> I am not at all sure that care pathways are the way forward after I tried
to introduce two; one on myocardial infarction and one on the
> management of fractured neck of femur. The MI one was pinched from
somewhere else and was frankly useless once I had studied it
> properly.

But surely this is an important point.  Care pathways may have a common
frame but local issues are fundamental to the making or breaking.   There
are a number of common parts of clinical pathways that dont have to be
reproduced eg: identifying best evidence practice.
>
> We wrote the # neck of femur one ourselves, setting times, variances and
so on. The pathway was modular, so that there was a scoring
> module to help the nurse decide if the leg was likely to be broken to
write the X-ray form and there was an X-ray module and ward module.
> I wrote the X-ray module myself as they didn't have a clue what I was on
about, and waited for the ward one. After two YEARS it
> appeared. It bore no relationship to what we were doing in A&E and wasn't
integrated at all!

Should'nt care pathways be produced in a multi-professional,
multi-disciplinary manner by collaboration and not by individaulas doing
their own thing.  Rowley could not such a delay have been anticipated  ?

>
> Now I appreciate these are operational rather than functional issues, but
there were functional issues as well. For example, we wanted to
> ensure that these patients were seen and given pain relief expeditiously
and set a target time of getting to X-ray after 40 minutes. That was
> fine, but meant that they disrupted our triage system with these patients
as a sort of 'special' category 3 - I really cannot justify seeing
> them in 10 minutes. There were also often severe delays waiting for X-ray
and waiting for beds, and other areas that we as A&E could not
> influence, and this led to staff becoming very frustrated that they kept
having to file variance reports, and me becoming frustrated because
> the issues these raised were all resourcing issues we all knew about
already. So it has, I am afraid, failed the Real World test and I have a
> nasty feeling that many more will.

Certainly pathways, even fast track ones can break down beacuse of factors
outside the control of A&E.  We reported fast tracking patients with
proximal femoral fractures in JAEM in 1996 but now have a follow up letter
coming out called 'fast tracking patients with a proximal femoral fracture -
more than just a broken bone' which shows our times have deteriorated again
but principaly we think beacuse of factors outside of A&E.  This reflects
the importance of having management on board in devising care pathways so
they understand that there can be a benefit to 'the whole system' by such
multi-disciplinary/professional involvement and they can be held accountable
for a chare in making the sytem work and accepting repsonsibilities for
variances.

regards

John Ryan


Dr John Ryan



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