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Cambridge Polytrauma Pathway: Are we making appropriately guided decisions?
William Wynell-Mayow1, Borna Guevel1, Benjamin Quansah1
1Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK.
Insights
Implementing the Cambridge Polytrauma Pathway improved early appropriate care for major trauma patients. Key improvements included better recording of lactate and fibrinogen levels, enhancing patient management in orthopaedic polytrauma cases.
Area of Science:
- Trauma Surgery
- Orthopaedic Surgery
- Critical Care Medicine
Background:
- Major trauma care requires timely and coordinated multidisciplinary interventions.
- Existing care pathways may not fully optimize Early Appropriate Care (EAC) for complex orthopaedic polytrauma.
- Addenbrooke's Hospital serves as a Major Trauma Centre for the East of England Trauma Network.
Purpose of the Study:
- To devise and implement the Cambridge Polytrauma Pathway to enhance Early Appropriate Care for orthopaedic polytrauma patients.
- To audit the pathway's impact on key performance indicators, including diagnostic imaging, laboratory monitoring, and surgical intervention timing.
- To assess the feasibility of introducing outcome scoring systems like GOS-E or EQ-5D for future evaluation.
Main Methods:
- Development of the Cambridge Polytrauma Pathway based on NCEPOD guidelines, literature review, and expert consultation.
- Initial audit of 59 orthopaedic polytrauma patients (2013-2013) followed by pathway implementation.
- Re-audit of 15 patients (2014-2015) to evaluate pathway effectiveness, comparing pre- and post-implementation data.
Main Results:
- Significant improvements in the recording of lactate and fibrinogen levels on admission and preoperatively (p<0.000 to p=0.015).
- Time to full body trauma CT scan remained unchanged (median 0.53h), indicating consistent diagnostic throughput.
- Reduction in out-of-hours definitive orthopaedic interventions from 8 to zero, with decisions shifted to daytime multidisciplinary meetings.
Conclusions:
- The Cambridge Polytrauma Pathway successfully improved adherence to Early Appropriate Care principles in orthopaedic polytrauma.
- Enhanced monitoring of key biochemical markers and a shift towards daytime multidisciplinary decision-making were key achievements.
- The pathway is anticipated to improve patient outcomes, with recommendations for standardized outcome assessment using GOS-E or EQ-5D.
Abstract:
Addenbrooke's Hospital, the Major Trauma Centre for the East of England Trauma Network, received 1070 major trauma patients between 1st January and 31st December 2014. In order to improve care, an audit was performed of 59 patients meeting our own selection criteria for orthopaedic polytrauma between 1st January 2013 and 31st December 2013. The Cambridge Polytrauma Pathway was devised through NCEPOD guidelines, literature review, internal and external discussion. It facilitates provision of best practice Early Appropriate Care, encompassing - multidisciplinary consultant decisions around the patient in our Neurological and Trauma Critical Care Unit, early full body trauma CT scans, serial measurements of lactate and fibrinogen levels, and out-of-hours orthopaedic theatre reserved for life-and-limb threatening injuries. Re-audit was conducted of 15 patients meeting selection criteria, admitted between 1st October 2014 and 31st March 2015. Significant improvements in recording of lactate and fibrinogen were demonstrated, both on admission (lactate - p<0.000, fibrinogen - p=0.015), and preoperatively (lactate - p=0.003, fibrinogen - p=0.030). Time to trauma CT was unchanged (p=0.536) with a median time to CT of 0.53h at re-audit (IQR 0.48-0.75). The number of patients receiving definitive orthopaedic intervention out-of-hours reduced from 8 to zero (p=0.195). The approach of facilitating management decisions to be made at early daytime MDT meetings has been adopted. It is anticipated that this pathway will improve outcomes in orthopaedic polytrauma patients and it is recommended that either the GOS-E, or the EQ-5D scoring systems be introduced to assess this.
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