Creating a Clubfoot Clinic

Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project

Top Contributors - Naomi O'Reilly, Kim Jackson, Rachael Lowe, Simisola Ajeyalemi, Rucha Gadgil and Olajumoke Ogunleye  

Introduction

The Ponseti Method is now becoming recognised as the accepted standard for the medical treatment of clubfoot. The goal of countrywide clubfoot treatment programs cannot be reached with the simple introduction of the technique to health care professionals in the country. This objective requires the construction of a well planned, strategic model which is broadly applicable, affordable and effective. Such a model must acknowledge and work within the specific limitations of each individual country. One such model is the CURE Clubfoot Kenya (CCK) program, which successfully recruited 362 patients within the first twelve months.

Considerations for clinic set up

Clinic days

Having a set clubfoot clinic day each week helps in many ways:

• Ensures availability of team members
• Enhances sensitization and awareness efforts
• Makes appointment scheduling easier
• Easier for referral sources to refer.
• Allows mothers to meet and support each other

Clinic team

Having a good team is clearly important for a clinic to work well. This includes: 


• Ensuring staff are committed and interested in clubfoot 

• Having the same staff each week and over time, for consistency and parent relationships 

• Ensuring that all staff are trained in the Ponseti method 

• Making sure each staff member understands their roles: 

  • Leader / coordinator

  • Preparing supplies

  • Assessment and treatment - casting, tenotomies, bracing
  • Parent education and support, including follow-up

  • Appointment scheduling 


Space

Having enough space for different clinic functions is important. The key functions for which space is needed are

Waiting area

• This is a good place for parent interaction and education. Can parents be encouraged to chat to others so that they can be encouraged and learn about the next stage of treatment? Often a grass area outside is just as good as a seated area inside.

Assessment and treatment

• Casting, tenotomies, bracing
• Some clinics have nice areas outside that work well which is fine too.

Parent education and support

• Remember sometimes confidentiality will be needed

Record storage

• Patient records should be stored so that they are organized and confidential

Supplies storage and set-up

• Supplies should be easily accessed before and during clinics

Anticipate needs

For a clinic to run well, it requires some planning by staff, including: 


• Monitoring supply levels and ordering more in a timely way 

• Ensuring patient records are available 

• Watch the process of the clubfoot correction and Pirani Scores to anticipate when the tenotomy will be required 

• Making sure tenotomies are booked ahead of time 

• Measure the foot on the day of the tenotomy so that the FAB is ready for when the cast is removed 

• Ensuring appointments are scheduled in a way that allows staff to identify when a patient misses an 
appointment 


Procedures

Every patient clinic visit should run in a similar way as follows:

Check and update patient information (e.g. parent contact phone numbers)

1. Inspect & remove cast
2. Assess the patient:
   • Parent report
   • Examination
   • Pirani score
   • Documentation
3. Decide treatment plan
4. Treat the patient
5. Provide parent education and support
6. Schedule and record next appointment
7. Document everything!
8. Take photos for progress
9. Complete any reports

Documentation

Accurate documentation will help you re-evaluate progress and make good clinical decisions. It allows you to check whether progress is going according to plan and whether the goal of your last treatment was achieved. Benefits of documentation include:

• It provides support and evidence for improvement of your clinic
• It allows you to know when to refer
• Parents can follow it
• Useful for research
• Raises awareness of coverage: how many children are you treating? Do you expect more / fewer? What access issues may arise?
• Provides evidence to the Ministry of Health and other funders

On a clinic level, documenting your outcomes can help evaluate whether the service provided is of a high quality. At each visit, record:

• Outcomes of each visit
• Pirani score
• Brace use
• Complications
• Any other problems

Ask Yourself:

• Is treatment going according to your plan?
• Was your last goal achieved?

Improving clinic quality

It is important with any health services to strive to improve the quality of service provision. This is the same for clubfoot treatment clinics. It is also good to have a plan for regular review of quality and how you will deal with any issues that arise. Working as a team is important. Below are some key ways that clinic teams can work on this:

1. Learn Together - At the end of each clinic, meet together and ask each other: “What could we have done better today?”
2. Receiving mentoring visits from someone more experienced and skilled is very helpful to improving competence and confidence:
   • Who can provide you with supervision and mentoring?
   • How often do you need this?
   • How can mentoring be recorded so that you know what areas you need to work on?
3. Reflect on the results of your treatment, for example:
   • Did the last cast cause problems, slip, break?
   • Did the Pirani score improve?
   • Are the Pirani scores progressing as you expect?
   • How is the mother coping? Is she complying?
4. Document well so that you and your team can evaluate your efforts
5. A number of indicators can be used to assess the quality of the service you are providing. It’s a good idea to participate in submitting data to a database or organization that provides reports so that you can receive information about your clinic, such as:
   • Average Number of casts per child
   • Tenotomy Rate
   • Compliance with foot abduction braces
   • Number of children who achieve plantigrade feet
   • Parental satisfaction
   • Rate of further surgical intervention
   • Recurrence rate

It is helpful to do an assessment of how well your clinic meets all of these elements, so that you can create a plan of how you will improve.