Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: A retrospective case-control study

Prevalence of and factors associated with trauma surgeons' referral and patients' willingness to acupuncture treatment after traumatic rib fractures: A single-center cross-sectional study

Background

Pain after traumatic rib fractures (TRF) detrimentally affects the injured. Multidisciplinary pain management is crucial for patient care. There is little empirical evidence on acupuncture as a multidisciplinary treatment for patients with TRF. This study aimed to illustrate the characteristics of the patients referred for or received acupuncture and explore the associated factors.

Methods

We conducted a cross-sectional study of Korean Trauma Data Bank and electronic medical records of patients aged 19 or older with TRF from August 2016 to October 2021 in the regional trauma center of Pusan National University Hospital. The sociodemographic and clinical characteristics of patients referred for acupuncture by trauma surgeons and those who received acupuncture were analysed descriptively. In multivariable logistic regression analyses, associations between covariates and either surgeon referrals for or patient willingness to receive acupuncture were quantitatively estimated.

Results

Among 2,937 injured patients, trauma surgeons referred 178 (6.1 %) to acupuncture. Among the referred patients, 111 (72.1 %) underwent acupuncture. Patients with polytrauma (aOR 0.46; 0.30 to 0.68) were less likely to be referred to acupuncture, whereas female patients (aOR 3.92, 1.31 to 11.77) were most likely to receive acupuncture.

Conclusions

A small proportion of patients with TRF were referred for acupuncture, but the referred patients were more likely to receive acupuncture. Polytrauma may be an important criterion for referral to acupuncture services from the perspective of trauma surgeons, while the willingness to receive acupuncture may be associated with gender-related factors. Further studies are warranted to investigate the role of acupuncture in the postinjury care of patients with TRF.

Pharmacists in Trauma: a randomised controlled trial of emergency medicine pharmacists in trauma response teams

BACKGROUND

Analgesia is an important component for patient well-being, but commonly delayed during trauma resuscitation. The Pharmacists in Trauma trial assessed the effects of integrating pharmacists into trauma response teams to improve analgesia delivery and medication management.

METHODS

This unblinded randomised trial compared emergency medicine (EM) pharmacist involvement in trauma callouts versus standard care at an Australian level 1 trauma centre. Randomisation was performed via an online single sequence randomisation service. Eligible patients included those managed with a trauma callout during working hours of an EM pharmacist. Pharmacists were able to prescribe medications using a Partnered Pharmacist Medication Charting model. The primary outcome was the proportion of patients who had first dose analgesia within 30 min compared using the χ2 test.

RESULTS

From 15 July 2021 until 31 January 2022, there were 119 patients randomised with 37 patients excluded as no analgesia was required. There were 82 patients included for analysis, 39 in the control arm and 43 in the intervention arm. The primary outcome was achieved in 25 (64.1%) patients in the control arm and 36 (83.7%) patients in the pharmacist arm (relative risk 1.31; 95% CI 1.0 to 1.71; p=0.042). Time to analgesia in the control arm was 28 (22-35) mins and 20 (15-26 mins) with pharmacist involvement; p=0.025. In the pharmacist arm, the initial dose of analgesia was prescribed by the pharmacist for 38 (88.4%) patients. There were 27 other medications prescribed by the pharmacist for the management of these patients. There were no differences in emergency and trauma centre or hospital length of stay.

CONCLUSION

Addition of the EM pharmacist in trauma response teams improved time to analgesia. Involvement of an EM pharmacist in trauma reception and resuscitation may assist by optimising medication management, with members of the team more available to focus on other life-saving interventions.

TRIAL REGISTRATION NUMBER

ACTRN12621000338864.

Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures

BACKGROUND

Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures.

METHODS

This is a single-center retrospective review (2015-2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC.

RESULTS

A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS.

CONCLUSION

VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.

Building consensus on the selection criteria used when providing regional anaesthesia for rib fractures. An e-Delphi study amongst a UK-wide expert panel

BACKGROUND

Rib fractures are associated with significant morbidity and mortality, and providing adequate analgesia is paramount in preventing early complications from these injuries. Multiple regional anaesthetic techniques can be used to provide analgesia for these injuries; however, few evidence-based guidelines exist for their use. The aim of this study was to establish consensus within an expert group on the selection criteria used when choosing regional anaesthetic techniques for rib fractures.

METHODS

The Delphi technique is a mixed-methods study format which uses a longitudinal survey process to develop consensus opinion amongst an expert group. A three-round modified e-Delphi study was undertaken using an online survey platform. Round one established cohort characteristics and identified key factors considered important by the group when selecting regional anaesthetic techniques for rib fractures. Subsequent rounds used Likert scales and free text comments to rate the participants' level of agreement with various statements generated from the first-round responses. The final consensus threshold was established as at least 70% of respondents stating, 'Strongly Disagree' or 'Disagree' or alternatively 'Agree' or 'Strongly Agree'.

RESULTS

An expert panel of UK-based consultants in anaesthesia and/or intensive care medicine was recruited. Participants worked in a variety of tertiary- and non-tertiary trauma care settings and were varied in their years of experience, approximate annual rib fracture caseload and preference for various anaesthetic techniques in rib fracture management. 54 participants took part in round one and generated 60 statements which were further analysed in an iterative process involving a total of three rounds. A total of 28 statements ultimately reached the pre-defined threshold for consensus within the expert group.

CONCLUSIONS

This e-Delphi study succeeded in building consensus across multiple statements relating to the selection criteria for regional anaesthesia in patients with rib fractures. These consensus statements can inform clinical practice, guide future research priorities and can be integrated into decision-making pathways across multiple hospital settings.

Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management

BACKGROUND

Trauma injuries are one of the main leading causes of death in the world. Training with guidelines and protocols is adequate to provide a fast and efficient treatment to patients that suffer a trauma injury.

OBJECTIVES

This study aimed to evaluate deviations from a set protocol, a new set of metrics has been proposed and tested in a pilot study.

METHODS

The participants were final-year students from the Universidad Autónoma de Madrid and first-year medical residents from the Hospital Universitario La Paz. They were asked to train four trauma scenarios with a web-based simulator for 2 weeks. A test was performed pre-training and another one post-training to evaluate the evolution of the treatment to those four trauma scenarios considering a predefined trauma protocol and based on the new set of metrics. The scenarios were pelvic and lower limb traumas in a hospital and in a prehospital setting, which allow them to learn and assess different trauma protocols.

RESULTS

The results show that, in general, there is an improvement of the new metrics after training with the simulator.

CONCLUSION

These new metrics provide comprehensive information for both trainers and trainees. For trainers, the evaluation of the simulation is automated and contains all relevant information to assess the performance of the trainee. And for trainees, it provides valuable real-time information that could support the trauma management learning process.

Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial

BACKGROUND

The benefit-risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O₂) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients.

METHODS

The OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO₂/FiO₂ ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O₂ and "early" NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and "late" NIV, indicated in patients with respiratory deterioration and/or PaO₂/FiO₂ ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS).

RESULTS

Study enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20-2.43), p = 0.60. The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73-5.89], p = 0.18, 0.85 [95%IC: 0.33-2.20], p = 0.74 and 2.14 [95%IC: 0.36-20.77], p = 0.41, respectively).

CONCLUSION

A prompt association of HFNC-O₂ with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure.

CLINICAL TRIAL REGISTRATION

NCT03943914, Registered 7 May 2019.

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society

BACKGROUND

Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.

METHODS

Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.

RESULTS

Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.

CONCLUSION

We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level IV.

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

Acute pain consult and management is associated with improved mortality in rib fracture patients

INTRODUCTION

Traumatic rib fractures result in significant patient morbidity and mortality, which increases with patient age and number of rib fractures. A dedicated acute pain service (APS) providing expertize in multimodal pain management may reduce these risks and improve outcomes. We aimed to test the hypothesis that protocolized APS consultation decreases mortality and morbidity in traumatic rib fracture patients.

METHODS

This is a retrospective observational, propensity-matched cohort study of adult patients with trauma with rib fractures from 2012 to 2015, at a single, large level 1 trauma center corresponding to introduction and incorporation of APS consultation into the institutional rib fracture pathway. Using electronic medical records and trauma registry data, we identified adult patients presenting with traumatic rib fractures. Patients with hospital length of stay (LOS) ≥2 days were split into two cohorts based on presence of APS consult using 1:1 propensity matching of age, gender, comorbidities and injury severity. The primary outcome was difference in hospital mortality. Secondary outcomes included LOS and pulmonary morbidity.

RESULTS

2486 patients were identified, with a final matched cohort of 621 patients receiving APS consult and 621 control patients. The mortality rate was 1.8% among consult patients and 6.6% among control patients (adjusted OR 0.25, 95% CI 0.13 to 0.50; p=0.001). The average treatment effect of consult on mortality was 4.8% (95% CI 1.2% to 8.5%;. p<0.001). APS consultation was associated with increased intensive care unit (ICU) LOS (1.19 day; 95% CI 0.48 to 1.90; p=0.001) and hospital LOS (1.61 days; 95% CI 0.81 to 2.41 days; p<0.001). No difference in pulmonary complications was observed.

DISCUSSION

An APS consult in rib fracture patients is associated with decreased mortality and no difference in pulmonary complications yet increased ICU and hospital LOS.

Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score

BACKGROUND

To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named "PIC Protocol" and "PIC Score," emphasizing continual assessment of pain, incentive spirometry, and cough ability.

OBJECTIVE

The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination.

METHODS

This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05.

RESULTS

There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score.

CONCLUSIONS

The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients.

Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review

OBJECTIVE

To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).

BACKGROUND

At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines.

METHODS

A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0.

RESULTS

Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report.

CONCLUSIONS

Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.

Utilization of Percentage of Predicted Forced Vital Capacity to Stratify Rib Fracture Patients: An Updated Clinical Practice Guideline

BACKGROUND

Rib fractures are the most common injuries diagnosed after blunt thoracic trauma and are a source of significant morbidity and mortality. Early identification of at-risk patients and initiation of effective analgesia are keys to mitigating complications from these injuries. Multiple tools exist to predict pulmonary decompensation after rib fractures; however, none has found a widespread acceptance. A clinical practice guideline (CPG) utilizing Forced vital capacity (FVC) has been in place at a single institution. The goal of this study is to update the CPG to use percentage of predicted FVC (FVC%) instead of FVC to triage patients with rib fractures.

MATERIALS AND METHODS

A retrospective study of 266 patients with rib fractures was conducted. Patients were divided into 3 groups based on FVC of <1000 mL, 1001-1500 mL, or >1500 mL for analysis. Data were analyzed with analysis of variance, and Youden's J Index was used to identify inflection points.

RESULTS

Patients in the high-risk category were more likely to be women, older than 65 years, admitted to the intensive care unit (ICU), transferred to the ICU, require intubation, and have overall longer hospital and ICU stays. The updated CPG triage cutoffs for admission to ICU, stepdown, and floor were redefined as FVC% values of <25%, 25-45%, and >45%, respectively.

DISCUSSION

The updated CPG using FVC% may more accurately identify patients with compromised physiology and be a better tool to help predict patients who are at risk for decompensation following rib fractures. A validation study for the updated CPG is in progress.

How does the implementation of a patient pathway-based intervention in the acute care of blunt thoracic injury impact on patient outcomes? A systematic review of the literature

BACKGROUND

Blunt thoracic injury is present in around 15% of all major trauma presentations. To ensure a standardised approach to the management of physical injury, patient pathway-based interventions have been established in many healthcare settings. It currently remains unclear how these complex interventions are implemented and evaluated in the literature. This systematic review aims to identify pathway effectiveness literature and implementation studies in relation to patient pathway-based interventions in blunt thoracic injury care.

METHODS

The databases Medline, Embase, Web of Science, CINAHL, WHO Clinical Trials Register and both the GreyLit & OpenGrey databases were searched without restrictions on date or study type. A search strategy was developed including keywords and MeSH terms relating to blunt thoracic injury, patient pathway-based interventions, evaluation and implementation. Due to heterogeneity of intervention pathways, meta-analysis was not possible; analysis was undertaken using an iterative narrative approach.

RESULTS

A total of 16 studies met the inclusion criteria and were included in analysis. Pathways were identified covering analgesic management, respiratory care, surgical decision making and reducing risk of complications. Studies evaluating pathways are generally limited by their observational and retrospective design, but results highlight the potential benefits of pathway driven care provision in blunt thoracic injury.

CONCLUSIONS

The results demonstrate the complexity of evaluating patient pathway-based interventions in blunt thoracic injury management. It is important that pathways undergo rigorous evaluation, refinement and validation to ensure quality and patient safety. Strong recommendations are precluded as the quality of the pathway evaluation studies are low.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

May the initial CT scan predict the occurrence of delayed hemothorax in blunt chest trauma patients?

PURPOSE

To assess the impact of delayed hemothorax on outcomes in blunt chest trauma patients without life-threatening condition at admission and characterize the predictive value of predefined anatomical factors for delayed hemothorax.

METHODS

In a single-centre retrospective study, every spontaneous breathing patient admitted for a blunt chest trauma without significant pleural effusion at ICU admission was included. A multivariable regression model was used to determine the covariate-adjusted odd of secondary respiratory complications in patients with delayed hemothorax ≥ 500 ml. The characteristics of rib fractures (number, location and displacement) were integrated into a logistic regression model to determine variables associated with delayed hemothorax in multivariate analysis.

RESULTS

Over the study period, 109 patients were included and the rate of delayed hemothorax ≥ 500 ml was 36%. Patients with delayed hemothorax had higher rates of pulmonary infections (OR 4.8 [1.6-16.4]) but no statistical association between delayed hemothorax and secondary respiratory failure (OR 2.0 [0.4-9.4]). A posterior location and a displaced rib fracture were independent predictors of delayed hemothorax (OR 3.4 [1.3-8.6] and OR 2.3 [1.1-5.1], respectively). At least one displaced rib fracture was more specific of delayed hemothorax than the commonly used threshold of three or more rib fractures (81.3 vs. 51.5%).

CONCLUSION

Delayed hemothorax is a frequent complication associated with increased risk of pulmonary infection. The posterior location and the displacement of at least one rib fracture in the initial CT scan were independent risk factors for predicting the occurrence of delayed hemothorax.

Improving analgesia prescription for trauma inpatients

Patients value effective pain relief. Complications of inadequate pain control include increased risk of infection, decreased patient comfort and progression to chronic pain, all of which have significant socioeconomic consequence. Accessibility to analgesia is vital to effective administration. This improvement project aimed to improve the consistency and adequacy of analgesia prescribing for trauma inpatients over a 12-month period. Four PDSA (‘plan, do, study, act’) cycles resulted in sustained and significant improvements in analgesia prescription. The interventions included senior encouragement, teaching sessions, targeted inductions and implementation of a novel e-prescribing protocol. Prospective data and real-time discussion from stakeholder medical and management teams enabled iterative change to practice. Drug charts were reviewed for all trauma inpatients (n=276) over a 10-month period, recording all analgesia prescribed within 24 hours of admission. Each prescription was scored (maximum of 10 points) according to parameters agreed by the acute pain specialty leaders. An improving trend was observed in the analgesia score over the study period. Each intervention was associated with improved practice. Based on observed improvements, a novel electronic prescribing protocol was developed in conjunction with the information technology department, resulting in maximum scores for prescribing which were sustained over the final 3 months of the study. This was subsequently adopted as standard practice within the department. One year following completion of the project, a further 3 weeks of data were collected to assess long-term sustainability—scores remained 10 out of 10. Addressing the prescribing habits of junior doctors improved accessibility to analgesia for trauma patients. The electronic prescribing tool made prescribing straightforward and faster, and was the most successful intervention. Doctor satisfaction using this time-saving tool was high. Identifying a stakeholder within the information technology department proved pivotal to transferring the project aims into clinical practice.

Long-term disability after blunt chest trauma: Don't miss chronic neuropathic pain!

Introduction The main objective of this prospective study was to assess the incidence of chronic pain and long-term respiratory disability in a single-center cohort of severe blunt chest trauma patients. Methods Over a 10-month period, all consecutive blunt chest trauma patients admitted in Intensive Care Unit (ICU) were screened to participate in a 3-month and 12-month follow-up. The following variables were prospectively assessed: persistence of chronic chest pain requiring regular used of analgesics, neuropathic pain, respiratory disability, physical and mental health status. Univariate and multivariable analysis were conducted to assess variables associated with chronic chest pain, neuropathic chest pain and respiratory disability. Results During the study period, 65 patients were included in the study. Chronic chest pain and respiratory disability were reported in 62% and 57% of patients respectively at 3 months postinjury. Neuropathic pain was reported in 22% of patients, associated with higher impairment of quality of life. A thoracic trauma severity score ≥12 and a pain score ≥4 at SICU discharge were the only variables significantly associated with the occurrence of neuropathic pain at 3 months (OR = 7 [2-32], p = 0.01 and OR = 16 [4-70], p < 0.0001). Conclusion According to the current study, chronic pain and long-term respiratory disability are very common after severe blunt chest trauma patients. Special attention should be paid to neuropathic pain, frequently under-diagnosed and responsible for significant impairment of quality of life.