Some Guidelines For The Operation Of Child Amputee Clinics
Hector W. Kay Clyde M. E. Dolan
Mr. Kay is Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, Washington, D.C. Mr. Dolan is Assistant Research Scientist, Prosthetics and Orthotics, New York University Post-Graduate Medical School, New York.
Some years ago the Subcommittee on Child Prosthetics Problems established minimum standards for cooperating juvenile amputee clinics. As interest has developed in this area, many new clinics have come into being. As a result, a large number of site visits to centers desirous of joining the program have been made, as well as many visits to participating clinics. It would appear that the techniques of clinic operation being practiced vary widely. Hector W. Kay, who has made the major number of these clinic visits, has been impressed with the desirability of documenting operational guidelines. I have enjoyed reviewing his thoughts on this matter and have encouraged him to publish them. It seems to me that these operational guidelines form an excellent basis upon which to establish clinic operations. It naturally follows that not everyone will be able to function in the specific manner recommended. Nevertheless if an attempt is made to develop a clinic routine similar if not identical to that described, a more efficient program for all concerned should result. I do recommend review of these guidelines and suggest implementation where and as possible.
-George T. Aitken, M.D., Chairman Subcommittee on Child Prosthetics Problems
Over the past decade the concept of the team approach to the treatment of the juvenile amputee has been discussed extensively and adequately. Little doubt remains that the combination of disciplines involved in the clinic team fosters the best patient care while providing maximum opportunity for the continuing education of medical and paramedical personnel.
The specific purposes of an amputee clinic meeting which can be identified are (1) treatment of the patient, including all aspects of surgical and prosthetic management; (2) education of resident physicians, students, parents, and patients; and (3) demonstration of the type and quality of service provided. In order to optimize these facets of the clinic process, to involve all contributing personnel maximally, and to insure adequate prosthetic management of any given case without excessive expenditure of time, it is necessary that administrative procedures be streamlined. The following suggestions should be considered as guidelines only, inasmuch as facilities, case loads, and available personnel vary significantly among institutions.
Agreement on Philosophy
There appears to be general agreement concerning the philosophy, goals, and purposes of the clinic team, and in recent years the essential features of an acceptable clinic have been described in a number of documents. In 1963 Fishman1 defined the prosthetic clinic and described its functions. Standards for the operation of child amputee clinics were outlined in a 1965 report of the Committee on the Care of the Handicapped Child2. Many aspects of this report, restated in terms of personnel, case load, and certain ancillary services, have been established as criteria by the Subcommittee on Child Prosthetics Problems in relation to the cooperative child amputee clinic program3. Broad implementation of the standards emphasized in these documents would serve to upgrade the total treatment program and operate both in the interest of patient welfare and continuing education. The present paper directs particular attention to the mechanics of clinic team function.
The functional and administrative operations of a child amputee clinic may be divided into two essential elements: (1) preclinic procedures, which will vary according to the patient's status (ranging from a new referral without a prosthesis to a follow-up on a patient fitted with a satisfactory prosthesis), and (2) clinic meeting procedures, which will follow a generally similar pattern regardless of patient status.
The purpose of the recommended preclinic procedures is threefold: (1) to insure that complete, updated data are available to the clinic, (2) to permit detailed observations by each member of the ancillary staff, so that recommendations to the clinic based on the member's specific professional area of interest may be formulated, and (3) to expedite the processing of patients at the actual clinic meeting.
Intake for new patients without prostheses. Parents and patients should be given a brief introduction to clinic procedures and principles, since the referring facility (if any) may differ significantly from the amputee treatment institution. The referral data should be examined by a staff member entirely familiar with the operation of the clinic and updated if necessary to include recent X-rays, family and patient history, and administrative data as appropriate. Depending on the institution and the individual case, a pediatrician, medical social worker, rehabilitation counselor, or other staff members might be involved in the intake interviews. Desirably, these intake procedures should be accomplished prior to the clinic meeting. The combined evaluation of the case should be available to the staff member who will be responsible for presentation of the case to the clinic. Information of a sensitive nature should be identified, so that it can be reserved for discussion in the absence of the parents or family.
Intake for new patients fitted with prostheses under the auspices of the referring agency. Procedures for this group should be essentially identical to those described above for new patients without prostheses, with the addition of a complete prosthetic checkout by a therapist, preferably in consultation with the prosthetist(s) serving the clinic. Checkout procedures should include fit and alignment, length, and efficiency (for upper extremity) . Such minor items as adjustments to harness, friction wrist units, and replacement of rubber bands, etc., if indicated, could be effected prior to the actual clinic meeting. To allow adequate time administratively, appointments for photographs and X-rays should preferably be scheduled in advance of the clinic meeting, as for new referrals without prostheses.
Preclinic checkout for old patients with new prostheses (acceptance of new prosthesis). A detailed checkout may be performed during the clinic meeting, but it is time-consuming. To conserve clinic time, therefore, appointments should be scheduled in advance of the meeting. For example, checkouts may be performed in the morning for an afternoon clinic, or they may be arranged just prior to the beginning of the clinic. If sufficient trained personnel are available, the checkout procedure could be carried out while other patients are being seen in the clinic, but such a system is generally not desirable, since the personnel involved would not have access to the discussion of all patients.
New prostheses should be carefully examined and tested," according to standard procedures, and the prescription reviewed to insure that the limb conforms to it. Necessary minor adjustments should be made, and recommendations concerning acceptance or rejection of the new prosthesis may be formulated. (Prostheses are formally accepted only at the clinic meeting, under the direction of the clinic chief.)
Preclinic checkout for old patients with prostheses returning for follow-up. The procedures followed with this group are essentially the same as for the preceding group, except that checkout is usually simplified considerably. Complaints and indications for minor adjustments are investigated and necessary measures taken. Records are reviewed immediately prior to the clinic meeting.
The Clinic Meeting
To achieve maximum value from the clinic meeting, it is recommended that the layout of the meeting area be carefully planned and that procedures follow an orderly routine. Litt(4) once described this format as a "serial clinic team operating in a formal context," and indeed some degree of formality seems desirable.
Physical setting. Clinic personnel, as described in the references cited, should all be present in an area which will permit adequate examination of the patient by clinic team members yet provide a teaching situation for the benefit of students and visitors (see Diagram 1 ). While many arrangements are possible, the essential elements are:
A grouping which provides for an intimate relationship between the clinic team and the patient. This grouping should be arranged in proximity to the dressing space, so that patients may be efficiently brought into and taken from the meeting area.
Convenient location of the accessory equipment and facilities required for the meeting. This includes an X-ray view box, an open area for ambulation, parallel bars, steps, a ramp, and performance testing equipment for the upper-extremity prostheses. It is often desirable to have a curtained or otherwise private cubicle available for specific patient examinations. However, this facility should only be used when necessary to insure privacy. The crowding of clinic personnel into a cubicle should be avoided.
Provision for separate seating arrangements for students and spectators. Since clinics necessarily meet in all kinds of locations, rigid specifications as to the meeting area are impractical. The layout shown in the diagram is intended solely to illustrate the points presented above.
Procedures. Patients should be called individually to the meeting area and should be prepared for examination in shorts, bathrobes, or the like. Only one patient and his family should be in the clinic meeting at a given time, unless others are included for orientation purposes.
Patients should be introduced by a member of the team designated as responsible for the case presentation. (This introduction may be made by the clinic chief, or the responsibility may be assigned to a resident or therapist on a semipermanent or rotating basis.) Occasionally it may be necessary to provide some background information before the patient is brought into the meeting, particularly if the case involves information which should be discussed in confidence rather than in the presence of the patient or his family. Personal data, identification of the disability, display of X-ray plates, a brief history of the individual's prior prosthetic treatment, and a discussion of capabilities should be included in this introduction. The information presented will necessarily be more complete for new patients not previously known to the clinic staff.
Following the basic presentation, the physical or occupational therapist and the prosthetist should make recommendations based upon their observations in preclinic checkout. If information from social workers or other personnel (including sociological and psychological information from therapists, doctors, etc.) is not sensitive, it too should be presented. Parents and patients should have the opportunity to ask questions or advance their own recommendations for evaluation by the team. The clinic chief or his designee should examine the patient, with particular reference to comments received from the patient, his parents, and the clinic staff.
Based upon medical, prosthetic, and sociopsychological data, plans for the treatment program are formulated. If no further discussion is warranted, the patient may be released to the administrative staff for arrangement of a subsequent appointment. Prosthetist's appointments, if required, can be arranged according to any system satisfactory to the prosthetist representative.
If sensitive information is to be discussed, the airing of which might prove embarrassing to the patient, his family, or the clinic team, the patient and/or family should be asked to return to the waiting area. They may be recalled if necessary, or the future plans may be presented by a staff member on an individual basis.
The writing of prescriptions or notes on a case is the responsibility of the clinic chief or his designated assistant. A prescription or recommendation for follow-up should be formulated at this time and entered in the patient's permanent records. The dictation of notes into a recorder is generally the most economical system if a large group of patients is to be seen at the clinic. However, a verbal summary of decisions reached on the case should be presented for the benefit of the patient and his family, clinic personnel, visitors, students, etc.
Appropriate equipment for checkout of both upper- and lower-extremity prostheses should be available-scales, pinch tester, cable adapters, rubber bands and applicator, Yates clamps, wrenches, graduated length-discrepancy blocks or boards, etc.
1. Fishman, Sidney, "Prosthetic and Orthotic Clinic Procedures," NYU Post-Graduate Medical School, 1963.
2. Siffert, R.S., "A Guide for the Management of the Child Amputee," Bul Amer Acad Orth Surg, Vol. 13, December 1965.
3. "Criteria, Child Amputee Clinics," Subcommittee on Child Prosthetics Problems, Committee on Prosthetics Research and Development, 1968 (unpublished).
4. Litt, B., "The Clinic Team in Orthotics and Prosthetics," Facility Facts, Vol. 1, Summer 1962.