Early DFU Care and Time-Out Before Amputation
diabeticfootcare
About half of non-traumatic amputations in the U.S. skip vascular testing. Here are answers on TOBA, the pause meant to check first.
Desmond Bell, founder of The Save a Leg, Save a Life Foundation, presented Time-Out Before Amputation (TOBA) at SAWC Fall 2026. These are the questions clinicians ask most, answered from his talk.
What is a Time-Out Before Amputation?
TOBA is a surgical safety framework for limb preservation. It borrows from the surgical time-out: a forced pause before an irreversible action that interrupts assumptions and ensures shared understanding.
Why is a pause needed?
Approximately 50% of non-traumatic lower extremity amputations in the U.S. are done without any vascular testing. Bell calls the result the "amputation lottery," where subjective opinion drives decisions instead of objective findings.
What would TOBA require?
- Objective vascular assessment before major amputation
- Multidisciplinary limb preservation programs
- Fewer preventable amputations and lower costs
The gap it targets has three parts: no standardized time-out, no mandated vascular assessment, and no required pathway verification.
What questions does the time-out ask?
- Was vascular status assessed?
- Was revascularization considered?
- Was multidisciplinary input obtained?
- Is the patient fully informed?
How often should arterial flow be tested in a diabetic foot ulcer?
At every visit, not only the first encounter. In high-risk patients, absent pulses can indicate no flow, but palpable pulses are never an indicator of sufficient flow. Bell's clinical pearl: it takes seconds. Clear wound care documentation makes vascular status easy to verify, and this guide on documenting vascular status in wound care notes shows how.
What does the economics look like?
The talk puts one preventable major amputation at $100,000 to $500,000 plus in lifetime costs, versus typically under $20K for an angiogram. Hidden costs include prosthetics replaced every three to five years, home modifications, and lost productivity and independence.
Where can I learn more?
See the step-by-step TOBA checklist and our vascular testing FAQ for diabetic foot ulcers. For the workflow side, visit diabetic foot care.