SIGN PROGRAM IN EAST AVENUE MEDICAL CENTER : AN ANALYSIS OF FOLLOW-UP

JESSE JERUS ALEM GABRIELI T. JOSON, MD, PTRP

TRAUMA

• One of the leading causes of great burden in the world (> 140,000 deaths per year in the U.S. alone)

• Low and middle-income countries - falls and traffic injuries are the top causes of disease burden

• Worldwide, estimated 5 million deaths annually from accidental injuries (95 % developing countries)

• Road traffic accidents - high-energy injuries, incidence of long bone fractures can be expected to dramatically increase concomitant with this growing pandemic

LONG BONE FRACTURES

• Tibia and femur fractures are the most common of the non-fatal long bone injuries following road traffic accidents (15 % of skeletal injuries sustained)

• Developed world - long bone fractures are commonly treated with intramedullary (IM) nailing, benefits over conservative treatment

• Nonsurgical treatment of femoral shaft fractures - increased length of hospital stay, higher incidence of morbidity and mortality

• Functional outcomes are improved for both femur and tibia fractures treated with IM nailing versus conservative methods

IM NAILING and SIGN

• Intramedullary nail fixation - standard treatment for both femoral and tibial shaft fractures (union rates, femur 97%)

• Success and ease of intramedullary nailing - indications have been expanded to include the periarticular portions

• The Surgical Implant Generation Network (SIGN) Fracture Care International - non-profit humanitarian organization (orthopaedic training and implants to hospitals in 3rd world countries in order to bring equality in fracture care management, founded by Dr. Lewis G. Zirkle

• 1999 - SIGN program has partnered with surgeons and hospitals from more than 50 countries worldwide, current 277 hospitals with SIGN programs in 52 countries

• Philippines - three (3) institutions with SIGN programs • East Avenue Medical Center (EAMC) • Southern Philippines Medical Center • University of the Philippines-Philippine General Hospital (UP-PGH)

SIGN IN THE PHILIPPINES

EAST AVENUE MEDICAL CENTER

• The SIGN program started in 2010 under our Chairman Emeritus, Dr. Mario B. Geronilla

• Since 2010, 225 cases reported and 110 cases of which has reported follow-ups

• Patients with fractures of the femur and tibia are screened whether they are eligible to receive the donated implants

• Patients excluded are: • financially capable • cases where there is a third party involved present for financing • nature of injury does not involve alcohol intoxication or drug use

SIGN PROGRAM

CONSIDERATIONS FOR APPLICATION

• Need for SIGN in the area • Percentage of Charity cases in the hospital

• Prompt and Consistent Communication • Hospital Infection Rate

MAINTAINING THE PROGRAM • Program stops submitting reports to the Surgical

Database for an extended period of time and does not respond to communications from SIGN

• Program does not submit reports to the Surgical Database for nails used and runs out of inventory (if there are no reports, they are not eligible for replacements). A program can be given the opportunity to purchase enough nails to restock their inventory but failure to do meet this requirement may render the program to be inactive

• Program does not meet the follow-up policy requirements for an extended period of time and does not respond to SIGN communications or make an effort to improve

FOLLOW-UP REPORTS PROBLEMS: • SIGN patients are seen at the General

Orthopaedic Out-Patient Clinic of EAMC (long lines, inconvenient)

• Record-keeping problems • Different resident physicians manning the

out-patient clinic (Inconsistency with the record keeping)

• patients who go to distant provinces immediately after discharge are discharged without any contact information elicited in their records

• Financial constraints • e.g. unemployed, street vendors, victims

of hit and runs, no funds for fares going to the hospital and back (provinces)

TECHNIQUES EMPLOYED

• In May 2013, creation of a separate SIGN Clinic (every Monday at 10 in the morning)

• A Cash bond was collected from patients

(P 5,000 = $100) - returned to the patient every follow-up consult, used to pay for their follow-up x-ray or in exchange of an x-ray film of their injury which they paid, used for paying transportation fares, laboratory exams (for possible peri-implant infections) or other x-ray requests of other skeletal injuries • A separate SIGN mobile phone was also used

to follow-up the patients especially those who went to distant areas.

TECHNIQUES EMPLOYED

Record keeping: • a separate logbook for SIGN patients

was designated. • Records of important information

such as complete address and contact number were made.

• A patient directory was started from the recent data available and also with previous data which were collected.

CULTIVATING CAMARADERIE

• In December 2013, a SIGN program Christmas Party to create a venue for SIGN patients to experience unity, camaraderie and belongingness

• The party became a place for strengthening ties towards fellow SIGN patient as well as SIGN surgeons

CULTIVATING CAMARADERIE

• There were also some form of inspiration and guidance given by old patients to new patients as the latter undergo the phase of rehabilitation

1ST SIGN-EAMC NEWSLETTER

INTERNET ACCESS • Another change was made in order to

increase the follow-up percentage, and this is to provide regular access to the web. This has shown to be a very efficient move since the follow-up percentage dramatically increased from 57% in March 2014 to 84% in April 2014

CURRENT FOLLOW-UP

• Maintained Follow-up percentage report > 70%

SIGN FOLLOW-UP POLICY

• it is agreed upon that all SIGN surgery will be reported within one week of surgery

• reports received after six weeks after surgery will entail a follow-up report in order to receive replacement implants for that particular patient

CONCLUSIONS

• There are various approaches and techniques on how to increase follow-up compliance from patients.

• These changes should be made depending on the need of each SIGN program. • Different SIGN programs deal with different levels of difficulties concerning their

follow-ups. • The steps that were undertaken by the SIGN program in East Avenue Medical

Center may or may not be applicable to all SIGN programs but it shows that adjustments should be made in order to tailor the program based on the specific need.

RECOMMENDATIONS

• Cash bond given was of great significance especially to those patients who have no money at all

• Funds generated were beneficial for all patients • If possible, this scheme may be imitated in other programs that have patients

who can afford • Share funds to the central SIGN office in order to generate more resources for

funding SIGN programs in areas with great need of support like in poverty-stricken areas or areas that experience high levels of conflict

RECOMMENDATIONS

• Adherence to the Follow-up policy of SIGN - consider numerous factors that hinder the improvement of follow-up consults

• Consider adjusting a program’s follow-up policy adherence based on the known limitations and capabilities

• Follow-up policy that is tailor-fitted can lead to successful follow-up percentages thereby ensuring the continuity of support from SIGN in order to sustain the delivery of quality fracture care and management especially to those who need them most