Early Appropriate Care and opportunities for integrated care pathwyas in orthopaedic trauma

Main Article Content

Heather Vallier

Abstract

Early appropriate care (EAC) is a treatment protocol for trauma patients with unstable fractures of the thoracolumbar spine, pelvis, acetabulum, and/or femur. The protocol was designed to expedite treatment based on patient physiologic readiness for definitive fracture surgery. In the EAC protocol, patients are aggressively resuscitated and managed by a multidisciplinary team. Upon achieving predefined thresholds for adequate resuscitation, patients undergo definitive stabilization of their fractures with the goal of performing surgery within 36 hours of injury. As an integrated care pathway, the EAC protocol defines a time dependent strategy to trauma care and minimizes complications and reduces cost through a multidisciplinary approach. Adoption of the EAC protocol was achieved through buy-in from all involved parties in the development phase and contributed to subsequent adherence to the protocol. As such, lessons learned from the development, institution and study of the EAC protocol may be applied to other clinical challenges in orthopaedic trauma, including fracture management in high-energy geriatric injuries as well as head injury.

Article Details

How to Cite
VALLIER, Heather. Early Appropriate Care and opportunities for integrated care pathwyas in orthopaedic trauma. Medical Research Archives, [S.l.], v. 5, n. 5, may 2017. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/1241>. Date accessed: 23 july 2024.
Keywords
pathway, early appropriate care, fracture, timing fixation, complication
Section
Review Articles

References

1. Jurkovich GJ, Mock C. Systematic review of trauma system effectiveness based on registry comparisons. J Trauma. 1999;47(3 Suppl):S46-55.
2. MacKenzie EJ, Weir S, Rivara FP, Jurkovich GJ, Nathens AB, Wang W, et al. The value of trauma center care. J Trauma. 2010;69(1):1-10.
3. Crichlow RJ, Zeni A, Reveal G, Kuhl M, Heisler J, Kaehr D, et al. Appropriateness of patient transfer with associated orthopaedic injuries to a Level I trauma center. J Orthop Trauma. 2010;24(6):331-5.
4. Nathens AB, Maier RV, Copass MK, Jurkovich GJ. Payer status: the unspoken triage criterion. J Trauma. 2001;50(5):776-83.
5. Manning BT, Callahan CD, Robinson BS, Adair D, Saleh KJ. Overcoming resistance to implementation of integrated care pathways in orthopaedics. J Bone Joint Surg Am. 2013;95(14):e100 1-6.
6. Jimenez Munoz AB, Duran Garcia ME, Rodriguez Perez MP, Sanjurjo M, Vigil MD, Vaquero J. Clinical pathway for hip arthroplasty six years after introduction. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(2-3):237-45.
7. Pearson S, Moraw I, Maddern GJ. Clinical pathway management of total knee arthroplasty: a retrospective comparative study. Aust N Z J Surg. 2000;70(5):351-4.
8. Leung AH, Lam TP, Cheung WH, Chan T, Sze PC, Lau T, et al. An orthogeriatric collaborative intervention program for fragility fractures: a retrospective cohort study. J Trauma. 2011;71(5):1390-4.
9. Adunsky A, Arad M, Levi R, Blankstein A, Zeilig G, Mizrachi E. Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients. Disabil Rehabil. 2005;27(18-19):1123-7.
10. Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27(10):543-51.
11. Vallier HA, Moore TA, Como JJ, Wilczewski PA, Steinmetz MP, Wagner KG, et al. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res. 2015;10:155.
12. Seibel R, LaDuca J, Hassett JM, Babikian G, Mills B, Border DO, et al. Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state. Ann Surg. 1985;202(3):283-95.
13. Bosse MJ, MacKenzie EJ, Riemer BL, Brumback RJ, McCarthy ML, Burgess AR, et al. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am. 1997;79(6):799-809.
14. Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma. 2010;69(3):677-84.
15. Bellabarba C, Fisher C, Chapman JR, Dettori JR, Norvell DC. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Spine (Phila Pa 1976). 2010;35(9 Suppl):S138-45.
16. Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491-9; discussion 9-501.
17. Morshed S, Miclau T, 3rd, Bembom O, Cohen M, Knudson MM, Colford JM, Jr. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009;91(1):3-13.
18. MacKenzie EJ, Hoyt DB, Sacra JC, Jurkovich GJ, Carlini AR, Teitelbaum SD, et al. National inventory of hospital trauma centers. JAMA. 2003;289(12):1515-22.
19. Taheri PA, Butz DA, Lottenberg L, Clawson A, Flint LM. The cost of trauma center readiness. Am J Surg. 2004;187(1):7-13.
20. Resources for Optimal Care of the Injured Patient, 6th ed. Rotondo MF, Cribari C, Smith RS, editors. Am Coll Surg. Chicago, IL, 2014.
21. Nathens AB, Jurkovich GJ, Cummings P, Rivara FP, Maier RV. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA. 2000;283(15):1990-4.
22. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-78.
23. Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States, 1960-2000. N Engl J Med. 2006;355(9):920-7.
24. Breedlove LL, Fallon WF, Jr., Cullado M, Dalton A, Donthi R, Donovan DL. Dollars and sense: attributing value to a level I trauma center in economic terms. J Trauma. 2005;58(4):668-73; discussion 73-4.
25. Vallier HA, Patterson BM, Meehan CJ, Lombardo T. Orthopaedic traumatology: the hospital side of the ledger, defining the financial relationship between physicians and hospitals. J Orthop Trauma. 2008;22(4):221-6.
26. Koval KJ, Tingey CW, Spratt KF. Are patients being transferred to level-I trauma centers for reasons other than medical necessity? J Bone Joint Surg Am. 2006;88(10):2124-32.
27. Vallier HA, Parker NA, Beddow ME. Reasons for transfer to a level 1 trauma center and barriers to timely definitive fracture fixation. J Orthop Trauma. 2014;28(12):e284-9.
28. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71(3):336-40.
29. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613-21; discussion 21-3.
30. Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br. 1999;81(2):356-61.
31. Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg. 2002;183(6):622-9.
32. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, et al. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53(3):452-61; discussion 61-2.
33. Pape HC, Tornetta P, 3rd, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17(9):541-9.
34. Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma. 2005;19(8):551-62.
35. O'Toole RV, O'Brien M, Scalea TM, Habashi N, Pollak AN, Turen CH. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics. J Trauma. 2009;67(5):1013-21.
36. McConnell KJ, Johnson LA, Arab N, Richards CF, Newgard CD, Edlund T. The on-call crisis: a statewide assessment of the costs of providing on-call specialist coverage. Ann Emerg Med. 2007;49(6):727-33, 33 e1-18.
37. Vallier HA, Dolenc AJ, Moore TA. Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma. 2016;30(6):306-11.
38. Childs BR, Vallier HA. Cost savings associated with a multidisciplinary protocol that expedites definitive fracture care. Am J Orthop (Belle Mead NJ). 2014;43(7):309-15.
39. Sladek ML, Swenson KK, Ritz LJ, Schroeder LM. A critical pathway for patients undergoing one-day breast cancer surgery. Clin J Oncol Nurs. 1999;3(3):99-106.
40. Fuss MA, Pasquale MD. Clinical management protocols: the bedside answer to clinical practice guidelines. J Trauma Nurs. 1998;5(1):4-11; quiz 27-8.
41. Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, et al. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med. 2009;7:32.
42. Shan LQ, Skaggs DL, Lee C, Kissinger C, Myung KS. Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2013;95(7):e40.
43. Sesperez J, Wilson S, Jalaludin B, Seger M, Sugrue M. Trauma case management and clinical pathways: prospective evaluation of their effect on selected patient outcomes in five key trauma conditions. J Trauma. 2001;50(4):643-9.
44. Weinberg DS, Narayanan AS, Moore TA, Vallier HA. Assessment of resuscitation as measured by markers of metabolic acidosis and features of injury. Bone Joint J. 2017;99-B(1):122-7.
45. Switzer JA, Gammon SR. High-energy skeletal trauma in the elderly. J Bone Joint Surg Am. 2012;94(23):2195-204.
46. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-7.
47. Kates SL, Mendelson DA, Friedman SM. The value of an organized fracture program for the elderly: early results. J Orthop Trauma. 2011;25(4):233-7.
48. Bergeron E, Clement J, Lavoie A, Ratte S, Bamvita JM, Aumont F, et al. A simple fall in the elderly: not so simple. J Trauma. 2006;60(2):268-73.
49. Moore L, Turgeon AF, Sirois MJ, Lavoie A. Trauma centre outcome performance: a comparison of young adults and geriatric patients in an inclusive trauma system. Injury. 2012;43(9):1580-5.
50. Heffernan DS, Thakkar RK, Monaghan SF, Ravindran R, Adams CA, Jr., Kozloff MS, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69(4):813-20.
51. Demetriades D, Karaiskakis M, Velmahos G, Alo K, Newton E, Murray J, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89(10):1319-22.
52. Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJ, Phillips TF, et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma. 1990;30(2):129-34; discussion 34-6.
53. Bradburn E, Rogers FB, Krasne M, Rogers A, Horst MA, Beelen MJ, et al. High-risk geriatric protocol: improving mortality in the elderly. J Trauma Acute Care Surg. 2012;73(2):435-40.
54. Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials. J Trauma Acute Care Surg. 2012;73(5):1046-63.
55. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216-22.
56. Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J. The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries. J Trauma. 1992;33(3):403-7.
57. Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma. 1997;42(1):1-5; discussion -6.
58. Scalea TM, Scott JD, Brumback RJ, Burgess AR, Mitchell KA, Kufera JA, et al. Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes. J Trauma. 1999;46(5):839-46.
59. Scalea TM, Maltz S, Yelon J, Trooskin SZ, Duncan AO, Sclafani SJ. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes. Crit Care Med. 1994;22(10):1610-5.
60. Davies C. Getting health professionals to work together. BMJ. 2000;320(7241):1021-2.
61. Gandhi TK, Puopolo AL, Dasse P, Haas JS, Burstin HR, Cook EF, et al. Obstacles to collaborative quality improvement: the case of ambulatory general medical care. Int J Qual Health Care. 2000;12(2):115-23.
62. Lee TH. Turning doctors into leaders. Harv Bus Rev. 2010;88(4):50-8.
63. Keen J, Moore J, West R. Pathways, networks and choice in health care. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(4-5):316-27.
64. Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. Int J Qual Health Care. 2000;12(2):133-42.
65. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39(8 Suppl 2):II46-54.
66. Vallier HA, Moore TA, Como JJ, Dolenc AJ, Steinmetz MP, Wagner KG, et al. Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients. J Orthop Trauma. 2015;29(11):e446-50.