Lower-Limb Preservation

Introduction

To support Ontario Health’s Lower-Limb Preservation Strategy (LLPS), the DET OHT has designed and is in the process of implementing the lower-limb care pathways by bringing together primary and community care, specialized foot and wound care, and acute care. The strategy aims to:

• Reduce preventable, non-traumatic major lower limb amputations across Ontario.
• Improve equitable lower-limb care pathways for early identification, cardiovascular risk factor, diabetes management, and wound care.

Why This Project?

Compared to similar publicly funded jurisdictions, Ontario has one of the highest rates of lower-limb amputation related to diabetes and peripheral artery disease.

According to the provincial data:

• 30% live with diabetes or prediabetes, and 10% live with diagnosed diabetes. (1)
• People with diabetes are almost 20 times more likely to be hospitalized for a non-traumatic lower-limb amputation compared to the general population. (1)
• 15-20% of people over 70 years are estimated to have peripheral vascular disease. (2)
• There are 1,200 non-traumatic major lower-limb amputations annually, which equates to one amputation every 7 hours. (3)
• 85% of the lower-limb amputations related to diabetes or peripheral artery disease are preventable. (3)
• Direct amputation healthcare cost accounts for approximately $140 million annually. (3)

Through the lead of Ontario Health, 12 OHTs and 12 vascular centres are advancing this initiative in their communities.

Demonstration Sites

OH has identified the following regions and sites for the program demonstration:

Progress at the Downtown East Toronto OHT

The DET OHT is one of the 12 OHTs identified to design clinical pathways and address gaps in lower limb preservation. This project provides substantial value to the DET OHT, as it seeks to improve access and coordination to services for individuals in need of lower limb care and at risk for complications. 

Upon the launch of the project, the steering committee undertook two high-level tasks: 

1. Environmental scan of lower-limb care
2. Project Design Mapping

Environmental Scan

To identify the current trends, care gaps, and patient referral pathways of foot care within the Downtown East area, the program team engaged and conducted surveys with multiple groups of care providers. These groups included care providers at St. Michael’s specialty clinics, CHC/FHTs, non-CHC/FHT Physician Groups, stand-alone foot clinics, and diabetes education teams. Through this exercise, two priority areas of action were identified; screening and prevention and escalation of care.

Screening and Prevention

Under this pathway, the multidisciplinary experts will collaborate to:

• educate patients and providers on timely examination of feet, especially for people at high risk of complications
• standardize and create screening capacity
• leverage information-sharing systems across organizations within DET OHT to flag and facilitate foot care for high-risk patients

Escalation of Care

To reduce complications of the lower limb and manage wounds effectively, this pathway will: 

• define a referral/management pathway for foot wounds
• dedicate a community-based clinical care consultant/navigator to support screening and prevention change initiatives
• dedicate a hospital-based clinical care consultant/navigator to support coordinating multidisciplinary lower-limb care (chiropody, vascular, orthopedics, diabetes) in St. Michael’s Hospital ambulatory settings

Videos

Watch: Preventing Wounds and Amputations in People with Diabetes

More Stories

• “The real secret sauce – the magic ingredient – was the structure underneath the pathway”: design thinking expert reflects on the lower limb care strategy
• “The hope is that everyone is getting care from the right place at the right time”: Two health care providers discuss timely intervention and prevention for lower-limb care
• Putting Feet First: DET OHT Unveils New Strategies to Reduce Lower-Limb Amputations
• Lower-Limb Care Program of the DET OHT is Gearing Up to Launch

References

1. Diabetes in Ontario: Backgrounder. Ottawa: Diabetes Canada; 2022. Retrieved from: https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2022_Backgrounder_Ontario_English_1.pdf
2. Beaumier M, Murray BA, Despatis MA, Patry J, Murphy C, Jin S, et al. Best practice recommendations for the prevention and management of peripheral arterial ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2020. 78 pp. Retrieved from: https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/1690-wc-bpr-prevention-and-management-of-peripheral-arterial-ulcers-1921e-final/file
3. Setterfield, M., & Scholey, L. (2022a). Saving Limbs and Lives: Building Out an Ontario Lower-Limb Preservation Strategy. Limb Preservation in Canada, 3(1), 26. Retrieved from: https://www.woundscanada.ca/docman/public/limb-preservation-in-canada/2022-vol-3-no-1/2504-lpc-spring-2022-v3n1-final-p-26-29-saving-limbs-and-lives/file