Injury, Int. J. Care Injured (2006) 37, 626—632
www.elsevier.com/locate/injury
Trauma case management: Improving patient outcomes Kate Curtis a,*, Yi Zou a, Richard Morris a, Deborah Black b a
St. George Hospital, University of New South Wales, Sydney, NSW, Australia School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
b
Accepted 6 February 2006
KEYWORDS Case management; Trauma patient outcomes; Trauma nurse; Complications; Trauma case management; Communication
Summary Background: The purpose of the study was to measure the effect of trauma case management (TCM) on patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates. Methods: TCM was provided 7 days a week to all trauma patient admissions. Data from 754 patients were collected over 14 months. These data were compared with 777 matched patients from the previous 14 months. Results: TCM greatly improved time to allied health intervention ( p < 0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis ( p < 0.038) and a trend towards decreased patient morbidity, unplanned admissions to the intensive care unit and operating suite. A reduced hospital stay LOS, particularly in the paediatric and 45—64 years age group was noted. Six thousand six hundred twenty-one fewer pathology tests were performed and the total number of bed days was 483 days less than predicted from the control group. Conclusion: The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use. # 2006 Elsevier Ltd. All rights reserved.
Introduction and background * Corresponding author. Tel.: +61 2 9350 3499; fax: +61 239503974. E-mail addresses:
[email protected] (K. Curtis),
[email protected] (R. Morris),
[email protected] (D. Black).
Trauma patient care is universally recognised as extremely time and resource intensive, and thus very costly.21,3,16 The plan of care for trauma patients can become fragmented because the complex health
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.02.006
Trauma case management care needs of the trauma patient and their family are not usually amenable to the actions of a single health care discipline.14 The need for multiple caregivers and specialties can lead to inefficiency, missed injuries, duplication of effort, and suboptimal care.19 A lack of planning, advocacy, coordination and communication also lead to fragmentation, uncertainty, decreased patient and staff satisfaction6 and increased complications.1 In addition increased length of stay, cost and resource use prevent more appropriate allocation and effective utilisation of current resources.8 While patients may be satisfied with each individual health professional, they recognise that the overall episode of care is often poorly coordinated or managed.15 To counter this phenomenon, various surgical specialties have implemented the concept of case management, and its use is now being recommended in wider clinical applications.1 Harrahill12 states that to increase the efficiency of a trauma service many trauma centres in the USA have implemented the role of trauma case manager and that it appeared to be an effective option to augment the traditional activities of the trauma nurse coordinator. The trauma case manager’s role is to negotiate, arrange and coordinate clinical services and to intervene at key points in the patient’s inpatient stay so to improve quality care while at the same time conserving hospital resources.10 Previous analysis of trauma case management (TCM) in our institution demonstrated that it improved the efficiency and effectiveness of trauma patient care.7 However, the study was limited by its small sample size, making extrapolation on the ultimate merits of TCM difficult. The current study was designed to overcome some of the shortcomings of the original investigation. In a survey of Australian trauma centres, most trauma coordinators identified a TCM as a desirable asset that would potentially improve trauma care efficiency and clinical outcomes.8 The minimal time that the trauma nurse coordinators had available for clinical service management implies that there might be a role for trauma case managers in busy trauma centres.
Aim The aim of this study was to determine the effect of trauma case management on patient outcomes such as length of stay (LOS), complications, missed injuries, and usage of allied health, pathology and radiology services. It was hypothesised that TCM would diminish morbidity, length of stay and
627 resource utilisation, and would increase allied health referral rates.
Materials and methods The study hospital is a 600 bed urban teaching hospital of a major NSW University. It is a designated Level One Trauma Centre, admitting over 2500 injured patients per year, of which approximately 220 have an ISS > 15. This ambispective descriptive cohort study compared two groups of patients: the first group comprised of consecutive patients admitted to the trauma centre during the 14 months prior to implementation of the TCM program (control group); the second group comprised of those admitted during the first 14 months after implementation of the TCM program (TCM group). All patients who fulfilled pre-existing trauma database entry criteria (Table 1) during the study period (1st March 2002 to 8th May 2003) were included in the study. Full approval by the hospital ethics committee was applied for and granted. The trauma service dataTable 1
Trauma activation criteria
Trauma triage/activation criteria (a) History/mechanism of injury: (1) Motor vehicle collision at speed >60 kph (2) Pedal cyclist struck by motor vehicle at >30 kph (3) Adult pedestrian struck by motor vehicle at >30 kph (4) Child pedestrian struck by motor vehicle at any speed (5) Fall greater than 3 m (6) Patients presenting via the ambulance service executing protocol 4 (i.e. bypassing another hospital) (b) Vital signs: (1) Shallow or retractive breathing (2) Cyanosis or oxygen saturation 10% in children
628 base was developed in 1993 and has a comprehensive data dictionary in which each item is fully defined. It contains data including patient demographics, a time line, treatment received in each trauma phase (for example (a) fluid type/amount received in the resuscitation phase, (b) DVT prophylaxis required, required and not received, or not required) complications and performance indicators. These data were collected by a trauma research nurse who reviewed trauma patient records daily, and once TCM was introduced, the trauma research nurse oversaw the data collection process. The TCM positions were filled by two trauma nurses who provided TCM coverage 7 days a week and after hours to 11 p.m. on Wednesdays, Thursdays to Fridays, to an average of 15—20 in-patients per day. These nurses were recruited based on their demonstrated previous experience in the field of trauma care as well as their ability to communicate and interact with other health care professionals of varied specialties and disciplines.10 Hospital wide awareness of the rationale for TCM was extremely important for its successful implementation, necessitating the education of nursing staff, managers and medical staff on role of the case manager. The TCM study proposal was circulated to the Divisional Heads, trauma surgeons and nursing administration. Meetings were arranged with a representative of every discipline involved in trauma care. Additionally, the case managers introduced themselves to staff on each ward round and explained their function. At the time of the study, patients requiring admission were admitted to the service of the on-call trauma surgeon (the trauma team) and any relevant subspecialties were consulted as needed. If injuries were not of a nature that required the care of a general surgeon, the trauma team would transfer the patient to the care of the relevant subspecialist after performing the tertiary survey, usually after 24 h of admission. Data entry and editing was conducted and/or overseen by the data manager and the first author for the entire study period. The following patient characteristics were used to validate the data sets for comparison: (1) (2) (3) (4) (5)
Patient age Patient age group Patient gender Day of week of presentation Month of presentation (to account for seasonal variation) (6) Inter-hospital transfer status (7) Mechanism of injury group
K. Curtis et al. (8) Injury severity score (ISS) (9) Injury severity score group (10) Dispatch route from the emergency department A 5% level of significance was used to detect differences in patient variables between the control and study groups. Analysis was conducted using SPSS. Chi-square testing was conducted to determine if there was any significant difference determined in the age groups: age 64. For interval or parametric numbers data such as age, a t-test was used. Also, for each variable the sample size, mean, standard deviation, and standard error of the mean were examined. However the distribution of patient age was not normal, thus the non-parametric Mann—Whitney U-test was conducted. Once the two groups had been matched the full data set was collated. Case mix data were obtained for the number of patients with allied health intervention, as well as the timing between hospital admission and time to the first allied health intervention. Allied health staff includes physiotherapy, occupational therapy and social work. The case-mix database contains information of the patient episode, including their DRG and the services provided during each episode, such as radiology and pathology tests. The trauma database provided the rest of the data. Non-parametric tests such as the Mann— Whitney U-test were used for highly skewed (nonnormal) interval data and the x2-test was used for categorical data. The interventions most commonly performed by the TCM were: (a) attending initial patient resuscitation and assisting clinically in the ED, (b) communicating the patient plan with all parties involved, including the clinicians, the patient and the family, (c) ensuring documentation of the patient management plan, and (d) identifying barriers to discharge. A checklist of standard TCM interventions was kept and updated daily for each patient over the course of the admission.
Results During the study our institution admitted 1541 trauma patients. Of these, 786 were admitted during the period prior to institution of the trauma case management program (the control group), and the remaining 755 were admitted after program initiation (the TCM group). Table 2 lists patient demographics and other characteristics of the study population. There were no statistically significant differences between the two groups.
Trauma case management
629
Table 2 Significance of difference between control and study group patient characteristics
Table 4 Allied health referral and time to assessment rates results
Patient characteristic
Control
Allied health group
Age (median) Gender (n)
32 36 0.090 a 531 528 0.171 b (m)/255 (f) (m)/227 (f) 76 80 0.547 a
Inter-hospital transfer (n)
TCM
p-Value
Injury severity score ISS overall (n) 9 ISS 15 (n) 226
9 337 222 195
0.011 a
Mechanism of Injury MVC (n) 293 Falls (n) 201 Pedestrians (n) 90 Assaults (n) 63
296 191 72 78
0.544 b
Dispatch route from ED ICU (n) 60 HDU (n) 89 Ward (n) 469 Died (n) 6
63 74 459 10
0.682 b
a b
0.400 b
Percentage of patients receiving allied health intervention Physiotherapy 55 Occupational therapy 33 Social work 37 Median days to allied health assessment/intervention Physiotherapy 1.5 Occupational therapy 3.5 Social work 3 a
p-Value calculated using Mann—Whitney U-test. p-Value calculated using x2-test.
Differences in complication and missed injury rates are presented in Table 3. There was a significant decrease in the incidence of coagulopathy ( p < 0.05) and deep vein thrombosis ( p < 0.04). Unplanned ICU admissions were reduced from 14 cases to 6 and respiratory failure cases reduced from 26 to 15. These differences were not statistically significant.
TCM group
*
Control group
p-Value a
45 27 32
64 years). Hospital LOS was significantly decreased in the paediatric group ( p < 0.05) and the median LOS for patients aged 45—64 years was reduced by 28% (from 7 to 5 days), but this was not statistically significant. The total number of bed days for all patients in the TCM group was 483 days less than predicted from the control group (Table 5). Reductions in length of stay were most evident in the moderately and severely injured patient groups (ISS 9—15 and >15). Despite this large reduction in occupied bed days, the decrease in overall trauma patient length of stay was not statistically significant.
Discussion Modern inpatient trauma care relies on a multitude of interrelated surgical and medical specialties, diagnostic tests, therapeutic interventions, and allied health services to reduce mortality and morbidity from severe injuries. The complexity of this care can often overwhelm the ability of the primary medical team so it is essential to ensure that the care is timely, well organised, and efficient. Trauma case management has been proposed as a way of ensuring that the myriad of details of care are neither forgotten (potentially leading to higher complication and mortality rates) nor duplicated (potentially leading to higher resource utilisation).
Complications In a study of trauma care evaluation methods published in 1999, Trooskin et al., concluded that complications as an outcome measure still remains relatively unevaluated in trauma, despite their importance in the current health care environment that stresses minimising costs and resource utilisation while increasing quality.23 More recently, Holbrook et al. conducted a comprehensive study investigating the impact of major in-hospital com-
plications on the quality of life of trauma patients in San Diego.13 They found that major complications were present in 10.1% of trauma patients, and that these complications, such as pneumonia, pulmonary embolus, bowel obstruction and wound infection, were strongly associated with excess resource utilisation, in addition to higher mortality, longer length of stay and increased costs in trauma patients. Perdue et al.18 highlighted the importance of being aware of the potential for older patients to develop complications when they retrospectively reviewed 5139 adult patients from a Level I trauma centre. They found that the mortality of the elderly trauma patient (age > 65) is twice that of younger patients, despite equivalent severity of injury scores and the rate of in-hospital complications is significantly higher. The implication of age-related morbidity and mortality for the trauma case manager is that they should be particularly wary of complication development in the more elderly trauma patient. This is also supported by Tornetta et al.22 who reviewed 326 charts of patients older than 60 years who were admitted to one of four Level I trauma centres after sustaining blunt trauma. They found that mortality could be predicted by injury severity and the complications of pneumonia, sepsis and adult respiratory distress syndrome. The current study found that the implementation of a trauma case management program in an urban trauma centre was associated with a significant decrease in the incidence of deep venous thrombosis and of coagulopathy among admitted trauma patients, even though there had been no policy or education program introduced during the study period regarding DVT prophylaxis or surveillance. In fact whilst each trauma patient was monitored for DVT development, no formal DVT prophylaxis guidelines or other post-initial resuscitation trauma management guidelines were developed until the study had been completed, which coincided with the appointment of a trauma director. The reduction in DVT incidence may be explained by improved care oversight, communication and the emphasis that the trauma case managers placed on ensuring that all patients had their DVT prophylaxis charted, reviewing each patient’s mobility status on a daily basis, as well as conducting regular staff education sessions. The reduction in coagulopathy could be explained by to the trauma case managers trauma education program which regularly highlighted the importance of warming intravenous fluid prior to infusion, preventing heat loss, active warming of the patient during the ED and operative phases, monitoring the
Trauma case management amount of crystalloid/colloid the patient received, and anticipating the need for blood products in a trauma resuscitation. In many instances, the case managers were present at the initial patient resuscitation and were able to implement the above principles. However the rate of coagulopathy in relation to TCM presence was not examined and is a limitation of this study. The decrease in respiratory failure (15 cases after TCM reduced from 26 prior to TCM implementation), whilst not statistically significant, might also be attributed to early intervention from the case manager. Age subgroup analysis showed that the majority of these multi-system injured patients had some form of chest wall injury and were older than 56 years. The case managers ensured the patients received early chest physiotherapy, adequate analgesia and were monitored in an appropriate acuity ward environment. TCM can assist in reducing complications and is contributing to the ongoing struggle to improve the quality of care and life of trauma patients whilst decreasing hospital and community resource use. The decrease in the number of pathology tests conducted (19%) may perhaps be partially attributed to a decrease in complications.
Allied health use Statistically significant increases in physiotherapy and occupational therapy referrals were demonstrated. In addition, the time to intervention by physiotherapy and occupational therapy was significantly reduced. Both fields overlap somewhat as both provide special splints, hand/upper extremity therapy, work conditioning programs. Both professions also aim to reduce pain, restore function, maximise personal productivity, and promote as much independence and well-being as possible.2,17 These multiple interventions require extensive planning, coordination and time, thus the earlier the referral is made, the sooner the process of rehabilitation can begin. The trauma case manager was able to identify which patient needed allied health services as soon as the patient was admitted and acted as a filter, ensuring appropriate referrals were made to the service as soon as possible. This in turn enabled allied health staff adequate time to prepare and plan for discharge of the patient. Despite a 36% increase in allied health staff intervention, there had been no increase in the levels of allied health staff employment. It is suggested that prior to TCM, many allied health staff were not aware of patient consultation requirements.
631
Communication Dutton et al. state, effective and efficient trauma patient care is extremely dependant on close communication between multiple service providers, something that is often difficult to accomplish on a daily basis.9 Difficulties arise because inter-service communications are frequently relegated to junior medical staff that frequently lack sufficient training in the intricacies of trauma care and coordinating multiple specialties, or because the primary care team is a subspecialty team such as orthopaedics or neurosurgery, may tend to focus only on their area of care. A survey conducted of new graduate doctors in Ireland found that 91% of respondents felt they did not possess the skills and characteristics required of them as an intern.11 Trauma case managers are able to minimise some of these shortcomings by assisting junior medical staff to fully evaluate each patient on a daily basis, monitor the progression of injuries and become aware of any pre-existing co-morbidities. The case managers also improve and hasten interspecialty communication via their frequent entries in the medical record and by liberal use of the telephone and face-to-face encounters with members of the involved specialty teams, nursing staff, allied health personnel, and the patient and his family. Other strategies that can be incorporated with trauma case managers have been successful in streamlining trauma patient care. Cornwell et al.5 from the USA and Simons et al.20 from Canada demonstrated that an enhanced trauma program, including a dedicated trauma admitting unit decreased the trauma patient mortality, particularly in the severely head injured patient. In addition Cohen et al.4 showed that a dedicated trauma service which improved continuity and integration of trauma care had a positive impact on the quality of care. Dutton et al.9 demonstrated that daily multidisciplinary rounds can shorten length of stay for trauma patients by 15%, although not every institution that provides care for trauma patients may have ready access to such resources, and the case manager certainly contributes to filling that void. Ideally, TCM is a service that would be beneficial 24 h a day, and be of great assistance after hours when staffing levels are considerably reduced, however current funding within the health care system would not allow for such provision.
Conclusion Trauma case management decreased complication rates, increased allied health referral rates, and decreased the time to allied health intervention
632 in this retrospective cohort study at a busy urban trauma centre. Further research opportunities in this area exist for multi-centre collaborative trials, although sampling issues and significance of comparison may be limited due to variance in clinical practice and in-hospital systems between institutions. The value of subjecting these changes to studies of this nature is limited due to the problems in sampling and the real benefits of instigating a trauma case management program may only become apparent through implementation and adapting qualitative and quantitative modes of assessment.
Acknowledgements The author acknowledges financial assistance from the College of Nursing and the New South Wales Nurses and Midwifery Board enabling the author to complete the study.
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