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Trauma case management is a model of care where patient care is overseen and coordinated by a nurse with expertise in trauma. They visit the trauma patient each day, review patient progress, ensure optimal care and that the patient, nursing and medical staff are all aware of the management plan.
Trauma Case Management
TCM has been practiced in the US since the early 1990’s. The US remained the only health care system to have formally embraced TCM. The nursing case management model has yet to be widely adopted in trauma care in both the UK and Australia. It is significant that case management has been recognised as an effective model of care for mental health and community patients, as they possess similar characteristics to trauma patients. Each of these patient groups is complex, requiring multidisciplinary care and extensive planning of care. The history and development of the nursing case management model is discussed below.
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 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).
The majority of TCM literature arises out of the US, where it has been practiced in various forms for over a decade, however TCM models and definitions of the role vary widely but reiterate the role of coordinator, facilitator and educator. Some authors acknowledge that they have struggled to find useful performance indicators to measure their effectiveness10,11. In addition, TCM has been shown to effectively implement trauma clinical pathways on selected patient groups demonstrating improved pain management, skin integrity and physiotherapy use12. An Australian retrospective cohort study at a busy urban trauma centre concluded that trauma case management decreased complication rates, improved staff satisfaction, increased allied health referral rates, and decreased the time to allied health intervention and the number of pathology tests. As well as demonstrating a trend towards a decrease in hospital resource use and length of stay13. Yet the real benefits of instigating a trauma case management program may only become apparent through implementation and adapting qualitative and quantitative modes of assessment. TCM interventions can be formally categorised into 7 groups as below6;9-12;14-20
- Direct patient care/clinical practice
- Increasing operational and communication effectiveness
- Initiating activity
- Initiate new consultation
Or in more informal terms many of the interventions performed by the trauma case managers can be described as follows:
Trauma case manager interventions
- A daily ward round and review of patient notes identifying and addressing any conflict in medical orders or lack of management plan
- Collaborating between multiple care givers and fostering communication between medical teams and paramedical and nursing staff
- Identifying barriers to discharge and contacting relevant personnel to overcome these
- Organising pathology or radiology and subsequent review in priority cases
- Documentation in medical notes of any intervention or alteration in patient care
- Informing the multiple teams, nursing and allied health staff, and patient of a new development
- Building a rapport by providing continuity of care with patients and acting as their advocate throughout their hospital stay
- Reassuring patients by ensuring that they and their families are kept well informed
- Feeding back patient and system problems to the Trauma Coordinator and Director
- Conducting formal and informal staff and patient education
- Data collection for the Trauma Database and other research projects
The following discussion describes the experience of the trauma case manager in an Australian Trauma Centre, adapted from the recently published “A day in the life of a trauma case manager” (21).
The TCM Role
The TCM begins each day at 0700hrs when the case manager locates any patients who presented to the Emergency Department or were admitted to a ward overnight. They make contact with each new patient, meet their family and familiarise themselves with the patients history, mechanism of injury, injuries, treatments, and plan of care. A tick box check list is completed which identifies any outstanding patient care needs, and a set of continuation notes are commenced. These notes are maintained by the case manager on duty each day, whenever intervention is performed or care changes. The case manager is also required to prospectively collect trauma data on each patient, which is entered into the trauma registry. The collated data allows the trauma service to examine and monitor adherence to already established standards of care and to identify where changes in care patterns are needed, giving rise to new and updated protocols and educational needs. At any one time the Trauma Case Manager may be coordinating between 10-25 patients at different stages of their stay.
The TCM plays a critical role in maintaining quality care for the trauma patient. The TCM is aware of all institutional clinical guidelines and protocols developed and used for the trauma patient, and thus are able to keep the continually rotating surgical trainees up to date with all guidelines and protocols and alert them to any quality issues experienced by the patient. The TCM role incorporates providing at least 2 hours per week of formal trauma related education to nursing, allied health and medical staff throughout the hospital, as well as many hours informal bedside teaching and assisting the trauma coordinator and director with other education projects.
The Case Manager on the Ward
The TCM participates in the trauma team daily ward round which commence around 0830hrs. Focusing on a multidisciplinary approach to trauma care the Case Manager liaises with the Trauma Occupational Therapist, Trauma Physiotherapist, Ward Social Worker, Nursing staff and medical teams and services, ensuring early referral to the appropriate teams. The ward round finishes around 1100hrs. The TCM then spends the rest of the day following up results, liasing with various teams and services, educating ward staff, answering pages and informing the trauma doctors of concerns regarding each patient. The TCM carries a page and can be contacted by the ward staff. At large ward nursing staff feel more confident speaking with the TCM regarding patient issues knowing the Case manager will speak with the various medical teams involved.
The Trauma Case Manager conducts a weekly multidisciplinary meeting, gathering ward nursing staff, allied health services and medical personnel to discuss the clinical pathway, discharge planning and the general care of trauma inpatients. This meeting provides a time for communication amid the various care providers with the aim to provide best patient care and decrease length of stay.
The Emergency Department
During the eight hour shift the Trauma Case Manager will also respond to trauma Calls in the Emergency Department (ED), providing trauma nursing expertise, education and an extra pair of hands. The case manager generally has an active roll in the resuscitation room, either as a resuscitation nurse or scribe. They also liaise with the relevant teams and services and when possible expedite the patients care, making early referrals to the allied health services and rehabilitation.
Other Trauma Care Models
Ideally, the trauma case manager would work within a dedicated trauma team, although many centres do not have such a service. 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 to ensure that the care is timely, well organised, and efficient. Other trauma models of care include:
Dedicated Trauma Team
Another solution to complex related care problems associated with trauma is a dedicated trauma admitting team with case managers as an integral member of the team. The trauma team, directed by a trauma surgeon admits all trauma patients and oversees care, including that of sub specialty services such as neurosurgical or orthopaedics. This is instead of multiple individual specialty surgical services all having some responsibility without a coordinated holistic approach. Several international studies demonstrated that an enhanced trauma program, including a dedicated trauma admitting unit decreased trauma patient mortality, particularly in the severely head injured patient (22, 23). Integration of trauma case using this model improves continuity and has a positive impact on the quality of care (24) and daily multidisciplinary rounds can shorten length of stay for trauma patients by (15, 25). The University of Pennsylvania Medical Center, as with many US trauma hospitals uses a trauma case management team that provides a multitude of efficiencies and optimises cost containment. They have expanded this service to include the complete management of emergency surgery patients. This change was welcomed by the trauma faculty, and increased operative cases for the residents and faculty involved. They demonstrated that the integration of emergency surgery patients into the trauma service did not adversely impact trauma patient outcomes, and that the LOS and percent of readmissions fell significantly 26. Not every institution that provides care for trauma patients may have ready access to or the need for such resources, and the case manager certainly contributes to filling that void.
The Development of Nursing Case Management
With the introduction of managed care in the US the entire health care industry was challenged to “reinvent itself” (1). With the resultant changes, a health system that focused on cost required care delivery strategies which were cost effective and positively affected patient, caregiver and system outcomes. In an attempt to deliver these objectives, strategies such as product line management followed by case management were introduced.
Product Line Management
Product line management was an early model of care delivery introduced in an effort to have better control of costs and to compete effectively in the changing health care system. It has been used in business for over 80 years as a management strategy to control costs (2) and its benefits are described as increased efficiency, reductions in the duplication of services, optimal use of resources, revenue enhancement and accelerated decision making (3). Product line management reduces the organisation structure with the rationale that the hospital is a business enterprise. By reducing the structure, it was assumed that the authority for decision making was decentralised and decisions could be made by those closest to the product or health service provision. The person who is considered to have the most knowledge about the product is the product line manager. However one of the main concerns with product line management was that nurses were not being selected as the product line manager4. How could a product line manager without any clinical knowledge manage the cost and quality of a person’s health care?
This focus on cost and productivity created conflict for the nursing profession, which was more concerned with the quality of patient care. The business orientation created by product line management was seen as detracting from the human caring aspects of nursing. The use of nomenclature including “product”, “customer”, or “market place” was considered inappropriate by the nursing profession and many care givers objected to this change in care delivery purely on an ideological basis.
Nursing Case Management
The nursing case management model was pioneered at the New England Medical Centre in Boston in 1987 (5). The case management model of patient care delivery is comprehensively described as a system of health assessment, planning service procurement, delivery, coordination and monitoring to efficiently meet the needs of clients (6). Zander’s nursing case management model differs from product line management in the following respects:
- The “product line” is managed, organised and coordinated by the actual caregivers who are accountable clinically and financially for each patient’s outcomes over the entire episode of illness.
- It is built on case-type specific protocols, outcomes and resources framed by reimbursement-allotted length of stay.
- Quality is prescribed in written detail, managed concurrently, and evaluated collaboratively.
- The patient and family are actively engaged as members of the multidisciplinary, collaborative, health care team (Zander, 1988).
There are various models and forms of case management. The term ‘case management’ evokes a sense of understanding that is more elusive than is generally acknowledged…what is, or is not, identified as case management is often determined by the commentator’s own position in the field 7.
The Case Management Society of Australia recognises the broad application of Case Management in diverse settings within the health and human services industries in Australia listed in Table 1.
Table 1: Areas of case management use in Australia (8)
- Aged Care
- Disability Services
- Child Welfare / Protection Services
- Workers' Compensation
- Long Term Care
- Acute Care
- Community Care
- Mental Health
The Impact of Case Management
In searching the literature determining if there is a relationship between case management and patient outcomes, there are some trends in the populations studied:
Populations most represented in the literature:
- Paediatric (chronic or hospitalised patients)
- Serious mental illness
- Case management within the hospital
And less frequently represented:
- Acute brain injury
- Workers compensation
- Spinal cord injury
In the Cochrane Library there are only five relevant reviews analysing the impact of case management and are limited to psychiatric services, diabetes mellitus, mental illness and various medical conditions (7). The overall conclusions from the reviews of literature in CINHAL and Cochrane are that case management is associated with quite varied outcomes: Sometimes care is superior to standard treatment; often there is no difference reported and sometimes it is inferior. There are several research questions remaining in relation to case management, most importantly, are there clearly specified interventions that are efficacious with a particular population? Although, it has been demonstrated that nursing case management is more cost effective in a nursing practice environment of moderate uncertainty, such as with a complex trauma patient (9). This equates to a working environment which necessitates nursing staff requiring more sophisticated knowledge and organisational skills. In addition, when caring for a complex patient, nurses require more information from and communication with treating medical teams9. The nurse case manager was able to provide this assistance and intervene as required.
The multi-injured trauma patient is complex and requires increased coordination and communication to ensure effective care. The TCM role is diverse and rewarding, enabling the case manager to be involved in and make a difference to trauma patient care from resuscitation to rehabilitation. In addition, the TCM role assists greatly in identifying systemic problems and staff education. Nurses are in an occupation that has interpersonal communication at its core and with their communication and organisational abilities are well suited to the TCM role.
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- Fraser M, Curtis K. A day in the life of a trauma case manager. Australasian Journal of Emergency Nursing. 2006.
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- Simons R, Eliopoulos V, Laflamme D, Brown DR. Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center. Journal of Trauma. 1999;46:811-816.
- Cohen MM, Fath JA, Chung RS, Ammon AA, Matthews J. Impact of a dedicated trauma service on the quality and cost of care provided to injured patients at an urban teaching hospital. Journal of Trauma. 1999;46:1114-1119.
- Dutton RP, Cooper C, Jones A, et al. Daily multidisciplinary rounds shorten length of stay for trauma patients. Journal of Trauma. 2003;55:913-919.
- FitzPatrick MK, Reilly PM, Laborde A et al. Maintaining Patient Throughput on an Evolving Trauma/Emergency Surgery Service. Journal of Trauma; Injury, Infection, and Critical Care. 2006;60:481-488.