medical center responded. The TDF and Capability-Opportunity-Motivation for Behavior Change (COM-B) framework—with its 3 components aligned with 6 behavior sources in 8 domains with further construct-level detail—were used for data analysis. Analysis was descriptive with barriers rank-ordered, facilitators identified by theme analysis, and strategies derived from written comments.

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%). Primary barriers fell within the knowledge, skill, and belief-in-capability capability-domains; and the professional role and environmental context opportunity-domains. Four capability and opportunity component facilitators emerged with corresponding strategies: education via short multimedia resources, hands-on clinical training, clinical support via champion mentors, and interdisciplinary coordination via automated multidisciplinary order set.

Conclusions

Identifying barriers and facilitators led to provider- and organization-level strategies that address capability and opportunity TDF components. Capability strategies included didactic education and clinical training supported by mentors. An automated multidisciplinary order set referral system emerged as the principal opportunity strategy. The order set aimed to improve communication regarding professional roles, enhance clinical training opportunities, and coordinate interdisciplinary care in the teaching hospital context of rotating multidisciplinary clinicians of a large urban quaternary medical center.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-025-00815-9.

Contributions to the literature.

• Clinical practice guidelines present best evidence-based practices for people undergoing lower extremity amputation (LEA).

• Knowledge and skills for specialized evidence-based care for the relatively small population undergoing vascular LEA is limited.

• Identifying capability and opportunity component barriers may facilitate multidisciplinary lower extremity amputation protocol (LEAP) implementation scaled for large urban settings.

• A standard multidisciplinary order set was identified as a facilitating strategy for evidence-based LEAP implementation in a large urban quaternary medical center with rotating staff.

• This organization- and provider-level study fits established system- and patient-level initiatives into a four-level framework for ultimately improving care for people after LEA.

Background

Approximately 150,000 Americans have non-traumatic vascular lower extremity amputation (LEA) each year [1]. Though far fewer than the number undergoing strokes or heart attacks annually, LEA incidence is increasing [2] with prevalence of people with vascular LEA—the most common cause—growing to more than 2 million by 2030 [3]. People with peripheral vascular and diabetes-related LEAs face immediate threats and functional challenges. Both first-year mortality and five-year re-amputation rates are ~ 50% [4, 5]. Vascular complications delay healing, limit mobility, and leave approximately half non-ambulatory after LEA [5], with diabetes the primary predictor of prolonged hospital length-of-stay [6].

European and American Clinical Practice Guidelines (CPGs) describe best evidence-based practices for initial rehabilitation after LEA including residual limb dressing and early mobilization [7, 8]. Post-amputation residual limb dressings promote healing, encourage functional mobility, and improve prosthetic outcomes [9]. Early mobilization speeds rehabilitation and shortens hospital length-of-stay [10]. Adopting post-amputation limb dressings [11] and early mobilization [12] improve rehabilitation outcomes after LEA and decrease postoperative lengths-of-stay [12–14]. Despite published CPGs, implementing evidence-based practices in rehabilitation settings is difficult [15] and some estimate integrating research into clinical care takes 17 years [16].

One implementation challenge is the multidisciplinary nature of post-amputation rehabilitation [17]. Each discipline plays specific roles in wound healing, self-care, and mobility [11, 18]. However, multidisciplinary teams with amputation-specific rehabilitation knowledge and skills are not universally available [7, 13, 14]. Hierarchical healthcare culture emphasizes physician knowledge, yet staff rotations mean cycles of training and relationship-building that challenges consistent practice and communication [19]. Some disciplines, yet not all, support evidence-based LEA care with educational curricular guidelines [20]. Smaller populations like people with LEA pose special difficulties because fewer clinicians may be familiar with relevant clinical problems and CPGs. These barriers hinder implementation of evidence-based multidisciplinary post-amputation practices [15, 21].

Pilot studies implementing early mobilization after LEA, using unit-based educators at a community hospital and a standard order set at a regional-tertiary care facility, have shown potential to improve care [12, 22]. Both studies also highlighted potential challenges for larger scale LEAP implementation in quaternary teaching hospital settings [12, 22]. The surgeon- and nursing-driven pilots emphasized that initial postamputation rehabilitation requires multidisciplinary clinician participation [12, 22]. Evidence suggests multidisciplinary coordination facilitates rehabilitation outcomes including shorter hospital length-of-stay [14]. General barriers to implementing multidisciplinary evidence-based practices have consistently included clinician values, skills, and awareness [23], yet specific barriers and facilitators after LEA at the large urban quaternary scale is unknown. Exploring specific barriers to evidence-based post-amputation practices and identifying facilitators to leverage in designing implementation strategies is a preliminary step for large scale implementation [24, 25]. This study’s purpose was to determine barriers, facilitators, and potential strategies for implementing a multidisciplinary evidence-based postoperative lower extremity amputation protocol (LEAP) at a large urban quaternary medical center.

Methods

This study was approved by the Institutional Review Board of the participating American major medical center caring for people after LEA in intensive care and medical units, and hosting training programs for all disciplines. The 2-part study was the planning phase for multidisciplinary evidence-based LEAP implementation. Part 1 was development, deployment, and analysis of a Theoretical Domain Framework (TDF) based survey to identify LEAP implementation barriers and facilitators [26]. Part 2 involved identification of potential strategies for facilitating LEAP implementation based on Capability-Opportunity-Motivation Behavior (COM-B) system analysis [26, 27].

The target behavior was adoption of evidence-based CPG postamputation rehabilitation practices, specifically limb wrapping and early mobilization to facilitate timely discharge [7, 8]. While the ultimate goal is improving patient-level outcomes such as earlier mobility milestones, shorter hospital lengths-of-stay, and faster prosthetic fitting, this study targeted provider- and organization-level behaviors adapted from the LEAP first described and trialed in a regional medical center in 2022 [12]. The provider- and organization-level efforts fit into the broad context of a theoretical overarching 4-level LEAP implementation model (Fig. 1). System-level interventions already deployed include the CPGs and educational guidelines for physical therapy amputation rehabilitation curricula [20]. Some patient-level outcomes have been improved with LEAPs in community hospital and regional medical center settings [12, 22]. With system-level interventions in place [7, 8, 20] and positive patient-level outcomes [12, 22], a descriptive survey study design was planned to identify barriers, facilitators, and potential strategies for LEAP implementation. The LEAP was then scaled for a large urban medical center providing quaternary care and multidisciplinary educational training programs [26].

Fig. 1.

Overarching Multilevel Implementation Theoretical Model for LEAP implementation with the Study Focus on the Organization and Provider Levels

The three-step survey development was conducted understanding that no single method has been established for selecting relevant domains [26, 28].

First, TDF domains were selected and adapted to the multidisciplinary teaching hospital LEAP implementation goal, accounting for the study’s planning stage and analysis of earlier pilots revealing provider- and organization-level challenges [12, 22, 26]. Eight relevant domains were categorized by behavioral change components and sources using the COM-B framework [26, 27]. Relevant constructs for each domain were identified and adapted from the TDF (Table 1) [26]. Barriers to specific CPG recommendations—limb wrapping and early mobilization—were anticipated and explored. Non-volitional constructs—patient availability—and those amenable to individual change were included [29].

Table 1.

COM-B Framework—Theoretical Domain Framework construct components organized by behavior change component and the source of behavior

Behavioral Change Components	Behavior Source	Domains	Constructs
CAPABILITY	Physical	Skills	Clinical skill, competence, ability experience
	Psychological	Knowledge	Knowledge of problem, evidence, and procedures
		Memory—Attention - Decision Process	Memory, attention, and Decision making
		Belief-in-capability	Confidence in ability
OPPORTUNITY	Social	Professional Role—Identity	Professional role, group, leadership, organizational commitment
	Physical	Environmental context	Availability or patients, available mentors, educational resources, organizational culture
MOTIVATION	Automatic	Emotions	Burn out, time
	Reflective	Belief in Consequences	Outcomes

Second,survey questions corresponding to each construct and domain inclusive of COM-B components and sources were developed [26]. Barriers to specific CPG recommendations were assessed with 3-level answers (very, somewhat, little). For clinician self-assessments, 4-level answers (very, somewhat, little, not at all) were used intentionally merging the last two responses anticipating that clinicians might reluctantly judge themselves “not at all” knowledgeable, competent, or confident [30, 31]. Other barriers were rated on 3-levels, with little barrier considered not a barrier.

Third, the survey was pilot tested with multidisciplinary professionals reflecting the planned recipients. Feedback guided minor editorial and procedural changes that were made to ensure survey ease and understanding before launch. Professionals involved in survey development and pilot testing were excluded from data collection.

A purposive sampling strategy including all clinicians from all disciplines participating in post-amputation care was chosen [32] recognizing the study’s exploratory nature, planning phase, and multidisciplinary involvement. Since teaching-hospital clinicians rotate for varying periods through different services with involvement sometimes limited to occasional weekend coverage, the survey was sent to all 389 multidisciplinary clinicians potentially providing postoperative LEAP care including vascular surgeons, rehabilitation medicine physicians and nurses, prosthetists, and occupational, physical, and recreational therapy professionals. The response rate goal was 60% as recommended for adequate representation [33]. Data was collected via anonymous Qualtrics™ (Qualtrics, Provo, UT, USA) survey to encourage frank responses, with a condensed 1-month response time to avoid evolving perceptions. No identifying personal data were captured to preserve respondent anonymity. Adopting an evidence-based LEAP depends on individual clinician behaviors and effective timely multidisciplinary communication, so both practitioner- and organization-level information was anticipated (Fig. 1).

Cross-sectional data analysis was descriptive and characterized context-relevant professional experience, post-amputation clinical experience with specific rehabilitation skills, and knowledge of evidence (Appendix 1). Analysis of determinants corresponded to TDF domain constructs (Table 1) with barriers rank-ordered per common practice [23] and items rated by > 80% as very much/somewhat a barrier signifying major barriers. Direct clinical experience involved performing clinical care on people living with limb loss. Indirect experience with people living with limb loss was defined as helping or observing were reduced into “once in a while” and “frequently” ratings versus “never” meaning no experience. Incomplete responses were anticipated. Each question’s actual response rate was calculated; missing data was not imputed to avoid bias or measurement error.

Qualitative written responses to open-ended questions were used to identify any additional barriers and potential facilitators (Appendix 1). Responses were organized using theme analysis by the primary investigator upon consensus discussion amongst pilot survey recipients. Planning stage facilitators, defined as factors enabling evidence-based intervention implementation [34], were categorized by most frequently recurring themes [35]. Strategies corresponding to identified facilitators were linked to relevant TDF domains at the construct level [34] to be placed in a causal pathway for implementation planning.

Results

Respondent characteristics

The 238 respondents, a 61.2% response rate, represented multiple disciplines: medicine (17.6%); nursing (16.4%); prosthetics (5.5%); physical (36.1%), occupational (23.1%), and recreational therapy (1.3%). Years of professional experience were < 2 (15.9%), 2–5 (25.4%), 6–10 (16.4%), 11–15 (11.6%), and > 15 years (30.6%). Amputation rehabilitation experience, excluding prosthetists, was low with < 9% rating themselves as very experienced and 15.5% reporting no experience (Table 2).

Table 2.

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

Clinical practice guidelines familiarity

Specific evidence-based postoperative limb wrapping and early mobilization CPG recommendations were highlighted as capability component barriers. The skills domain arising from physical behavior sources included clinical skill, competence, and ability experience. Psychological behavioral sources included knowledge domain constructs such as knowledge of the problem, evidence, and procedures. Psychological behavior sources also include the belief-in-capability domain as outlined in Table 1. Knowledge of post-amputation problems and related evidence was limited: 60.6% of respondents were unfamiliar with problems delaying hospital discharge, 92.8% of respondents were unfamiliar with the CPGs (Table 3). Specific post-amputation rehabilitation skills were also limited. While > 80% of respondents were somewhat or very familiar with soft limb dressings and 75% of respondents reported at least some indirect experience (Appendix 2), 43.2% of respondents were unfamiliar and 70% of respondents had no direct experience applying semirigid/rigid post-amputation dressings (Appendix 2). Across professions, most clinicians had direct early mobilization experience as soon as postoperative day one, but 88.5% of non-prosthetists lacked experience using temporary prostheses (Appendix 2). Most reported no/little competence applying soft limb dressings and majorities across disciplines and experience levels had no/little competence with semirigid/rigid dressings. Belief-in-capability marked by confidence also varied with specific clinical skills. The majority of respondents were very/somewhat confident using soft limb dressings; but had no/little confidence using semirigid/rigid dressings. Confidence adopting early mobilization post-amputation was higher than competence, but 93.4% reporting no/little competence using temporary prostheses for early mobilization across non-prosthetist disciplines and all experience levels (Appendix 2).

Table 3.

Self-Reported Knowledge of the Problem, Evidence-Base, and Specific Procedures by Years of Experience (% of all respondents, modes bolded)

Knowledge of	< 2y	2-5y	6-10y	11-15y	> 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

Some totals do not add up to 100.0% due to rounding

Barriers

Twelve major barriers were identified by more than 80% of respondents, with barriers identified by fewer than 80% considered minor (Table 4). Barriers spanning both Capability and Opportunity components were revealed.

Table 4.

Respondent Perception of Degree to which Barriers Exist to Implementation and Recurring Themes within Written Comments

Barriers Rated Very or Somewhat a Barrier	(%)	Recurring Themes (n)
1. Clinician comfort & confidence with temporary prostheses *	86.9	–
2. Clinician comfort & confidence in wound dressing *	86.3	–
3. Timely prosthetic support *	86.0	16
4. Communication between surgeons/physicians & rehab team *	85.6	21
5. Insufficient number of amputees for experience *	85.4	16
6. Clinician training with amputees *	85.1	56
7. Communication with prosthetic team *	85.0	–
8. Clinician experience with amputees *	84.7	44
9. Lack of administrative/institutional directives *	83.7	19
10. Interdisciplinary coordination *	82.2	27
11. Access to professional clinical training *	82.2	56
12. Knowledge of the problem *	81.0	32
13. Sufficient wound care and prosthetics supplies	78.3	–
14. Lack of automated referral system	76.4	18
15. Department productivity demands for clinicians	75.2	16
16. Knowledge of the evidence supporting wound dressing	74.9	35
17. Hospital culture	73.8	19
18. Access to evidence and clinical practice guidelines	72.4	7
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	–

^* major barrier

^** not a barrier

Capability component barriers included clinician confidence in specific skilled behaviors. The top two of seven capability barriers were: using temporary prostheses (86.9%) for majorities of all experience levels and professions including prosthetists, and postoperative limb dressings (86.3%) for majorities of all experience levels. Four other capability barriers in the skills and belief-in-capability domains were clinical experience, clinician training, access to training, and support. Limited experience with limb dressings and early mobilization was apparent for clinicians with ≤ 15 years-experience, though most therapists did not consider early mobilization knowledge a major barrier. The seventh capability barrier was post-amputation problem knowledge, especially among clinicians with < 2 years-experience.

Opportunity domain constructs were highlighted by five barriers: interdisciplinary coordination, administrative/institutional directives, multidisciplinary and team communication, and insufficient post-amputation patients. All related to perceived professional roles, leadership, and multidisciplinary communication within the environmental context including organizational culture and limited LEA population. Belief-in-consequences or emotions domains were not major barriers for most clinicians across professions and experience levels including clinician attitude or readiness to change, communication with non-English speakers, and time and productivity demands (Table 4).

Facilitators

Written comments from 102 respondents revealed recurring themes that were then tabulated (Table 4) and paralleled barriers identified in the survey responses (Appendix 1). Recurring themes introduced no new barrier categories suggesting the survey captured the full range of potential barriers and internal content validity. The 14 recurring themes spanned all 6 capability and opportunity domains. Skill was most common and included clinical training, access to professional training, and clinical experience. Knowledge included knowledge of the problem and evidence supporting wound dressing, and access to the clinical practice guidelines. Belief-in-capability included timely prosthetic support and insufficient number of patients. Memory-attention-decision making included the lack of administrative/institutional directives or an automated referral system. Professional role included interdisciplinary coordination and communication between surgeons/physicians and the rehabilitation team. The environmental context domain included hospital culture and department productivity demands.

The recurring themes led to the emergence of four facilitators to address barriers across all 6 domains accompanied with suggested strategies LEAP implementation (Table 5): 1-Didactic education to enhance evidence-based knowledge with clinical practice resources for just-in-time access via hospital network. 2-Clinical training for skill development through hands-on training scheduled periodically to account for hospital rotations. 3-Clinician support by champion mentors to enhance educational resources in the clinic context. 4-Multidisciplinary communication streamlined by creating an automated order set to clarify professional roles, and minimize memory, attention, and decision-making burden for continually rotating, multidisciplinary teaching hospital clinicians. Order automation minimizes inadvertent non-referrals providing more clinical experience opportunities. The four strategies address both physical and psychological or social behavior sources in the COM-B model capability and opportunity components to aid implementation causal pathway planning.

Table 5.

Barriers, Facilitators, and Proposed Strategies within the COM-B Framework

Components	Domains	Barriers	Facilitators	Strategies
CAPABILITY	Skills	Clinician experience, Clinical training, Access to training	Clinical training: Clinician support:	Hands-on training Champion mentors
	Knowledge	Knowledge of the problem and evidence for procedures, Access to CPG	Didactic education:	Clinical practice resources for just-in-time access via hospital network
	Belief-in-capability	Timely support, Insufficient patients	Clinical training: Clinician support:	Hands-on training Champion mentors
	Memory-Attention- Decision Process	Lack of administrative directives and a referral system	Multidisciplinary communication:	Automated order set
OPPORTUNITY	Professional Role/Identity	Interdisciplinary coordination, Communication between surgeon/physicians and rehab team	Multidisciplinary communication:	Automated order set
	Environmental context	Hospital culture, Department productivity	Multidisciplinary communication: Clinician support:	Automated order set Champion mentors

Discussion

This study identified barriers, facilitators, and strategies for implementing an evidence-based multidisciplinary LEAP scaled for a large quaternary care level urban teaching hospital. Exposed capability barriers included limited knowledge of CPG evidence and problems encountered post-amputation; limited clinical skill and post-amputation rehabilitation experience; and limited confidence and capability to perform specific procedures. Limited knowledge, skills, and confidence in post-amputation rehabilitation could be partly attributed to opportunity barriers: insufficient LEA patients to gain experience, clinical support, and organizational coordination. Facilitators identified with corresponding strategies were clinician education via accessible didactic education, regular hands-on training, champion mentors for clinical support, and an automated LEAP order set coordinating multidisciplinary care and communication.

Results conformed with systematic review findings identifying clinician awareness of relevant research as a top barrier for implementing research into practice [23]. Challenges facing people postamputation are not isolated to one institution. With system-level interventions in place [7, 8, 20] and pilot LEAPs at smaller institutions suggesting improved patient-level outcomes [12, 22]; the current study addressed organizational- and provider-level barriers within the multi-level framework (Fig. 1). An automated referral system can have downstream opportunity effects by streamlining multidisciplinary communication, optimizing interdisciplinary coordination, and minimizing lost referrals that cause insufficient patients [12, 22]. Sustainable clinical training is a challenge for any teaching hospital with rotating clinicians, especially large institutions hosting multidisciplinary educational programs, potentially ameliorated by champion mentors not used in community and regional hospital LEAP implementation efforts [12, 22]. Thus, practitioner-level strategies addressing barriers were recommended emphasizing accessible educational programming addressing procedural and evidence-based knowledge gaps and regular hands-on training supported by champion mentors [36]. Implementing evidence-based practices takes years as many factors influence health outcomes [16, 37], so while the ultimate goal is clinical impact, patient-level outcomes remain for future study.

Clinician attitude was not a barrier reflected by confidence to adopt evidence-based practices exceeding clinical competence, insufficient time not considered a major concern [23, 38], and clinicians’ readiness to change. Clinical skills and confidence in capabilities were behavior-specific with some variation across disciplines and experience levels suggesting discipline-specific strategies could help. Specific behaviors such as semirigid/rigid postoperative dressings and temporary prostheses for which insufficient clinical competence and confidence was widespread across professions and experience levels were dropped.

The next implementation planning steps, recognizing multiple factors affect behavior change functions, were to prepare a suggested LEAP causal pathway strategies (Fig. 2) [27]. Creating accessible educational resources addresses gaps in postamputation knowledge, evidence, and procedural ability to build foundational confidence [38, 39]. Designing hands-on multidisciplinary training programs facilitates clinical skill development. Recruiting champions is a precondition for program support, leadership, and multidisciplinary mentorship that can moderate clinician habits through the propensity to mimic others [27]. Finally, creating a multidisciplinary automated referral system with standard order set reduces referrals lost to oversight [19] and minimizes self-imposed clinician restriction based on cultural medical hierarchy [27]. An automated multidisciplinary order set may also affect other motivation domains [38] by empowering disciplines unrecognized for their contributions [40], fostering teamwork and group purpose [27], and motivating through perceived requisite action or incentivism of cost savings associated with shorter hospital lengths-of-stay [27]. A new automated system requires administrative review, organizational approval, and electronic medical record installation. The recommended strategies activate mechanisms along the causal pathway that can plausibly lead to measurable short-term outcomes including more rehabilitation referrals and CPG adherence and ultimately long-term improved patient outcomes (Fig. 2) [36, 37].

Fig. 2.

Implementation Causal Pathway of the LEAP—Lower Extremity Amputation Protocol

Study limitations include sample size which could limit the scope of written responses barriers, and potential response and recall biases. The survey could have included motivation component questions about expected outcomes. Finally, the study was constrained to strategic planning and implementation outcomes remain unexplored.

Conclusions

This study identified barriers, facilitators, and corresponding strategies to implementing an evidence-based multidisciplinary LEAP for postoperative amputation rehabilitation at the provider- and organization-level. Primary barriers included limited knowledge of post-amputation rehabilitation challenges and CPG evidence; clinical skill, competence, and experience; and confidence in capability. Primary facilitators that emerged—didactic education, clinical training, clinical support, and multidisciplinary communication—led to strategies focused on accessible clinician education, hands-on training, champion mentors, and an automated multidisciplinary order set. The planned strategies primarily addressed capacity and opportunity components of behavior change and adds provider- and organization-level strategies to the existing system- and patient-level interventions in the LEAP implementation framework.

Abbreviations

COM-B

Capability Opportunity Motivation—Behavior

CPGs

Clinical Practice Guideline(s)

LEA

Lower Extremity Amputation

LEAP

Lower Extremity Amputation Protocol

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.

Funding

This study had no funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

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.

Competing interests

The authors declare that they have no competing interests.