Trauma case management and clinical pathways: prospective evaluation of their effect on selected patient outcomes in five key trauma conditions

Major trauma coordinators in the UK: A survey of demographics and role functions

BACKGROUND

Trauma coordinators (TCs) play a key role in managing patients with complex injuries, coordinating care across multiple specialties. This study aimed to investigate the current role functions of TCs in the UK, compare them to findings from 2015, and explore differences between TCs in Major Trauma Centres (MTCs) and Trauma Units (TUs).

METHODS

A UK-wide cross-sectional survey was conducted using an online questionnaire. Participants included trauma coordinators from MTCs and TUs. Data on role functions, clinical activities, and professional background were analyzed using descriptive statistics.

RESULTS

There were 153 responses from TCs from 22 of the 27 trauma networks in the UK. Respondents reported 54 different role titles. Nurses comprised 65 % of the respondents, with 45 % holding a master's qualification. Clinical activities accounted for 51 % of the role, an increase from 39 % in 2015. Data entry and research responsibilities decreased. Advanced or autonomous practice was reported by 19 % of respondents, with more TCs from TUs engaging in independent prescribing.

CONCLUSION

The role of TCs has evolved since 2015, with increasing clinical responsibilities and more professionals working at advanced practice levels. However, there remains considerable variation in role titles and functions, reflecting the need for standardization and further research on the impact of TC roles on patient outcomes.

Chest trauma clinical practice guideline protects against delirium in patients with rib fractures

Introduction

Traumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated with rib fractures, evidence-based interventions have been implemented, including effective pain management, pulmonary hygiene, and early walking. Vancouver General Hospital, a level 1 trauma center in British Columbia, Canada, developed a comprehensive multidisciplinary chest trauma clinical practice guideline (CTCPG) to optimize the management of patients with rib fractures. This prospective cohort study aimed to assess the impact of the CTCPG on pain management interventions and patient outcomes.

Methods

The study involved patients admitted between January 1, 2021 and December 31, 2021 (post-CTCPG cohort) and a historical control group admitted between November 1, 2018 and December 31, 2019 (pre-CTCPG cohort). Patient data were collected from patient charts and the British Columbia Trauma Registry, including demographics, injury characteristics, pain management interventions, and relevant outcomes.

Results

Implementation of the CTCPG resulted in an increased use of multimodal pain therapy (99.4% vs 96.1%; p=0.03) and a significant reduction in the incidence of delirium in the post-CTCPG cohort (OR 0.43, 95% CI 0.21 to 0.80, p=0.0099). There were no significant differences in hospital length of stay, ICU (intensive care unit) days, non-invasive positive pressure ventilation requirement, ventilator days, pneumonia incidence, or mortality between the two cohorts.

Discussion

Adoption of a CTCPG improved chest trauma management by enhancing pain management and reducing the incidence of delirium. Further research, including multicenter studies, is warranted to validate these findings and explore additional potential benefits of the CTCPG in the management of chest trauma patients.

Level of evidence

IIb.

Analgesia for rib fractures: a narrative review

PURPOSE

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.

SOURCE

Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.

PRINCIPAL FINDINGS

Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.

CONCLUSION

Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management

BACKGROUND

Trauma injuries are one of the main leading causes of death in the world. Training with guidelines and protocols is adequate to provide a fast and efficient treatment to patients that suffer a trauma injury.

OBJECTIVES

This study aimed to evaluate deviations from a set protocol, a new set of metrics has been proposed and tested in a pilot study.

METHODS

The participants were final-year students from the Universidad Autónoma de Madrid and first-year medical residents from the Hospital Universitario La Paz. They were asked to train four trauma scenarios with a web-based simulator for 2 weeks. A test was performed pre-training and another one post-training to evaluate the evolution of the treatment to those four trauma scenarios considering a predefined trauma protocol and based on the new set of metrics. The scenarios were pelvic and lower limb traumas in a hospital and in a prehospital setting, which allow them to learn and assess different trauma protocols.

RESULTS

The results show that, in general, there is an improvement of the new metrics after training with the simulator.

CONCLUSION

These new metrics provide comprehensive information for both trainers and trainees. For trainers, the evaluation of the simulation is automated and contains all relevant information to assess the performance of the trainee. And for trainees, it provides valuable real-time information that could support the trauma management learning process.

Exploring perspectives and adherence to guidelines for adult spinal trauma in low and middle-income healthcare economies: A survey on barriers and possible solutions (part I)

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Most spinal trauma occurs in low- and middle-income countries (LMICs), but some elements may limit the application of current guidelines.

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In LMICs, a respectable proportion of physicians treating spinal trauma is not aware of any guidelines on this topic.

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Most physicians managing spinal trauma in LMICs believe that following the guidelines may positively affect patient outcomes.

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Most believed they have the capability to apply, the guidelines, but variation according to income and geographical region exists.

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The perceived limitations and their relevance to guideline adherence vary across different income and geographic areas worldwide.

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Resource-targeted guidelines for spinal trauma are considered a valuable option to overcome the limitations of real-life application of the current guidelines.

Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score

BACKGROUND

To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named "PIC Protocol" and "PIC Score," emphasizing continual assessment of pain, incentive spirometry, and cough ability.

OBJECTIVE

The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination.

METHODS

This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05.

RESULTS

There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score.

CONCLUSIONS

The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients.

How does the implementation of a patient pathway-based intervention in the acute care of blunt thoracic injury impact on patient outcomes? A systematic review of the literature

BACKGROUND

Blunt thoracic injury is present in around 15% of all major trauma presentations. To ensure a standardised approach to the management of physical injury, patient pathway-based interventions have been established in many healthcare settings. It currently remains unclear how these complex interventions are implemented and evaluated in the literature. This systematic review aims to identify pathway effectiveness literature and implementation studies in relation to patient pathway-based interventions in blunt thoracic injury care.

METHODS

The databases Medline, Embase, Web of Science, CINAHL, WHO Clinical Trials Register and both the GreyLit & OpenGrey databases were searched without restrictions on date or study type. A search strategy was developed including keywords and MeSH terms relating to blunt thoracic injury, patient pathway-based interventions, evaluation and implementation. Due to heterogeneity of intervention pathways, meta-analysis was not possible; analysis was undertaken using an iterative narrative approach.

RESULTS

A total of 16 studies met the inclusion criteria and were included in analysis. Pathways were identified covering analgesic management, respiratory care, surgical decision making and reducing risk of complications. Studies evaluating pathways are generally limited by their observational and retrospective design, but results highlight the potential benefits of pathway driven care provision in blunt thoracic injury.

CONCLUSIONS

The results demonstrate the complexity of evaluating patient pathway-based interventions in blunt thoracic injury management. It is important that pathways undergo rigorous evaluation, refinement and validation to ensure quality and patient safety. Strong recommendations are precluded as the quality of the pathway evaluation studies are low.

Effectiveness of non-pharmacological interventions for pain and physical function in adults with rib fractures: a systematic review protocol

REVIEW QUESTION/OBJECTIVES

The review question is: what are the effects of non-pharmacological therapeutic interventions on pain and physical function in adults with rib fractures?The objectives of this systematic review are to determine.

Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: A retrospective case-control study

INTRODUCTION

This single-centre retrospective case-control study aimed to assess the effectiveness of a multidisciplinary clinical pathway for blunt chest trauma patients admitted in emergency department (ED).

PATIENTS AND METHODS

All consecutive blunt chest trauma patients with more than 3 rib fractures and no indication of mechanical ventilation were compared to a retrospective cohort over two 24-month periods, before and after the introduction of the bundle of care. Improvement of analgesia was the main outcome investigated in this study. The secondary outcomes were the occurrence of secondary respiratory complications (pneumonia, indication for mechanical ventilation, secondary ICU admission for respiratory failure or death), the intensive care unit (ICU) and hospital length of stay (LOS).

RESULTS

Sixty-nine pairs of patients were matched using a 1:1 nearest neighbour algorithm adjusted on age and indices of severity. Between the two periods, there was a significant reduction of the rate of uncontrolled analgesia (55 vs. 17%, P<0.001). A significant increase in the rate of primary ICU transfer during the post-protocol period (23 vs. 52%, P<0.001) was not associated with a reduction of secondary respiratory complications or a reduction of ICU or hospital LOS. Only the use of non-steroidal anti-inflammatory drugs appeared to be associated with a significant reduction of secondary respiratory complications (OR=0.3 [0.1-0.9], P=0.03).

CONCLUSION

Implementation of a multidisciplinary clinical pathway significantly improves pain control after ED management, but increases the rate of primary ICU admission without significant reduction of secondary respiratory complications.

Implementation evaluation and refinement of an intervention to improve blunt chest injury management-A mixed-methods study

Aims and objectives

To investigate uptake of a Chest Injury Protocol (ChIP), examine factors influencing its implementation and identify interventions for promoting its use.

Background

Failure to treat blunt chest injuries in a timely manner with sufficient analgesia, physiotherapy and respiratory support, can lead to complications such as pneumonia and respiratory failure and/or death.

Design

This is a mixed‐methods implementation evaluation study.

Methods

Two methods were used: (i) identification and review of the characteristics of all patients eligible for the ChIP protocol, and (ii) survey of hospital staff opinions mapped to the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementation. The characteristics and treatment received between the groups were compared using the chi‐square test or Fischer's exact test for proportions, and the Mann–Whitney U‐test for continuous data. Quantitative survey data were analysed using descriptive statistics. Qualitative data were coded in NVivo 10 using a coding guide based on the TDF and Behaviour Change Wheel (BCW). Identification of interventions to change target behaviours was sourced from the Behaviour Change Technique Taxonomy Version 1 in consultation with stakeholders.

Results

Only 68.4% of eligible patients received ChIP. Fifteen facilitators and 10 barriers were identified to influence the implementation of ChIP in the clinical setting. These themes were mapped to 10 of the 14 TDF domains and corresponded with all nine intervention functions in the BCW. Seven of these intervention functions were selected to address the target behaviours and a multi‐faceted relaunch of the revised protocol developed. Following re‐launch, uptake increased to 91%.

Conclusions

This study demonstrated how the BCW may be used to revise and improve a clinical protocol in the ED context.

Relevance to clinical practice

Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions. Enhancing the self‐efficacy of emergency nurses when performing assessments has the potential to improve patient outcomes and should be included in implementation strategy.

Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol

Rib fractures are common among patients sustaining blunt trauma, and are markers of severe bodily and solid organ injury. They are associated with high morbidity and mortality, including multiple pulmonary complications, and can lead to chronic pain and disability. Clinical and radiographic scoring systems have been developed at several institutions to predict risk of complications. Clinical strategies to reduce morbidity have been studied, including multimodal pain management, catheter-based analgesia, pulmonary hygiene, and operative stabilization. In this article, we review risk factors for morbidity and complications, intervention strategies, and discuss experience with bundled clinical pathways for rib fractures. In addition, we introduce the multidisciplinary rib fracture management protocol used at our level I trauma center.

ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study

BACKGROUND

Blunt chest injuries not treated in a timely manner with sufficient analgesia, physiotherapy and respiratory support are associated with increased morbidity and mortality. The aim of the study was to determine the impact of a blunt chest injury early activation protocol (ChIP) on patient and hospital outcomes.

METHODS

In this pre-post cohort study, the outcomes of patients with blunt chest injury who received ChIP were compared against those who did not. Data including injury severity, patient outcomes, hospital treatments and comorbidites were extracted from medical records. The primary outcome was pneumonia. Secondary outcomes evaluated health service delivery. Logistic and multiple regressions were used to adjust for potential confounding variables.

RESULTS

546 patients were included, 273 in the before-ChIP cohort and 273 in the after-ChIP cohort. The incidence of pneumonia following the introduction of ChIP was reduced by 4.8% (95% CI 0.5-9.2, p=0.03). In the after-ChIP cohort, more patients received a pain team review (32% vs. 13%, p<0.001), physiotherapy (93% vs. 86%, p=0.005) and trauma team review (95% vs. 39%, p<0.001). There was no difference in length of stay (p=0.50).

CONCLUSIONS

ChIP improved the delivery of healthcare services and reduced the rate of pneumonia among patients with isolated chest trauma.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue

OBJECTIVES

We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay.

DESIGN

Prospective consecutive series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0.

INTERVENTION

Femur, pelvis, or spine fractures treated surgically.

MAIN OUTCOME MEASUREMENTS

Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded.

RESULTS

Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days).

CONCLUSIONS

Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery

Blunt chest trauma is associated with a high risk of morbidity and mortality. Complications in blunt chest trauma develop secondary to rib fractures as a consequence of pain and inadequate ventilation. This literature review aimed to examine clinical interventions in rib fractures and their impact on patient and hospital outcomes. A systematic search strategy, using a structured clinical question and defined search terms, was performed in MEDLINE, EMBASE, CINAHL and the Cochrane Library. The search was limited to studies of adult humans from 1990-March 2014 and yielded 977 articles, which were screened against inclusion/exclusion criteria. A hand search was then performed of the articles that met the eligibility criteria, 40 articles were included in this review. Each article was assessed using a quantitative critiquing guideline. From these articles, interventions were categorised into four main groups: analgesia, surgical fixation, clinical protocols and other interventions. Surgical fixation was effective in patients with flail chest at improving patient outcomes. Epidural analgesia, compared to both patient controlled analgesia and intravenous narcotics in patients with three or more rib fractures improved both hospital and patient outcomes, including pain relief and pulmonary function. Clinical pathways improve outcomes in patients ≥ 65 with rib fractures. The majority of reviewed papers recommended a multi-disciplinary approach including allied health (chest physiotherapy and nutritionist input), nursing, medical (analgesic review) and surgical intervention (stabilisation of flail chest). However there was a paucity of evidence describing methods to implement and evaluate such multidisciplinary interventions. Isolated interventions can be effective in improving patient and health service outcomes for patients with blunt chest injuries, however the literature recommends implementing strategies such as clinical pathways to improve the care and outcomes of thesetre patients. The implementation of evidence-practice interventions in this area is scarce, and evaluation of interventions scarcer still.

The trauma nurse coordinator in England: a survey of demographics, roles and resources

INTRODUCTION

Following the introduction of the regional trauma system in 2012 the role of the trauma nurse coordinator (TNC) has been rolled out. This study aims to determine the demographic and practice profile of nurses performing the TNC role in England.

METHODS

An electronic survey of TNCs across the 18 trauma networks in England was conducted.

RESULTS

Fifty-three TNCs responded (62%) to the survey. Seventeen different role titles identified. The majority of TNCs had an emergency or trauma/orthopaedics clinical background. The largest proportion of time spent was clinical (38%). Least amount of time was spent in the education (7%), and research (3%). Nearly a quarter of respondents (23%) had some form of formal research training, nearly half (47%) were assisting others in research. Over half (55%) of respondents felt that they did not have adequate human resources to conduct their role.

DISCUSSION

This research has provided baseline information about nurses in the role of TNC, their role titles and domains of the role 18 months after the formal introduction of trauma networks in England. There are some marked similarities and differences in the time spent in the different domains of the role between these findings and those published internationally.

Systematic review of multidisciplinary rehabilitation in patients with multiple trauma

Background

Multiple trauma is a cause of significant disability in adults of working age. Despite the implementation of trauma systems for improved coordination and organization of care, rehabilitation services are not yet routinely considered integral to trauma care processes.

Methods

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Physiotherapy Evidence Database, Latin American and Caribbean Literature on Health Sciences and Cochrane Library databases were searched up to May 2011 for randomized clinical trials, as well as observational studies, reporting outcomes of injured patients following multidisciplinary rehabilitation that addressed functional restoration and societal reintegration based on the International Classification of Functioning, Disability and Health.

Results

No randomized and/or controlled clinical trials were identified. Fifteen observational studies involving 2386 participants with injuries were included. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach assessed methodological quality as ‘poor’ in all studies, with selection and observer bias. Although patients with low functional scores showed improvement after rehabilitation, they were unable to resume their pretrauma level of activity. Their functional ability was significantly associated with motor independence on admission and early acute rehabilitation, which contributed to a shorter hospital stay. Injury location, age, co-morbidity and education predicted long-term functional consequences. Trauma care systems were associated with reduced mortality. The gaps in evidence include: rehabilitation settings, components, intensity, duration and types of therapy, and long-term outcomes for survivors of multiple trauma.

Conclusion

Rehabilitation is an expensive resource and the evidence to support its justification is needed urgently. The issues in study design and research methodology in rehabilitation are challenging. Opportunities to prioritize trauma rehabilitation, disability management and social reintegration of multiple injury survivors are discussed.

Clinical pathways in transplantation: a review and examples from Beth Israel Deaconess Medical Center

Clinical pathways (CP) have been developed to aid in the management of many surgical and medical conditions. Studies show the benefits of CP on outcomes including reduction in length of stay (LOS), morbidity, costs, and improvement in patient satisfaction (Arch Surg 2008: 394: 31; J Eval Clin Pract 2007: 13: 920; Arch Otolaryngol Head Neck Surg 2000: 126: 322; Circulation 2000: 101: 461; BMC Pulm Med 2006: 6: 22; Int J Health Care Qual Assur 2006: 19: 237; Am J Med Qual 2005: 20: 83; Am J Surg 2006: 192: 399; Am Surg 2005: 71: 152). Reports of CP in solid organ transplantation are lacking, possibly given the complexity of the transplant procedures that entail a complex, multidisciplinary pre-operative evaluation, inpatient, and post-operative time frames. We have developed CP from presentation for transplant evaluation to post-transplant follow-up for liver, kidney, and pancreas transplantation and live kidney and live liver donation and are making them available online for viewing. Our CPs encompass the pre-operative, peri-operative, and post-operative period, including both outpatient and inpatient care. We propose that transplantation is an ideal forum for successful implementation of CP, given the rigorous process that centers are subject to for CMS approval and the ample opportunity for improving our patients' lives by improvement in and streamlining of the entire process of clinical care from end-stage organ failure to post-transplant long-term management. Our CPs can be found at http://bidmc.org/CentersandDepartments/Departments/TransplantInstitute/TransplantClinicalPathways.aspx.

Do AR-DRGs adequately describe the trauma patient episode in New South Wales, Australia?

The use of Diagnosis Related Groups (DRGs) may not be an accurate tool to provide reimbursement for trauma services. This study aimed to determine whether Australian Refined Diagnosis Related Groups (AR-DRGs) adequately describe the trauma patient episode and to identify AR-DRG groupings where reimbursement was not commensurate with actual cost. The AR-DRG allocated costs and actual costs of a sample of 206 trauma patient episodes were reviewed during a three-month period. Of the AR-DRG groups identified in the patient episodes, 62.8% were not commensurate with actual cost incurred, equating to an overall loss of $113,921 from under-funded acute trauma patient episodes over a three-month period. Assault-related penetrating trauma, traffic-related and sport-related incidents were all inadequately reimbursed using AR-DRGs compared with the actual cost of treatment. Cases involving female patients, patients aged 45 years or less and those with moderate injuries were similarly underfunded. AR-DRGs are not adequate to describe the extent of injuries experienced by trauma patients and there is a need to investigate alternative funding models for trauma services.

The impact of clinical nurse specialists on clinical pathways in the application of evidence-based practice

The purpose of this article was to address the call for evidence-based practice through the development of clinical pathways and to assert the role of the clinical nurse specialist (CNS) as a champion in clinical pathway implementation. In the current health care system, providing quality of care while maintaining cost-effectiveness is an ever-growing battle that institutions face. The CNS's role is central to meeting these demands. An extensive literature review has been conducted to validate the use of clinical pathways as a means of improving patient outcomes. This literature also suggests that clinical pathways must be developed, implemented, and evaluated utilizing validated methods including the use of best practice standards. Execution of clinical pathways should include a clinical expert, who has the ability to look at the system as a whole and can facilitate learning and change by employing a multitude of competencies while maintaining a sphere of influence over patient and families, nurses, and the system. The CNS plays a pivotal role in influencing effective clinical pathway development, implementation, utilization, and ongoing evaluation to ensure improved patient outcomes and reduced costs. This article expands upon the call for evidence-based practice through the utilization of clinical pathways to improve patient outcomes and reduce costs and stresses the importance of the CNS as a primary figure for ensuring proper pathway development, implementation, and ongoing evaluation.

Testing the effectiveness of the Amputee Mobility Protocol: a pilot study

We studied prolonged length of stay (LOS) in the acute care setting on a medical-surgical vascular unit, related to loss of functional mobility status after lower extremity amputation, and implementation of the Amputee Mobility Protocol (AMP) as a standard of care for all patients pre- and post-lower extremity amputation who were admitted to the medical-surgical vascular unit. A comparative pre-post observational study evaluated the effect of AMP on level of functional mobility and LOS after lower extremity amputation in the patient population on the medical-surgical vascular unit. Data was collected retrospectively from patient chart reviews from November of 2004 to March of 2005 for the pre-AMP group and through concurrent patient chart reviews from November of 2005 to March of 2006 for the post-AMP group. Dependent variables included functional mobility and LOS, which were evaluated by a modified Functional Independence Measure (FIM) score and the hospital LOS. Forty-four eligible patients were enrolled in the AMP pilot study during a 5-month period. The sample population consisted of 30 patients pre-AMP and 14 patients post-AMP. LOS for transmetatarsal amputations decreased by 0.7 days, whereas functional mobility increased by a minimum of one level in the modified FIM score. Functional mobility increased for transtibial amputations by one level and transfemoral amputations by 2 levels using the modified FIM score. LOS increased for patients undergoing transtibial (7.1 days) and transfemoral (2.7 days) amputations. This quality improvement project heightened staff awareness regarding ambulation and its impact on functional mobility and early discharge. Vascular nurses were able to affect patients' functional mobility and LOS by implementing a standardized AMP. Data showed that using the standardized AMP increased patients' functional mobility but did not significantly decrease acute care setting LOS. The AMP continues to be used for this patient population because of its impact on functional mobility and independence. This pilot study relates to 3 of the top 20 vascular research priorities: 1) an interdisciplinary strategy to improve the patient's level of functional independence and thereby decrease LOS and cost; 2) the nursing intervention of early, predetermined ambulation schedules will increase the nursing knowledge of strategies that facilitate recovery after vascular surgery in this population; and 3) factors that affect patient outcomes after these three major vascular procedures will be addressed in pilot outcomes. Limitations of the AMP pilot study included the small sample size, staff turnover, and lack of a concurrent control group. The next phase of this project will create and implement a similar activity protocol for patients after abdominal aortic aneurysm repair and various types of lower extremity bypass procedures.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.

Adverse Outcomes in Younger Rib Fracture Patients

BACKGROUND

Recent studies on the impact of rib fractures after blunt trauma have shown a linear relationship between age, increasing number of rib fractures, and complications, including mortality. Others have documented that age-related morbidity increases before age 65 in trauma patients. We hypothesize that patients as young as age 45 demonstrate increased morbidity with injuries similar to older patients.

METHODS

We performed a retrospective cohort study involving all blunt trauma patients with rib fractures, excluding those with severe head and abdominal injuries and those dying within 24 hours, admitted between January 2001 and December 2004. Outcome parameters included pulmonary complications, ICU length of stay, hospital and ICU length of stay, Injury Severity Score (ISS), number of vent days, number of rib fractures, mechanism of injury, and discharge disposition.

RESULTS

Of the 3,094 patients admitted, 307 met the inclusion criteria (9.9%). Based on statistical analysis of age, number of rib fractures, and adverse outcome variables, patients were separated into 4 groups: Group 1: younger than 44 years old with 1 to 4 rib fractures, Group 2: younger than 44 years with greater than 4 rib fractures, Group 3: 45 years or older with 1 to 4 rib fractures, and Group 4: 45 years or older with more than 4 rib fractures. Age groups and outcome variables were compared with chi-square, analysis of variance and multiple regression analysis. Respiratory failure, pneumonia, and associated thoracic injuries were increased in Group 4 patients compared with other groups (P < 0.05). Mortality and length of stay were not different between groups.

CONCLUSIONS

Patients as young as 45 with more than 4 rib fractures are at increased risk for adverse outcomes. Efforts to improve outcomes in rib fracture patients should focus not only on elderly patients, but on those as young as 45 years. Based on these data, we established a rib fracture clinical pathway focusing on patients 45 years and older with more than 4 rib fractures.

Maintaining Patient Throughput on an Evolving Trauma/Emergency Surgery Service

BACKGROUND

The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized.

METHODS

An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest.

RESULTS

The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01).

CONCLUSIONS

The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

The volume-outcome relationship: don't believe everything you see

This paper investigates methodological limitations of the volume-outcome relationship. A brief overview of quality measurement is followed by a discussion of two important aspects of the relationship.

Is trauma centre care helpful for less severely injured patients?

BACKGROUND

Trauma centres have been shown to reduce the number of preventable deaths from serious injuries. This is due largely to the rapid response of surgeons and health care teams to resuscitate, evaluate, and operate if necessary. Less is known about the effectiveness of trauma centre care on those patients who have not incurred immediate life-threatening problems and may not be as critically injured. The purpose of this study was to review the use of physician and hospital resources for this patient population to determine whether trauma team and trauma centre care is helpful or even needed.

METHODS

This was a retrospective study of consecutive trauma patients (n=1592) admitted from 1998 to 2002 to the trauma service of an urban level I trauma centre and recorded in the hospital trauma registry. Patients were triaged in a tiered response to more or less severely injured. All patients' care was directed by trauma surgeons.

RESULTS

Of the 1592 patients, 398 (25%) received a full trauma team response (Class I), 1194 were less seriously injured (Class II). The ISS for the Class I patients was 19+/-18 and for Class II patients 10+/-10. Nineteen percent of Class II patients had an ISS>15. Overall mortality in Class II patients was 2% including 20 unexpected deaths. Four hundred and three Class II patients (34%) had multisystem injuries. Of the Class II patients 423 (35%) were sent to the ICU or OR from the ED, 106 of whom required an immediate operation and 345 required an operation prior to discharge. Complications developed in 129 patients (11%), the majority of which were pulmonary.

CONCLUSIONS

A large proportion of those patients thought initially to be less severely injured required resources available in a trauma centre, including specialty care, intensive care, and operating room accessibility. Over one-third of these patients had multisystem injuries and almost 20% were considered major trauma, needing prioritisation of care and expertise ideally found in a trauma centre environment. Complications developed in a sizable number of patients. This patient population, because of its heterogeneity and propensity for critical illness, deserves the resources of a trauma centre.

Guideline validation in multiple trauma care through business process modeling

Clinical guidelines can improve the quality of care in multiple trauma. In our Department of Trauma Surgery a specific guideline is available paper-based as a set of flowcharts. This format is appropriate for the use by experienced physicians but insufficient for electronic support of learning, workflow and process optimization. A formal and logically consistent version represented with a standardized meta-model is necessary for automatic processing. In our project we transferred the paper-based into an electronic format and analyzed the structure with respect to formal errors. Several errors were detected in seven error categories. The errors were corrected to reach a formally and logically consistent process model. In a second step the clinical content of the guideline was revised interactively using a process-modeling tool. Our study reveals that guideline development should be assisted by process modeling tools, which check the content in comparison to a meta-model. The meta-model itself could support the domain experts in formulating their knowledge systematically. To assure sustainability of guideline development a representation independent of specific applications or specific provider is necessary. Then, clinical guidelines could be used for eLearning, process optimization and workflow management additionally.

Morbidity from rib fractures increases after age 45

BACKGROUND

Recent studies have demonstrated increased morbidity in elderly patients with rib fractures after blunt trauma. As a first step in creating a multidisciplinary rib fracture clinical pathway, we sought to determine the relationship between increasing age, number of rib fractures, and adverse outcomes in blunt chest trauma patients, without major abdominal or brain injury.

STUDY DESIGN

We performed a retrospective cohort study involving all blunt patients greater than 15 years old with rib fractures, excluding those with Abbreviated Injury Scores (AIS) greater than 2 for abdomen and head, admitted to an urban Level I trauma center during 20 months. Outcomes parameters included the number of rib fractures, Injury Severity Score (ISS), intrathoracic injuries, pulmonary complications, number of ventilator days, length of stay in the intensive care unit (ICU), hospital stay, and type of analgesia.

RESULTS

Of the 6,096 patients admitted, 171 (2.8%) met the inclusion criteria. Based on an analysis of increasing age, number of rib fractures, and adverse outcomes variables, patients were separated into four groups: group 1, 15 to 44 years old with 1 to 4 rib fractures; group 2, 15 to 44 years old with more than 4 rib fractures; group 3, 45 years or older with 1 to 4 rib fractures; and group 4, 45 years or more with more than 4 rib fractures. The four groups had similar numbers of pulmonary contusions (30%) and incidence of hemopneumothorax (51%). Ventilator days (5.8 +/- 1.8), ICU days (7.5 +/- 1.8), and total hospital stay (14.0 +/- 2.2) were increased in group 4 patients compared with the other groups (p < 0.05). Epidural analgesia did not affect outcomes. Overall mortality was 2.9% and was not different between groups.

CONCLUSIONS

Patients over the age of 45 with more than four rib fractures are more severely injured and at increased risk of adverse outcomes. Efforts to decrease rib fracture morbidity should focus not only on elderly patients but those as young as 45 years. Based on these data we have initiated a multidisciplinary clinical pathway focusing on patients 45 years and older who have more than four rib fractures.

The impact of trauma case management on patient outcomes

BACKGROUND

Previous investigations demonstrate that nursing case management in the acute care setting improves patient outcomes. However, these findings provide limited information specific to trauma patients.

METHOD

The effect of trauma case management (TCM) was measured using practice-specific variables such as in-hospital complications, missed injury rates, and length of stay. Other measures included staff satisfaction and use of allied health services. Data from 148 patients with an Injury Severity Score < 16 in the 5 months after the introduction of TCM were compared with 327 patients from the previous 12 months.

RESULTS

Results demonstrated a trend toward reduced length of stay overall, more so in the older and more severely injured. TCM greatly improved missed injury detection rates (p < 0.0015) and coordinated allied health use more efficiently (p < 0.0001). Staff surveys exhibited a perceived dramatic improvement in the effectiveness of patient care (p < 0.0001).

CONCLUSION

The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution.

Initial management of the poly-trauma patient: a practical approach in an Australian major trauma service

The initial management of the poly-trauma patient is of vital importance to minimizing both patient morbidity and mortality. We present a practical approach to the early management of a severely injured patient as practiced at Liverpool Hospital in Sydney, Australia. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.