Chapter 14 Vascular 2026

Published: 28/04/2026

14.10 Major lower limb amputation

Dr Rebecca Thorne, Dr Judith Gudgeon, Dr Adam Pichel 

Why do this quality improvement project?

Patients undergoing major lower limb amputation are often frail, acutely unwell and with underlying overt or covert comorbidities. As a result, this surgery carries significant risks, including a perioperative mortality

of 12.4–22%1. This project aims to compare local processes, pathways and clinical outcomes against best- practice national guidance, to identify areas requiring improvement leading to an ultimate goal of reduced perioperative morbidity and mortality.

Background

In the UK, approximately 6,000 major lower limb amputations are performed annually.2 The average readmission rate for this procedure is 16.5% (Getting It Right First Time, GIRFT)3 and up to 70%   of these patients die within five years of surgery.1 Data from the 2014 National  Confidential Enquiry into Patient Outcome and Death (NCEPOD) and 2018 nationwide Getting It Right First Time (GIRFT) reports revealed significant variation in unit outcomes and considerable delays from decision to operate to definitive surgery.1,3 Following these reports, the Vascular Society revised its 2012 best practice pathway for major amputation to incorporate the recommendations of the NCEPOD report.2 The aim of the pathway is to standardise practice, and to reduce and maintain the national 90-day mortality to less than 10%.

  • NCEPOD lower limb amputation report.1
  • Vascular Society guidance on major amputation surgery.2
  • GIRFT Programme National Specialty report on vascular surgery.3
  • RCoA Guidelines for the Provision of Anaesthesia Services for Vascular Procedures 2019.4

Suggested data to collect

Standards

Measures

Involvement of a multidisciplinary teampre- and postoperatively.

 

 

 

Proportion (percentage) of patients undergoing a majorlower limb amputation who have a documented multidisciplinary team discussion.

Asappropriate the proportion (percentage) of patients seen by associated medical specialties (e.g. diabetic teams, cardiology, comprehensive geriatric assessments).

 

Timely review and surgery on elective lists with surgeons and anaesthetists with a regular practice in vascular surgery.

 

 

 

 

 

Proportion (percentage) of patients who were reviewed within 12 hours of admission by a consultant  vascular surgeon.

Proportion (percentage) of patients whose surgery was carried out on a dedicated elective vascular operating list within a prescribed time frame.

Proportion (percentage) of patients who were assessed preoperatively by a vascular consultant anaesthetist, consultant anaesthetist or post-fellowship resident.

Time taken from decision to amputate to definitive surgery (urgent cases <48hrs from decision to amputate).

 

Specialist vascular anaesthetic care.4

 

Percentage of patients anaesthetised by consultant vascular anaesthetist or post-fellowship resident.

 

Specialist acutepostoperative pain management.5 Is there a major lower limb amputation perioperative pain management protocol? If not, one should be created.

 

 

 

Percentage of patients who received regional technique as part of anaesthetic plan.

Percentage of patients who had peripheral nerve catheter inserted for postoperative pain management.

Percentage of patients reviewed by the acute pain team within 12 hours of surgery or on the first postoperative day.

 

 

Rehabilitation and discharge planning should start before surgery.

 

 

Percentage of patients with a documented discharge planprior to theirsurgery. This shouldinvolve medical, nursing, physiotherapist and occupational healthstaff.

 
Vascular major lower limb amputation should be performed in a vascular centre with agreed transfer pathways in place from spoke to hub centres.

Look for the presence of a transfer pathway and whether it works in a timely manner.

 
Data on procedures shouldbe submitted to the National Vascular Registry Cross-check to review the percentage of patients who underwent major lower limb amputation recorded in the Registry.
The ratioof below-knee to above-knee amputations should be less than one. Measure the ratio of below-knee amputations compared with above-knee amputations.

Recognition of patients who are at the end of life, minimise futile surgery and refer appropriately for palliative care.

 

Measure the proportion of patients with unsalvageable limb ischaemia who do not come to major lower limb amputation and who have had a formal referral to palliative care.*

 

Return to theatre for major stump revision / debridement

 

Measure return to theatre rate from surgical complications / wound infection 

 

In-hospital mortality rate is in keeping with national average

 

Compare outcome data with National Vascular Registry

 

Drinking, eating and mobilising after surgery (DrEaMing) – CQUIN 2024 for surgical patients

 

 

Measure these outcomes after surgery though accepting that mobilising is significantly harder to achieve in this group. Transfer to chair may be measurable. 

 

 

QI methodology

  • Use a driver diagram to provide an overview of the aims of the project. Use it to help to analyse where you might be able to make quick and easy improvements in the management of major lower limb amputation in your hospital.
  • Define the key aims for improvement and link these to the desired (aspirational) outcomes. Remember to engage the full support of colleagues in the surgical department and allied healthcare professionals; this is vital to the project success.
  • Choose a combination of interventions that you think are easy to implement and achievable (ideally choose three to five in total). This might include i) early decision making within a multidisciplinary team (MDT) by senior doctors from the relevant specialties, ii) placing patients on scheduled lists with a consultant anaesthetist, iii) following a standardised pain management protocol, and iv) DrEaMing. Once agreed with the relevant stakeholders, pilot your change ideas to exclude any barriers to implementation that were not anticipated. Consider using run charts for each measure. This will demonstrate the areas where more work needs to be done. Assess whether the change idea(s), when well implemented, brings about improvements to your desired outcome measures (e.g. reduction in length of stay or mortality). When developing and implementing the bundle it is vital to take a team-based approach, incorporating all the stakeholders, including patients if possible
  • Sustaining the change is challenging but is assisted by continued data collection and use of run charts to illustrate the effect of any quality improvement intervention on process and outcomes and to encourage continued engagement.

References

  1. NCEPOD. Lower Limb Amputation: Working Together: A Review of the Care Received by Patients Who Underwent Major Lower Limb Amputation due to Vascular Disease or Diabetes. London: NCEPOD; 2014 https://www.ncepod.org.uk/2014lla.html
  2. Vascular Society. A Best Practice Clinical Care Pathway for Major Amputation Surgery. Lichfield: Vascular Society; 2016  https://vascularsociety.org.uk/_userfiles/pages/files/qips/best-practice-care-for-major-amputation-april-2016.pdf
  3. Horrocks M. Vascular Surgery: GIRFT Programme National Specialty Report. London: GIRFT; 2018 https://gettingitrightfirsttime.co.uk/vascular-surgery-report/
  4. Royal College of Anaesthetists. Guidelines for the Provision of Anaesthetic Services Chapter 15: Guidelines for the Provision of Anaesthesia Services for Vascular Procedures 2025 https://rcoa.ac.uk/gpas/chapter-15-2025
  5. Neil MJE. Pain after amputation. BJA Educ 2016;16:107–112.
  6. Drinking, eating and mobilising CQUIN, GIRFT  https://gettingitrightfirsttime.co.uk/new-cquin-for-2023-to-ensure-more-patients-drink-eat-and-mobilise-within-24-hours-of-surgery/