Trauma case management and clinical pathways: prospective evaluation of their effect on selected patient outcomes in five key trauma conditions.
BACKGROUND
This study evaluated the implementation of clinical pathways and case management between July 1998 and July 1999 in five key trauma conditions: severe head injury, fractured ribs, fractured pelvis, blunt abdominal trauma, and fractured femurs presenting to a single trauma service.


METHODS
Thirteen key elements of care with expected outcomes were defined for each key trauma condition. Deviations from expected outcome were defined as variances. Attainment of the expected outcomes was measured before (stage 1) and after introduction (stages 2 and 3) of clinical pathways and case management. Nonattained outcomes were quantified and categorized into time of occurrence, and relationship to staff, patient, or system.


RESULTS
Two hundred thirty-five patients were studied, with a mean age of 41.8 (SD, 20.6) years and mean Injury Severity Score (ISS) of 11.7 (SD, 11.0). The mean number of observed variances per patient for stage 1 was 51.7 (SD, 43.5); stage 2, 42.3 (SD, 32.9); and stage 3, 23.2 (SD, 21.7) (p = 0.0001 for both stage 1 and stage 2 compared with stage 3). There was a significant improvement in outcomes achieved from stage 1 (92.7%; 95% confidence interval, 92.5-92.9%), to stage 3 (96.7%; 95% confidence interval, 96.5-96.9%). Of the total number of variances seen, 0.2% related to system errors, 25% related to patient factors, and 75.8% related to staff. The proportion of staff-related variances was significantly reduced in stage 3.


CONCLUSIONS
Clinical pathways and case management identified areas in need of remedial action and improved the delivery of patient care to our trauma population. It has set a template for the future management of our trauma service.
Sesperez
J
J
Department of Trauma and Epidemiology, Liverpool Hospital, Liverpool, BC, New South Wales, Australia.
Wilson
S
S
Jalaludin
B
B
Seger
M
M
Sugrue
M
M
D000007:Abdominal Injuries / Q000628:therapy; D000328:Adult; D000704:Analysis of Variance; D019985:Benchmarking; D019090:Case Management / Q000592:standards*; D006259:Craniocerebral Trauma / Q000628:therapy; D019091:Critical Pathways / Q000592:standards*; D005260:Female; D005264:Femoral Fractures / Q000628:therapy; D050723:Fractures, Bone / Q000628:therapy; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000145:classification / Q000191:economics / Q000401:mortality / Q000628:therapy*; D009517:New South Wales / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D010384:Pelvic Bones / Q000293:injuries; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012253:Rib Fractures / Q000628:therapy; D014193:Trauma Centers; D014949:Wounds, Nonpenetrating / Q000628:therapy