Financial and recovery worry one year after traumatic injury: A prognostic, registry-based cohort study

Tram-track cycling injuries: a significant public health issue

AIM

Many cycling collisions occur due to human error, cycling ability, distraction or infrastructure. One such infrastructural issue for cyclists sharing the road with tram lines is where the wheel of the bicycle gets caught in the rail track itself or in a gap between the rail and the road margin resulting in a sudden stall of the bicycle and potentially significant injury. This study aims to describe the crash characteristics of tram-track cycling collisions and their associated injuries.

METHODS

A retrospective chart review was conducted over 2 years, looking at cyclists that presented to St James's Emergency Department (ED) following injuries sustained due to a bicycle wheel catching in the on-road tram tracks.

RESULTS

Forty-eight patients were identified over a 2-year period. Sixty per cent of cyclists sustained limb fractures with 14% requiring orthopaedic surgery. Fifty per cent of patients were not wearing a helmet at the time of the incident and 54% of the collisions occurred around Dublin city centre during rush hour.

CONCLUSION

Further prospective multi-centre studies are required to properly describe the magnitude cycling accidents around the Luas tracks and inform future public health measures in this area.

Adult patient and carer experiences of planning for hospital discharge after a major trauma event: a qualitative systematic review

PURPOSE

To identify, evaluate and synthesize qualitative literature on adult patients and carer experiences of planning for discharge from an acute setting after a major trauma event.

METHODS

The JBI approach to meta-aggregation was followed. Qualitative studies exploring patient and carer discharge planning experiences of major trauma were included in the systematic review. A comprehensive search was conducted in five databases, supplemented by grey literature. Eligible studies were appraised for methodological quality by two reviewers and data extracted using standardized JBI tools.

RESULTS

Four synthesized findings emerged using 69 findings from sixteen papers. (i) Patients and carers feel generally unprepared to manage at home after discharge, (ii) early identification of patients' post discharge needs allows for appropriate referrals and supports to be organised prior to discharge, (iii) patients and carers value participation in the discharge planning process to facilitate a considered, organized and timely discharge from hospital (iv) the timely presentation, delivery, language used, format and relevancy of information impacts how patients and carers manage their discharge.

CONCLUSION

This meta-synthesis demonstrates that patients and carers predominantly have poor experiences of discharge planning after major trauma. Adoption of patient centered principles may improve patient and carer experiences of the discharge planning process.

IMPLICATIONS FOR REHABILITATIONPatients and their carers benefit from a client-centred approach where their needs are recognised and their collaboration encouraged in important decisions, and if they are adequately prepared to reintegrate into their community.Patients can benefit from having a trauma pathway healthcare professional to provide support and advocacy services throughout their hospital admission and after discharge.Discharge planning that is organised, prepared and collaborative leads to a more positive patient experience.Discharge information should be individualised and presented in an easily accessible format for patients and carers.

I'll be back - Predictive validity of adults' expectations for recovery after fractures - A longitudinal observational study

PURPOSE

Recovery after fractures due to accidents relates to all aspects of the biopsychosocial model. Therefore, it is difficult for the patients to foresee the consequences of the fractures. This study aimed to examine 1) patients' expectations regarding the impact of the injury on everyday life, 2) predictive validity of their expectations after six months, and 3) factors that predict a return to work.

PATIENTS AND METHODS

Patients were 18-64 years old and hospitalized with simple or compound/multiple fractures due to an accident. During admission, structured interviews were conducted with a questionnaire covering working conditions, expectations regarding recovery, sports, economy, family, household, and return to work. Additionally, mental and physical status were covered with Short Musculoskeletal Function Assessment questionnaire (SMFA) and Short Form 36, and working conditions were uncovered too. After six months, telephonic interviews were conducted with the 164 available patients to elucidate the impact of the fractures on everyday life, their health status, and sick leave. Likelihood ratios, post-test probabilities, and logistic regression analysis were performed to establish if patients' expectations predicted recovery, economy, sports, family, household, and return to work.

RESULTS

Few patients' baseline expectations about everyday life were met. The likelihood ratios were small, and the post-test probabilities for expectations consistent with outcomes were between 18% and 68%, with recovery as the lowest and participation in sports as the highest. In the multivariate analysis, patients' expectations did not predict short-term (less than two months) or long-term sick leave (more than three months). Self-rated health and the bother index of SMFA were significant short-term and long-term predictors for sick leave. Additionally, vitality, pain, and decision latitude at work predicted sick leave of less than two months.

CONCLUSION

A few days after the accident, patients' expectations about everyday life are not associated with outcomes six months later. Likelihood ratios indicate difficulties for the patients in predicting fractures' consequences on various aspects of everyday life. Return to work was associated with self-rated health and the bother index of SMFA. Future research should examine if fracture patients can benefit from comprehensive, individual counseling during admission to set appropriate expectations.

The role of perceived patient injustice on pain related and functional outcomes in orthopaedic patients; a systematic review

Introduction

Higher levels of perceived patient injustice has been associated with higher levels of pain and poor functional outcomes in patients with chronic musculoskeletal pain. We wanted to investigate if there was any evidence of this association in patients who underwent orthopaedic surgery.

Materials and methods

A systematic search of the literature was performed independently by two researchers on the electronic databases of MEDLINE, EMBASE, Google Scholar, Web of Science, and the Cochrane Database of Systematic Reviews and data extracted in accordance with PRISMA guidelines for systematic reviews. Outcomes of interest were pain, pain intensity, pain interference, opiate use, disability, physical function, return to work, quality of life, depression, anxiety, post-traumatic stress, social functioning and quality of life.

Results

Five studies were identified for qualitative analysis involving elective and trauma orthopaedic patients. All studies identified a positive correlation between higher levels of perceived injustice and depression, pain intensity and interference as well as reduced function and higher levels of disability.

Conclusions

Higher levels of perceived patient injustice is associated with worse pain and functional outcomes in patients who undergo orthopaedic surgery in the traumatic and elective setting. Further research is warranted to further elucidate this association and identify potential therapeutic interventions.

Are trauma surgical societies adequately addressing mental health after injury?

BACKGROUND

Survivors of physical trauma, their home caregivers, and their medical providers all have an increased risk of developing psychological distress and trauma-related psychiatric disease. The purpose of this study was to describe the frequency and change over time of trauma society research presentations regarding mental health to identify opportunities for growth.

METHODS

Archives from 2018 to 2020 from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association were reviewed. The studies that measured mental illness, psychosocial distress, and other psychosocial factors were assessed: for (1) the use of patient-reported outcome measures ; (2) the association of psychosocial variables with outcomes; and (3) the interventions investigated. Change over time was assessed using χ2 analysis.

RESULTS

Of 1,239 abstracts, 57 (4.6%) addressed at least 1 mental health-related factor. Mental health was more frequently studied over time (2018 [3.2%]; 2019 [3.5%]; 2020 [7.7%]; P = .003). The most frequently measured factors were post-traumatic stress disorder, quality of life, general mental health, and depression. Seventeen (29.8%) abstracts addressed substance abuse, most commonly opioid abuse. Seven (12.3%) abstracts measured mental health in caregivers or medical providers. Patient-reported outcome measures were used in 32 studies (56.1%). Two-thirds of studies reported findings suggesting that mental illness impairs trauma-related outcomes. Only 5 (8.8%) investigated interventions designed to reduce adverse outcomes.

CONCLUSION

Although academic discussion of mental health after trauma increased from 2018 to 2020, the topic remains a limited component of annual programs, patient-reported outcome measures remain underutilized, and intervention studies are rare.

Patterns of patient outcomes following specialist pain management in Australasia: a latent class analysis using the ePPOC database

ABSTRACT

The increasing demand for pain management and limited resources available highlight the need to measure treatment effectiveness. We analysed data collected at 75 specialist persistent pain services located in Australia and New Zealand to calculate overall treatment outcome for patients receiving care during 2014-2020. Socio-demographic and clinical information was provided for 23,915 patients, along with patient-reported measures assessing pain, pain interference, depression, anxiety, stress, pain catastrophizing and pain self-efficacy. Latent Class Analysis identified four distinct outcomes based on patients' pattern of responses across the assessment tools at treatment end. Group 1 (n=8,369, 35%) reported low/mild severity across all clinical domains at the end of care, while Group 4 (n= 7,081, 30%) were more likely to report moderate/high severity on all domains. Group 2 (n=1,991, 8%) reported low/mild pain with moderate/high psychological distress at treatment end, and Group 3 (n=6,474, 27%) reported moderate/high pain with low/mild psychological distress. Multi-variable logistic regression identified those factors associated with the different groups. In particular, factors most predictive of a poor (Group 4) vs. good outcome (Group 1) were unemployment (due to pain or other reasons), requiring an interpreter, widespread pain, pain of longer duration and attributing the pain to an injury at work. The results may allow identification of those most likely to benefit from the services currently provided, and inform development of alternative or enhanced services for those at risk of a poor outcome.

Factors impacting trauma-specific quality of life following injury: A multi-center assessment in Lebanon

OBJECTIVE

Injuries account for a large portion of the global burden of disease, representing over 10% of all disability adjusted life years (DALYs). This study analyzes the economic impact of injury for those experiencing moderate-to-severe injury in Beirut, Lebanon. It further examines the impact of different demographic and socioeconomic factors on trauma-specific quality of life 1-2 years following injury.

METHODS

This was a prospective cohort study following patients 1-2 years after being treated for injury at one of three hospitals in Beirut, Lebanon. Patients interviewed by phone. In addition to questions on financial impact, access to healthcare, and socioeconomic status, the Trauma-specific Quality of Life (TQoL) Questionnaire was used to assess quality of life following injury. Multivariable linear models were constructed to examine TQoL and demographics among institutes.

RESULTS

116 patients completed interviews. The average out-of-pocket cost of injury was 2975.42 USD, 65% of which was borrowed. 21% of people lost employment due to injury. Patients at Geitawi Hospital and the Rafic Hariri Governmental Hospital borrowed more on average and had higher reductions in employment than patients at the American University of Beirut Medical Center (AUBMC). There was a loss of income for those employed at the time of injury, with a mean monthly loss of 261.6 USD. The economic impact of injury was 10,329.00 USD. 25% of patients reported difficulty with accessing follow-up care, predominantly due to cost. Mean-adjusted Trauma-specific Quality of life (TQoL) was highest at AUBMC. Education was associated with functional recovery in the TQoL questionnaire; for every additional year of education there was an increase in the functional recovery domain of 0.03.

CONCLUSION

Individuals that experienced moderate-to-severe injury in Beirut, Lebanon, suffered financial repercussions, including reductions in income, less employment, or unemployment. Across all patients surveyed, higher level of education was associated with better functional quality of life. More study into the intricacies of accessing healthcare care in Lebanon, especially given the current economic and political climate, are crucial to maintain the health of those experiencing injury and can help inform targeted interventions.

Status and influencing factors of patients with kinesiophobia after insertion of peripherally inserted central catheter: A cross-sectional study

This study aimed to investigate the current status and influencing factors of kinesiophobia in patients after insertion of peripherally inserted central catheter (PICC). A total of 240 patients with PICC were included. Their postinsertion status and influencing factors were investigated using the general information questionnaire, Tampa Scale of Kinesiophobia (TSK), Medical Coping Modes Questionnaire, Numerical Rating Scale, and Self-rating Anxiety Scale. The mean TSK score was 36.49 ± 4.19 points, and 89 patients (37.08%) had kinesiophobia. Multiple linear regression analysis showed that factors such as education level, age, monthly income level, catheterization history, face, pain level, anxiety, and number of needle insertions influenced postoperative kinesiophobia in patients with PICC (P < .05). The total variation in the TSK score was 71.8%. The incidence of kinesiophobia was relatively high after PICC insertion. The medical staff needs to undertake targeted intervention measures to help minimize kinesiophobia after PICC insertion, allowing patients to perform scientifically correct functional exercises and attain physical recovery.

Six-months outcome after fracture for working-age persons analyzed using the International Classification of Functioning, Disability, and Health - a prospective cohort observational study

BACKGROUND

Fractures following trauma affect physical and mental health for working-age persons, and the International Classification of Functioning, Disability, and Health (ICF) can help therapists understand the fractures' impact on daily lives.

PURPOSE

To examine self-reported functioning and outcomes six months after upper and lower body fractures and compare limitations using the ICF.

METHODS

Data were collected from 160 patients with fractures as part of a prospective cohort study. The primary outcome measure was the Short Musculoskeletal Function Assessment questionnaire that covers all domains of the ICF. Moreover, sick leave, sense of coherence, and physical activity were reported.

RESULTS

Six months after the injury, function had improved significantly, but patients reported problems on all domains in the ICF with few differences between the upper and lower body groups. Leisure activities caused problems for 63 (38.8%) of the patients and bothered 86 (53.8%). Problems performing work bothered 63 (39.4%) with no significant difference between the groups, although a significantly higher proportion in the upper body group had returned to work within two months (p < .001).

CONCLUSION

Six months after fractures, adults reported problems on all ICF domains, especially on the participation dimension, which therapists should address in the rehabilitation process.

Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery

BACKGROUND

Value-based healthcare models aim to incentivize healthcare providers to offer interventions that address determinants of health. Understanding patient priorities for physical and socioeconomic recovery after injury can help determine which services and resources are most useful to patients.

QUESTIONS/PURPOSES

(1) Do trauma patients consistently identify a specific aspect/domain of recovery as being most important at 6 weeks, 6 months, and 12 months after an injury? (2) Does the relative importance of those domains change within the first year after injury? (3) Are differences in priorities greater between patients than for a given patient over time? (4) Are different recovery priorities associated with identifiable biopsychosocial factors?

METHODS

Between June 2018 and December 2018, 504 adult patients with fractures of the extremities or pelvis were surgically treated at the study site. For this prospective longitudinal study, we purposefully sampled patients from 6 of the 12 orthopaedic attendings' postoperative clinics. The participating surgeons surgically treated 243 adult patients with fractures of the extremities or pelvis. Five percent (11 of 243) of patients met inclusion criteria but missed their appointments during the 6-week recruitment window and could not be consented. We excluded 4% (9 of 243) of patients with a traumatic brain injury, 1% (2) of patients with a spinal cord injury, and 5% (12) of non-English-speaking patients (4% Spanish speaking [10]; 1% other languages [2]). Eighty-six percent of eligible patients (209 of 243) were approached for consent, and 5% (11 of 209) of those patients refused to participate. All remaining 198 patients consented and completed the baseline survey; 83% (164 of 198 patients) completed at least 6 months of follow-up, and 68% (134 of 198 patients) completed the 12-month assessment. The study participants' mean age was 44 ± 17 years, and 63% (125 of 198) were men. The primary outcome was the patient's recovery priorities, assessed at 6 weeks, 6 months, and 12 months after fracture using a discrete choice experiment. Discrete choice experiments are a well-established method for eliciting decisional preferences. In this technique, respondents are presented with a series of hypothetical scenarios, described by a set of plausible attributes or outcomes, and asked to select their preferred scenario. We used hierarchical Bayesian modeling to calculate individual-level estimates of the relative importance of physical recovery, work-related recovery, and disability benefits, based on the discrete choice experiment responses. The hierarchical Bayesian model improves upon more commonly used regression techniques by accounting for the observed response patterns of individual patients and the sequence of scenarios presented in the discrete choice experiment when calculating the model estimates. We computed the coefficient of variation for the three recovery domains and compared the between-patient versus within-patient differences using asymptotic tests. Separate prognostic models were fit for each of the study's three recovery domains to assess marginal changes in the importance of the recovery domain based on patient characteristics and factors that remained constant over the study (such as sex or preinjury work status) and patient characteristics and factors that varied over the study (including current work status or patient-reported health status). We previously published the 6-week results. This paper expands upon the prior publication to evaluate longitudinal changes in patient recovery priorities.

RESULTS

Physical recovery was the respondents' main priority at all three timepoints, representing 60% ± 9% of their overall concern. Work-related recovery and access to disability benefits were of secondary importance and were associated with 27% ± 6% and 13% ± 7% of the patients' concern, respectively. The patients' concern for physical recovery was 6% (95% CrI 4% to 7%) higher at 12 months after fracture that at 6 weeks postfracture. The mean concern for work-related recovery increased by 7% (95% CrI 6% to 8%) from 6 weeks to 6 months after injury. The mean importance of disability benefits increased by 2% (95% CrI 1% to 4%) from 6 weeks to 6 months and remained 2% higher (95% CrI 0% to 3%) at 12 months after the injury. Differences in priorities were greater within a given patient over time than between patients as measured using the coefficient of variation (physical recovery [245% versus 7%; p < 0.001], work-related recovery [678% versus 12%; p < 0.001], and disability benefits [620% versus 33%; p < 0.001]. There was limited evidence that biopsychosocial factors were associated with variation in recovery priorities. Patients' concern for physical recovery was 2% higher for every 10-point increase in their Patient-reported Outcome Measure Information System (PROMIS) physical health status score (95% CrI 1% to 3%). A 10-point increase in the patient's PROMIS mental health status score was associated with a 1% increase in concern for work-related recovery (95% CrI 0% to 2%).

CONCLUSION

Work-related recovery and accessing disability benefits were a secondary concern compared with physical recovery in the 12 months after injury for patients with fractures. However, the importance of work-related recovery was elevated after the subacute phase. Priorities were highly variable within a given patient in the year after injury compared with between-patient differences. Given this variation, orthopaedic surgeons should consider assessing and reassessing the socioeconomic well-being of their patients throughout their continuum of care.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Adult patient and/or carer experiences of planning for hospital discharge after major trauma: a qualitative systematic review protocol

OBJECTIVE

To investigate patient and/or carer experiences of planning for discharge from an acute setting after a major trauma event.

INTRODUCTION

The experience of injury through major trauma is a worldwide issue that affects people of any age. These patients often experience long-lasting disability. During discharge from the acute setting, patients are at a high risk of experiencing an adverse event due to the complex nature of the process. This review aims to explore patient/carer opinion of their encounter with the discharge planning process following major trauma.

INCLUSION CRITERIA

This review will consider studies that include patients aged between 18 and 65 who had major traumatic central nervous system injury or were allocated an Injury Severity Score >12, with demonstrated possibility of having an ongoing disability at least one year post-injury. Qualitative studies exploring patient and/or carer experiences of their participation in discharge planning from a trauma unit, acute ward or inpatient rehabilitation to a community setting will be included.

METHODS

A three-stage search will be conducted and will include unpublished and gray literature. Databases to be searched include PubMed, Embase, PyscInfo, Scopus and CINAHL. Only studies published in English will be considered. Identified studies will be screened for inclusion in the review by two independent reviewers. Data will be extracted using a standardized tool and reviewers will discuss any disagreement. Data synthesis will adhere to the meta-aggregative approach to categorize findings. The categories will be synthesized into a set of findings that can be applied as evidence-based practice.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019138431.

Pain catastrophizing, kinesiophobia and fear-avoidance in non-specific work-related low-back pain as predictors of sickness absence

The influence of pain catastrophizing, kinesiophobia and fear-avoidance attitudes towards non-specific low-back pain has been scarcely studied in an occupational insurance provider context. The objective of this work is to ascertain the relationship between these psychosocial variables with work absence, its duration and the disability of subjects with work-related low back pain. This is a descriptive observational methodological strategy. All patients with work-related non-specific low back pain who attended to an occupational health hospital during the study period were included consecutively. Clinical variables of kinesiophobia, pain catastrophizing, fear-avoidance attitudes, disability and pain were collected; sociodemographic variables of sex, age, type of work, educational level, occupational status and duration in days of work absence were recorded. Kinesiophobia (b = 1.43, P = 0.011, r = 0.333), fear-avoidance beliefs in its global dimension (b = 0.910, P = 0.014, r = 0.321), fear-avoidance beliefs in its work dimension (b = 1.255, P = 0.016, r = 0.321) and pain catastrophizing (b = 0.997, P = 0.013, r = 0.340) show individual association with the duration of sickness absence. Kinesiophobia (b = 0.821, P = 0.011, r = 0.30) and fear-avoidance beliefs (b = 1.760, P = 0.016, r = 0.28) are associated with disability (Kinesiophobia, b = 0.880, P = 0.045, r = 0.26; Fear-avoidance beliefs, b = 0.724, P = 0.010, r = 0.34). Kinesiophobia, fear-avoidance beliefs and pain catastrophizing are related to an increase in the duration of work absence and disability in patients with back pain in an occupational insurance provider context.

The Impact of Income Sources on Financial Stress in Workers' Compensation Claimants

PURPOSE

Workers' compensation schemes usually recompense workers below their regular wage. This may cause financial stress, which has previously been associated with poorer health and work outcomes after injury. We sought to determine the level of financial stress experienced by injured workers and the influence of post-injury income source on financial stress.

METHODS

Analysis of a cross-sectional national survey of 4532 adults who had been injured at work and had at least one day of workers' compensation paid. Financial stress at time of survey was measured on a scale of 1-10 and subsequently dichotomised at the top quartile for further analysis. The effect of current main income source on financial stress, adjusted for demographic and psychosocial confounders, was assessed using logistic regression.

RESULTS

Sixty-nine percent of workers whose main income was social assistance or insurance and 54% whose main income was workers' compensation were experiencing financial stress. Relative to wages or salaries, workers with a main income from social assistance or insurance (odds ratio: 3.33, 95% CI 2.22-5.00) and workers' compensation (1.71, 1.31-2.24) had higher odds of financial stress. Workers with a main income of an aged pension or superannuation had lower odds of financial stress (0.52, 0.28-0.97).

CONCLUSION

Injured workers receiving workers' compensation or social assistance benefits are vulnerable to increased financial stress. Given the potential negative consequences of financial stress on health, particularly mental health, this study suggests the need for careful consideration of income replacement benefits in the design of workers' compensation schemes.

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.

Experiences of Healthcare in Australia's Workers' Compensation Schemes: A Cross-Sectional Study

OBJECTIVE

To determine personal, injury, and scheme factors are associated with experiencing stressful healthcare provider (HCP) interactions, and to determine impact of stressful HCP interactions on return to work (RTW).

METHODS

Using the 2018 National RTW Survey of 4574 injured workers that submitted a workers' compensation claim, multivariable logistic regression determined factors associated with stressful HCP interactions (recorded as "a bit stressful" to "extremely stressful") and RTW (self-reported yes/no at interview).

RESULTS

Workers claiming for mental illness, who found healthcare difficult to access, who consulted with multiple HCPs, and who experienced psychological or financial stress, were significantly more likely to experience stressful HCP interactions. Stressful HCP interactions were associated with lower odds of RTW.

CONCLUSIONS

Findings provide impetus to investigate why HCP interactions are stressful to enable efforts to reduce stress, possibly improving RTW outcomes.

Creating Value by Prioritizing Mental and Social Health After Injury

Given the strong influence of mental and social health on symptom intensity and magnitude of limitations, attempts to increase value in orthopedic trauma must attend to emotional and social recovery. Low value and potentially harmful interventions after trauma such as excessive reliance on medication, low value surgeries for "delayed healing" or "symptomatic implants," repeated visits with a physical therapist, and other biomedical interventions often reflect misdiagnosis and mismanagement of social and mental health. A better approach is to anticipate emotional and social recovery; to get social and mental health specialists involved immediately after injury; and to develop strategies that set firm limits on biomedical tests and treatments that are unlikely to contribute to health and risk reinforcing stress, distress, and less effective coping strategies.

Medical-legal partnerships: 11 years' experience of providing acute legal advice for critically ill patients and their families

Background

Medical-legal partnerships integrate lawyers into health care to identify and address legal problems that can create and perpetuate disparities in health for patients and their families. They have previously been utilised for patients who are at high-risk of being disadvantaged such as the elderly, the disabled and those affected by chronic diseases. We have used a partnership to address the legal needs of patients with acute, critical illness including major trauma.

Method

In 2007, a free, comprehensive legal advice service was established at University Hospital Southampton NHS Foundation Trust. The service is bound by strict guidelines which have been endorsed by NHS England. The legal service is specifically prevented from acting against the NHS. A retrospective analysis of the service over a period of 11 years was undertaken to look at the range of legal advice sought. Where a potential compensation claim against a third party was identified, the percentage of cases where the legal service was instructed was noted and the outcome for those cases was examined in further detail.

Results

Five hundred and fifty-one patients and or their families have been referred to the legal service. Of these, 343 had sustained major trauma. Over 2300 hours of free legal advice were provided on non-compensation issues, primarily related to welfare benefits, local authority assistance, obtaining power of attorney or seeking Deputyship from the Court of Protection and claims against existing insurance policies. Two hundred and seventy-five of the 551 patients (50%) were found to have a potential compensation claim against a third party. The legal service was instructed to pursue a claim in 82 cases. Interim payments of nearly £13 million were provided and £128 million of compensation has been awarded in 51 cases that have been settled.

Discussion

Medical-legal partnerships are well-established in the USA. We have demonstrated that in UK, there is a demand for early legal advice for patients who have sustained critical illness including major trauma. More data are required to identify the rehabilitation outcomes for patients who have received legal support. A similar medical-legal partnership should be considered at every acute NHS Trust.