Nerrolyn Ford, CPO (Aus), PhD, British Columbia Institute of
Technology (BCIT), Vancouver, is working on a prosthetic outcomes
study that emphasizes:
- Standardized assessment and record keeping protocols;
- The fitting of appropriate devices based upon such
assessment; - Continuity of care including assessment of outcomes; and
- Accountability based upon performance indicators and
utilization of database information.
Her study proposal points out that “quality improvement and
accountability are of utmost importance…and require constant
update and review of client-based activities.” A standardized
record-keeping system that is understandable and accessible to all
will allow the accumulation of a country-wide database that could
prove invaluable-not only in cases of componentry recalls, but in
identifying trends such as repair frequency and service.
Currently, she explained, it is difficult to track outcomes
because everyone keeps records differently, using their own
qualitative assessment systems in maintaining patient files. To
gain an overall picture of the progress of patients through
examination of records compiled from different parts of the country
is like comparing apples to oranges, she said. “Everybody should
use the same system, so things like fitting times can be tracked
and compared.”
The project, which has just been approved and is still in its
initial phase, will depend upon cooperative input from engineers
and experts from a variety of other backgrounds. Ford’s team is
just starting prosthetic studies and developing quality systems for
prosthetic care based on her guidelines above.
“The first step will be a pilot study on a small population of
perhaps 20 patients, handled as though we were operating a small
clinic,” Ford explained. “Our initial objective will be to develop
a system that can be easily used by all clinicians-one that can be
standardized with regards to performance indicators, replacement
times, etc., and, most importantly, documented.”
She expects the study to be ongoing for about two years; its
success will depend upon its acceptance by the professional
community.
Prosthetics Outcomes Study
The BCIT has presented a proposal for the provision of
prosthetic devices to Health Canada clients. Here is some
additional information:
Summary
The British Columbia Institute of Technology presents the
following proposal for the provision of prosthetic devices to
Health Canada clients. Key components of this proposal are;
- Standardised assessment and record keeping protocols,
- Provision of appropriate devices based upon and justified by a
complete patient assessment - Continuity of care including formal assessment of patient
outcomes - Accountability based upon performance indicators published in
biannual reports and year-round access to data base
information
Mission statement
To provide Health Canada clients with appropriate devices in a
transparent and accountable manner as part of developing a quality
system for the provision of prosthetic and orthotic devices.
Introduction
Prosthetics is a health care environment that is rapidly
changing as new developments are made in the areas of device
technology and patient management strategies. In the following
proposal, aimed at developing service provision protocols for
Health Canada clients, it is recognised that quality improvement
and accountability are of utmost importance. Further to this it is
recognised that these issues require constantly update and review
of client based activities. It is anticipated that the proposed
study will not only focus the administrative operations of
prosthetic service delivery for Health Canada Clients but also
contribute to the overall quality of service delivery to the
amputee.
In order to supply Health Canada clients with appropriate
prosthetic devices in a transparent and accountable manner we
propose the following Quality Loop.
Quality Loop for Prosthetic Service
Delivery
The elements of the quality loop are manifested by the
following deliverables
Deliverables
- Assessment Report Complete assessment of the
amputee patient is essential to the derivation of an appropriate
prosthetic prescription. A complete patient assessment must include
the following: Medical history – summary of the
diagnosis, date of onset, associated condition, concurrent
treatment modalities and past history of prosthetic management
Psychological profile – Including analysis of
patient needs and manner of coping with the disability,
psychological disorders related to the disability and unrelated
psychological disorders Biomechanical presentation
– Record of passive and active range of motion measurements, degree
of structural deformities, muscle strength grading, level of
sensation and recording of any recent trauma or open wounds. This
should also include an assessment of gait if the patient is
ambulatory Anthropometric data collection –
Recording of all appropriate measurements, casts and data files
necessary to produce a model of the extremity from which a
prosthesis can be made. We propose to employ a standardized
electronic form for patient assessment. The interactive electronic
form will allow for easy clinical access to patient information,
generation of individual patient reports that may be forwarded to
prescribing physicians and as a means of gathering patient
statistics for research and data analysis purposes. - Device Prescription of components for
prosthetic devices will be based upon patient assessment outcomes.
Devices will fall under two general categories: Device
Categories : Interim – Interim devices
are prescribed for the period immediately after amputation when the
patients’ residual limb is rapidly changing shape. It is recognised
that a good prosthetic fit during this time is essential for rapid
wound healing and reducing the rehabilitation time for the amputee.
During the time proceeding surgery, when the amputees’ residual
limb is undergoing significant changes in shape and volume, it may
be necessary to fabricate new prosthetic sockets on a regular
basis. The number of interim prostheses required will differ for
each individual patient. As prosthetic fit during this stage of
rehabilitation is vital for wound healing and patient
rehabilitation it is proposed that the provision time for an
interim device will be as short as possible. The componentry used
in a prosthetic device will be determined by the outcomes of
patient assessment and in discussion with the prescribing physician
and rehabilitation team. When possible components will be re-used
in each subsequent interim limb. Definitive
Definitive devices are prescribed to amputees who have a stable
residual limb and are unlikely to require any short-term prosthetic
socket alterations. These prostheses are often cosmetically
finished and with the exception of repairs it is anticipated that
the amputee will use these prostheses for two to three years. The
prescription of componentry for definitive prostheses is determined
by the outcomes of patient assessment and in discussion with the
prescribing physicians and members of the rehabilitation team. - Follow-up Patient follow-up and review is
essential in a quality system. We propose the following protocols
for follow-up with amputee patients. Interim prosthetic
patients Follow-up one week after provision of the device,
once every two weeks for the first two months and then on a monthly
basis until a definitive device is prescribed. Definitive
patients Follow-up two weeks after device provision and
then once every six months. Activities conducted during follow-up
visits include the following:- Patient assessment – As described above and evaluated against
prior visits - Minor Repairs
- Major Repairs
- Patient assessment – As described above and evaluated against
- Other deliverablesInteractive
database * The proposed
interactive data-base would linked client assessment and follow-up
information. In addition the data-base would include information
pertaining to:- devices supplied
- components used – including serial numbers for tracking
purposes - location
- current status
* essential if a QA system is to be
developedBiannual Report- Summary and analysis of previous 6 months activities including
detailed analysis of performance indicators (see below)
New Technology Report briefing on:
- New prosthetic componentry and scientific data related to their
function and usage. - New treatment modalities relating to amputee rehabilitation
including scientific literature related to their success. - Review and update of patient assessment tools
From the data collected in the proposed clinic additional reports
may be generated on request. Such reports may include:- Reports related to biomechanical effectiveness of prescribed
devices - Reports related to psychosocial effectiveness
- Reports related to the appropriateness of various
components
Performance Indicators As part of a quality
improvement process, it is recognised that the proposed research
facility must be able to provide relevant indicators that reflect
the consumption and use of its outputs, the relative quality of
those outputs and essential epidemiological data on its client
base. These indicators should be reliable, current, readily
available and comparable between jurisdictions. Quality Indicators
for the proposed study include the following: Completion
Time Data A report which reflects the time to provide a
prescribed prosthetic service. Separation by prosthesis type will
be available. Ongoing monitoring of these periods is to be carried
out to identify trends and improvement opportunities.
Replacement Time (Useful Life of a Prosthesis)
Period of time between acquittal of a prosthesis and acquittal of
its replacement, further subdivided by prosthesis type.
Repair Frequency Frequency of Major and Minor
repairs to selected prosthesis and specific componentry. Ongoing
monitoring of these repairs to identify trends. Service
Outputs Reports by period based on acquittal data
indicating count of services provided and sorted by type.
Cost of services Average cost of services by
period. Individual and summary report for prosthesis by code.
Clinic Attendance Count of appointments by clinic
by date and by reason. Operations It is proposed
that this project would run under the Centre for Rehabilitation
Engineering and Technology that Enables (CREATE). This research
centre was developed in partnership with the Neil Squire Foundation
(NSF) and is a facility devoted to development of devices,
technologies and products for people with disabilities.
Staffing Needs:- Prosthetist
- Technician
Access to:
- Physiotherapist
- Occupational Therapist (available through NSF)
- Diabetic Care Specialist
- Biomechanist (Dave Kenyon/Yvette Jones)
Capital Equipment:
- Biomechanical analysis lab (evtl.)
- Clinic Setting – Private assessment and casting room and
consultation office (initially classroom could be converted)
