After getting elite medical training in New Orleans and San Francisco, Leigh Ann O’Banion returned home to Fresno, California five years ago to practice vascular surgery. She quickly got tired of seeing her limb-loss patients slip through the cracks of the health care system, so she trained a nurse in her practice, Jessica Dodson, to guide new amputees through the post-operation maze.

As we describe in the March/April issue, the results of O’Banion’s initiative have been nothing short of spectacular—healthier outcomes, happier patients, and a near-doubling of the success rate for prosthesis uptake. We only had room to tell a small part of the story in the print edition, so here’s a longer version of our conversation with Dr. O’Banion. The transcript has been edited for clarity and length.

How did Jessica’s role as amputee patient navigator come into being? Was it driven by patients asking for more support? Or was it more about your practice finding that patients weren’t having good outcomes?
During my residency in general surgery and my fellowship in vascular surgery at UCSF in San Francisco, I noticed that everyone wants to focus on limb salvage. Everyone wants to save a limb. If we fail—and statistically, we’re going to fail a lot—then no one seems to care anymore. And it’s not really that they don’t care, but they think there’s nothing more they can do. They’re like, “Oh, we failed. We had to amputate.”

Whose voices are you channeling there? Is that how the surgical team feels?
I think it’s everyone involved. I think sometimes even the patients feel like they’re done. Everyone feels like, “We pushed, we tried so hard to save the leg, but we failed, and we ended up with a major amputation. And that’s the end.” When in fact, it’s actually just the beginning. It’s the beginning of your new life as an amputee. And I would argue, after doing this for five years and really putting my heart and soul into this project, that for a large majority of patients, it’s actually a better life than they had before the amputation. Before amputation, perhaps they were getting wound care on a weekly basis. Maybe they weren’t working, they were in constant pain, they were suffering, they couldn’t care for their family, and their family had an undue burden caring for them. I just don’t think that we’ve focused on the amputee enough.

I don’t know if you’re familiar with the San Joaquin Valley in California, but it’s got a highly disadvantaged patient population. I used to have a lot of patients getting discharged with their wheelchair, and they didn’t speak English in many cases, and maybe no one told them that they were supposed to see their surgeon again or a PT or a prosthetist. Maybe they went to a nursing home, and someone just took out their staples and sent them on their way without any other support.

I went back and looked at our patients over a ten-year period. What we found was that the average hospital stay after getting an amputation was seven days. They weren’t routinely getting limb protectors, and only about half were going on to receive a prosthesis—which means the other half were being put in a wheelchair and never walking again. And that just seemed alarming to me. I thought, There’s got to be a way we can do better.

I started with something called ERAS, which stands for Enhanced Recovery After Surgery. These are standardized protocols that are put in place across all sorts of surgical specialties and followed for every patient, and they’re evidence-based. So let’s say you get a spinal surgery. The ERAS protocols might say you get your Foley catheter out on post-op day one, you meet with physical therapy on post-op day two,  you’re discharged on post-op day three, you meet with an outpatient PT on post-op day four, yada yada, yada.

We didn’t have one of these for amputation surgery. So we met with all of the members of that team—which is occupational therapy, physical therapy, social workers, prosthetists—and I asked, “What are we missing here? Why can’t we do this?” And they’re like, “We have to do this.” So we created an electronic health record order set and got it put into place.

How did Jessica end up in charge of the program?
I just went to her and said, “I have this crazy idea. What if we designate one person to help new amputees deal with their prescriptions, their surgical scar, their followup appointments, and it’s always the same person so the patient feels like they have a connection who they feel comfortable with? I’ll even give you a fancy business card.”

And I will tell you, Jess is so amazing. Just yesterday, one of my patients fell on his wound, and all he had to do was text Jess a picture of it. He didn’t have to talk to a receptionist and ask for an appointment. He didn’t have to tell his whole story to somebody who doesn’t know him. He called Jess, and she knew exactly what to do and how to help. Every patient who’s just lost a limb—who’s just lost a part of themselves—should have that connection. They need that connection. Having a support system is what’s going to get them from amputation to ambulation. 

Was there a single incident that gave you this idea? Or was it just something that dawned on you after seeing certain outcomes over and over again?
During my fellowship, we’d go on hospital rounds and see these patients. When we’d discharge somebody, I would ask: “Where are they going?” No one could really tell me, and I never saw them again. But I’d always wonder: What happens to them next? Who takes care of them? Who makes sure that they get their prosthesis? You just start asking questions. I love the scientific portion of being a doctor. When you have a passion for that, you’re always asking yourself these questions. If you don’t get a good outcome, instead of just saying, “Oh shucks, that didn’t go well,” I’m the person who asks: “Why didn’t it go well? What can I do better?” There were certain aspects of our practice that needed to get better. We have a prosthetist next door [from our practice] and another one across the street. We are surrounded by prosthetists. So I thought, Why can’t we make sure our patients get over there? It’s really just a matter of developing a relationship.

Did cultivating those relationships take a lot of effort?
We already had a loose relationship in the sense that one of my partners was very close with one of the prosthetists, so a number of his patients got plugged in right away. But since we’ve brought Jess into this role, they’re actually seeing the patient in the hospital and they meet the patient right after they get their amputation. That’s huge, because now you have two teams keeping an eye on the patient when they’re discharged. And now the prosthetic clinics have Jess’s cellphone number, so if they see a patient and they need a prescription, they can just call her. She brings it to me, I sign it, it’s done.

We’ve also had more intimate conversations with the prosthetist about what barriers they have to getting a prosthesis covered by insurance companies. We developed smart phrases in our electronic health record where we explain the K level of the patient and the motivation of the patient, so that when the prosthetic clinic sends in the authorization, there’s no question about whether or not it gets approved. The language is in there, and that makes it a huge difference. It takes less than 30 seconds, but it makes all the difference in the world—because if that doesn’t happen, then the prosthetist goes to the primary care doctor and asks for a prescription, and now you’re talking about six more weeks of delay.

What has to happen for this to become the universal standard of care rather than the exception?
It is so crazy that you asked me that, because I was just on another call with two of my colleagues, Dr. Kate McGarrigle at the University of North Carolina and Dr. Karen Wu at UCLA. The three of us are working on trying to develop a project where we look what needs to happen to implement this across America, and how we can make this part of the national ERAs guidelines. We’re working on a grant proposal to develop a toolkit that anyone can download, and it gives them a step-by-step guide for what they need to do to implement this in their hospital system.

We’ve had success here in Fresno, and Dr. McGinnis has had some some success with this at UNC. We’ve gone from 50 percent of our patients receiving a prosthesis to 90 percent. So we’ve really demonstrated that this pathway can improve outcomes. But none of that means anything if we can’t do this all across America, for all patients.

We want to talk to our own patients and find out what their experience was, what they perceive we can do to make it better, and figure out how we can fine-tune this. That’s the next step.

Change is never easy. Are there people or institutions who are invested in the old way of doing things who might be resistant to this approach?
Sure, but it’s my job to make sure that changes. You can’t sit and do things the same way you’ve done for 30 years. That’s not the way we get better. It’s not the way we improve patient care. Not everybody is going to have a Jessica in their office, but a lot of prosthetic clinics are adopting care coordinators. That’s the beauty of a team approach. Each member of the team can take on as much responsibility as they have the capability to offer to make sure the patient has a good outcome. If a surgical practice doesn’t have the bandwidth to employ an amputation coordinator, maybe they can partner with a prosthetist who does, or maybe a rehab facility, maybe a physical therapy outpatient clinic. Each team member can play a role, and together you can achieve the best outcome.

Amplitude
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