Pathways of Care in Vascular Surgery

Abstract

J. D. Beard and S. Murray tfm Publishing Ltd. 2002 363 pages, price £30. This book contains much more than might be suggested by its title. It is a multi-authored, multidisciplinary work—based on a symposium held in Sheffield in June 2002. Unlike many books of this type it has been well edited and avoids the re-duplication and lack of continuity that can occur. It is a distillation of current vascular surgical thinking from the members of the Joint Vascular Research Group. This is a well-established group of British vascular specialists so this book can be taken as current state-of-the-art for U.K. vascular management. Although integrated care pathways were a major stimulus for this publication it really offers a great deal more. I particularly liked the concept of grading for evidence and recommendations. These are used consistently throughout. Evidence is graded by legal equivalents; where level 1 is as in criminal law, “beyond reasonable doubt”, whereas level 2 is as in civil law—“balance of probabilities”. Level 3 is anything else, i.e. unproven. Recommendations for action in the book are, A—strong, B—evidencebased but may need interpretation, and C—pragmatic or personal. The book opens with a chapter on nurse led vascular clinics. Nurses have led the move to protocols and pathways with more enthusiasm than doctors and suitably the co-editor is a nurse. There is wide use of algorithms, some more useful than others. There is a tendency to make these over-complex, so that they sometimes become rather confusing. There is an astonishingly wide range of information presented, in the most part concisely and clearly. The book covers diagnosis, medical and surgical treatment, and follow-up of all the main vascular conditions. Of note are excellent chapters on lymphoedema, deep venous thrombosis and an unusually honest section covering endovascular repair of aortic aneurysms. There are good chapters on carotid disease although I was faintly alarmed by the summary statement: “There are over 140 key steps that must be undertaken by the team looking after a patient undergoing a carotid endarterectomy. Failure to complete any of these may result in poor outcome”. The final section of the book is an unusual mixture covering risk management, audit, clinical networks and emergency transfer of patients. There is a specific chapter on developing integrated care pathways. A nice touch in the foreword welcomes all readers to go to the JVRG website and download care pathways that have already been written. They are encouraged to use them as a dynamic resource with a request to use and adapt them, returning suggested improvements to the site. Overall, this book succeeds in bridging the different disciplines involved in managing vascular disease and potentially will have a very wide readership. It is more up-to-date and more readable than the more definitive textbooks. It is well-referenced for further reading. Finally, it is good value for money. It should be on every vascular ward as well as in the library.