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 an d case management between July 1998 and July 1999 in five key trauma condit ions: 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 define d as variances. Attainment of the expected outcomes was measured before (st age 1) and after introduction (stages 2 and 3) of clinical pathways and cas e management. Nonattained outcomes were quantified and categorized into tim e 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 = 0.0 001 for both stage 1 and stage 2 compared with stage 3), There was a signif icant 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. Conclusion: 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 s ervice.