Developing a Care Pathway for Patients with Fractured Neck of Femur - Essay Example

Developing a care pathway for patients with fractured neck of femur Clinical pathways are proposed as a means of providing high quality carein a timely and cost-effective manner. These pathways consist of treatment protocols that aim to streamline and standardize management with multidisciplinary input from medical, nursing, paramedical and administrative staff. The above definition of clinical pathways was discussed in the study done by Choong et. al. The study was entitled "Clinical Pathway for Fractured Neck of Femur: A Prospective, Controlled Study." The objective of the study is to assess the outcome of using a clinical pathway for managing patients with fractured neck of femur. The study is done in St. Vincent Hospital, Melbourne, Victoria in October 1, 1997 to November 30, 1998. It has 111 patients with 80 women and 31 men with mean age of 81 years old. They have found that a proactive multidisciplinary approach can reduce the length of stay. The study also shows that early intervention is another way to reduce the stay in the hospital therefore the risk of having complications brought about by the longer stay in the hospital has lessen. St. Vincent Hospital includes patients with language and cognitive difficulties. Since not all of their population does not speak English. They believed that the inclusion would test the efficacy of clinical pathways in the delivery of multidisciplinary care. Also during the study they found no significant clinical difference in time of mobilization or complication or readmission rates. Possible explanation includes the frequent existence of unstable and often untreated premorbid conditions in patients with fractured neck of femur, which requires attention during their acute admission. In contrast, patients undergoing elective joint replacement have the benefit of preadmission assessment clinics which may resolve expected medical, allied health or discharge issues before admission.. ( Choong , Langford, Dowsey, Santamaria 2000 ) The report of the South Tyneside health Care Trust in 2003 which is written by Allen Reece, includes the period between the patient's arrival in A&E and her arrival on the orthopedic ward. The standard recommended by the Royal College of Physicians is that a patient with a fracture of the femoral neck should be in bed on a war within an hour of arrival at the hospital. The pathway starts at the waiting after the Triage to see the A&E doctor, which could be up to an hour since patient with these case are given low priority. Another hour of waiting for the X-ray department since they could handle one patient at a time. The next wait would be for the porter staff to come to take the patient to the X-ray Department and again, once the X-rays have been taken, another one to bring the patient back to A&E. The films had then to be interpreted by the A&E doctor, who may not have been immediately available. Once the diagnosis has been made, the orthopedic doctor on duty had to see the patient and the transfer to the ward again another wait for the porter. They want to make the pathway much easier for the patient they make a study and make necessary adjustment to lessen the waiting time. The changes were made, on arrival the patient is seen by a senior A&E nurse who has undergone appropriate training. The nurse assess the patient's need for analgesia and administer it according to protocol. The A&E Nurse fills out the X-ray request form and contacts the X-ray Department. The Bed Coordinator is contracted and warned of the portable need for an orthopedic bed. The patient is offered the use of a cordless telephone to contact relatives and or neighbors. The patient is taken to the X-ray department and the films taken. Once the radiographer made necessary impression the radiographer notifies the A&E. Since the patient will take only for a few minutes in the x-ray department the porters will wait for her and take the patient directly to the orthopedic ward. If no fracture is seen, the patient is returned to A&E for further assessment. The following has been the result of the changes, the delay for waiting of doctors has been eliminated and the time to administration of analgesia has been reduced. A one way journey has been implemented from A&E to x-ray to ward. Unlike before the patient was sent back to the A&E after x-ray. The waiting for porters is also removed. The ward bed is organized earlier and a standard set of admission blood samples routinely done and recorded, so clinical information available on ward early for pre-operative assessment. The new pathway done by the South Tyneside Health Care Trust came into practice on June 1 2001. (Reece, 2003). One of the focuses of the NHS framework is to reduce the waiting for A&E from arrival to admission, transfer or discharge. (Department of Health, 2004). The study above shows the same focus on their study which I guess they achieved it. In November 1997 the A+ Network Center for Best Patient Outcomes was invited by Orthopedic Service at Auckland Healthcare to assist clinicians with the development of a clinical pathway for patients with a fractured neck of femur (#NOF). The purpose of this is to outline why and how the original intention of a pathway evolved from what was initially seen as a linear, uncomplicated process to becoming a non linear chaotic one, resulting in the implementation of computerized Clinically Integrated System (CIS). The CIS models seek to promote an interdisciplinary approach to patient care, by linking there specialized concepts of patient management namely: evidenced base practice, clinical design and outcome management into a single framework for managing care. It uses the strategies associated with participatory action research as the developmental process to achieve this goal. The experiences of working with clinicians and patients in this area have helped to identify some key change management strategies that have assisted in the development and implementation of the model. In addition, it has challenged some of the commonly held assumptions about what constitutes successful change management. (Jenny Bornholdt ,1991). The Center met monthly as part of the multidisciplinary team (MDT) established to develop the pathway. Use of the pathway was restricted for patients who were identified as the "standard" or "uncomplicated" patient. If complications developed, then the patient had to be removed from the pathway. The Clinical Nurse Specialist had done some preliminary work on pathways through personal contact with other hospital centers. However the assigning of #NOF did not sit well with the MDT. They are concerned with the standardizing a patient; removing clinician autonomy; and a lack of mechanisms for capturing and resolving adverse patient outcomes. By 1999 the original idea of the pathway for this group had been superseded by the implementation of computerized CIS model based on the philosophies of evidence-based practice; clinical redesign; and outcome management using the principle of participatory action research to develop and implement the model. The intention of developing CIS for patients with a fractured neck of femur has spread with the implementation of CIS models in a variety of clinical settings. The new insights on how to improve patient care delivery and manage change effectively have helped to strengthen and improve the original model.(Bornholdt,1991). Modernization of the pathway using the CIS seems to be not the exact change that the Department of Health (DOH) wants to impart. In the National Standards it does not mentioned about the computerization of the system. This pathway was further developed into the pre-admission pathway. The following ideas and principles that I will enumerate are base to the work developed by the Elective surgery team of Queensland in 1998 written by Dr. R L Sable "Guidelines for Pre-admission Clinics, Discharge Planning and Transitional Care." Pre-admission assessments are conducted for patients who have planned admission to hospital. It determines the patients' fitness for procedures and ensures the adequate arrangements are made in preparation for hospitalization. The purpose of pre admission is to optimize the patient healthcare, to explain the procedures in an innovative way, to assess the situation careful and to give the best care for the patient. The principles of pre-admission are as follows :(Stable, 1998). 1. The principles of pre admission are conducted on an outpatient basis wherever possible. The advantage of pre admission assessment is that it reduces the number of days in the hospital therefore the risk of infection and other adverse outcomes which may occur in the hospital is lessen. 2. It aims to optimize a patient's health status prior to admission. In this principle the pre admission visit includes a comprehensive assessment such as the medical background check, nursing and allied health assessment with appropriate referral to and consultation with other specialties where necessary. It includes the emotional, social and mental assessment. Good communication which may include the use of interpreter services. The use of screening tools to identify patient needs including high risk patient. The pre-assessment process should occur two or three weeks prior to admission. 3. Patient and their carers are the primary focus of pre-admission. They are informed, educated and supported throughout the process. Patients and carer are directly involved in the management therefore they are informed about the case and treatment the patient will receive in the hospital, the expected length of stay and outcome, any transitional care the patient will receive, the need for rehabilitation and likely supports at home. 4. Where other health professional across the continuum of care provide relating to the condition is occurring, those practitioners are involved in the pre-admission process. Health Service Districts will have procedures in place to ensure that relevant information is collected prior to the patient's pre-admission visit. The input from a patient's general practitioner in the pre-admission process will vary, depending on the relationship between the general practitioner and the patient, the reason for admission. 5. Patient information is made available to all relevant providers in an efficient and timely manner. Admission documentation in the medical record. Standardized, up-to-date, client/medical records are readily accessible at pre-admission. The information available at pre-admission includes a general practitioner referral containing information concerning treatment that has been provided. Relevant and medical history, social, family and emotional history, together with smoking and alcohol habits are collected. Referrals from specialists and community providers. Each hospital will establish a process to ensure that the information is available for the pre admission assessment. 6. Process for both admission and discharge planning commence during pre-admission. The patient care is outlined and progress along the critical pathway, bed management and theatre scheduling may be documented for action in the discharge planning process. The healthy service district implements discharge planning procedures. 7. Accountability process is in place to evaluate and improve the pre-admission process. Pre admission process and clinics require evaluation and continuous improvement. The pre admission clinics should continue to improve their services according to the governments given framework. Certain organization will be checking on their standards. The #NOF is does not get a popular reaction since there are lapses on the system. The standardizing and eliminations of patients in the pathways does not get the positive result with MDT. A new framework of Health Care Standards is being published. It represents the government's response to the consultation on the health care standards. It describes the level of quality that health care organizations, including NHS foundation trusts, and private and voluntary provides of NHS care, will be expected to meet in terms of safety; clinical and cost effectiveness; governance; patient focus; accessible and responsive care; care environment and amenities and public health. National Service Frameworks (NSFs) and National Institute for Clinical Excellence (NICE) guidance are integral to a standard-based system. They have a key role in supporting local improvements in service quality. Organizations performance will be assessed not just on how they do on national targets but increasingly on whether they are delivering high quality standards across a range of areas, including NSFs and NICE guidance. The Standards set are organized within seven domains stated above: 1. Safety - Health care organization continuously and systematically review and improve all aspects of their activities that directly affect and apply best practice. 2. Clinical and Cost Effectiveness - Patients achieve health care benefits that meet their individual needs through health care decisions and services based on what assessed research evidence has shown provides effective clinical outcomes. 3. Governance - Managerial and clinical leadership and accountability, as well as organizations culture, systems and working practices, ensures that probity, quality assurance, quality improvement and patient safety are central components of all the activites of the health care organizations 4. Patient Focus - Health care is provided in partnership with, patients their carers and relatives, respecting their needs, preferences and choices, and in partnership with other organizations whose services impact on patient well-being. 5. Accessible and Responsive Care - Patients receive services as promptly as possible, have choice in access to services and treatments, and do not experience unnecessary delay at any stage of service delivery or of the care pathway. 6. Care Environment and Amenities - Care is provided in environment that promote patients and staff well-being and respect for patients needs and preferences in that they are designed for the effective and safe delivery of treatment, care or a specific function, provide as much privacy as possible. Are well maintained and cleaned to optimize health outcomes for patients. 7. Public Health - Programmes and services are designed and delivered in collaboration with all relevant organization and communities to promote, protect and improve the health of the population served and reduce health inequalities between different population groups and areas. The following are commitments of the government to be achieved; reduce to four hours the maximum wait in A&E from arrival to admission transfer or discharge. Guaranteed access to a primary care professional within 24 hours and to a primary care doctor within 48 hours, and to achieve a maximum wait of 6 months for elective orthopedic. (Department of Health, 2004). The government wants a better service to the people and they are making it possible by the help of different association that are all concern in making a standard for better health care. The care pathway has helped a lot especially in the older people in the financial and their stay in the hospital. From the time of their arrival in the hospital up to the discharge time even in their own home, healthcare organization are making each possible way to improve their services. It started with a long wait and then shortened into a fastest way because of the study done by clinics, hospital and other organization. The home care after discharge seems to be the next target of the government. After the discharge of the patient they want to provide rehabilitation and education to those who needed it. To be able to develop a care pathway in an innovative way the government, organizations, clinics, hospital and other healthcare should work together, shares their knowledge and conduct study for an innovative way of improving the pathway. References 1. "Clinical Pathways for Fractured Neck of Femur: A Prospective, Controlled Study" Peter FM Choong, Anna Langford, Michelle Dowsey, Nick Santamaria. MJA 2000 3. "Case 4- They wanted a Clinical Pathway, But We Ended up with a Clinically Integrated system: What went wrong" Read More