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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Partyka C, Asha S, Berry M, Ferguson I, Burns B, Tsacalos K, Gaetani D, Oliver M, Luscombe G, Delaney A, Curtis K. Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial. JAMA Surg 2024; 159:810-817. [PMID: 38691350 PMCID: PMC11063926 DOI: 10.1001/jamasurg.2024.0969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/02/2024] [Indexed: 05/03/2024]
Abstract
Importance Rib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures. Objective To determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures. Design, Setting, and Participants This multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023. Interventions Patients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone. Main Outcomes and Measures The primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points. Results A total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups. Conclusions and Relevance This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements. Trial Registration http://anzctr.org.au Identifier: ACTRN12621000040864.
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Affiliation(s)
- Christopher Partyka
- Emergency Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Aeromedical Operations, NSW Ambulance, Bankstown Aerodrome, New South Wales, Australia
| | - Stephen Asha
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
- St George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Melanie Berry
- Emergency Department, Orange Base Hospital, Orange, New South Wales, Australia
- RPA Virtual Hospital, Sydney, New South Wales, Australia
- Orange Clinical School, University of Sydney, Orange, New South Wales, Australia
| | - Ian Ferguson
- Aeromedical Operations, NSW Ambulance, Bankstown Aerodrome, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Brian Burns
- Aeromedical Operations, NSW Ambulance, Bankstown Aerodrome, New South Wales, Australia
- Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia
- Discipline of Emergency Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Katerina Tsacalos
- Emergency Department, The Sutherland Hospital, Caringbah, Sydney, New South Wales, Australia
| | - Daniel Gaetani
- South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Campbelltown and Camden Hospitals, Campbelltown, New South Wales, Australia
- School of Medicine, University of Western Sydney, Campbelltown, New South Wales, Australia
| | - Matthew Oliver
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Trauma Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Greenlight Institute, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Georgina Luscombe
- School of Rural Health, Sydney Medical School, University of Sydney, Orange, New South Wales, Australia
| | - Anthony Delaney
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Division of Critical Care, The George Institute of Global Health, University of New South Wales, Sydney, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kate Curtis
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sidney, New South Wales, Australia
- Critical Care Research, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
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Schieren M, Defosse JM, Annecke T. [Specialised Intensive Care Treatment Concepts for Severe Chest Trauma]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:354-367. [PMID: 38914078 DOI: 10.1055/a-2149-1814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.
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Kourouche S, Curtis K, Considine J, Fry M, Mitchell R, Shaban RZ, Sivabalan P, Bedford D. Does improved patient care lead to higher treatment costs? A multicentre cost evaluation of a blunt chest injury care bundle. Injury 2024; 55:111393. [PMID: 38326215 DOI: 10.1016/j.injury.2024.111393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/08/2024] [Accepted: 01/27/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Blunt chest injury is associated with significant adverse health outcomes. A chest injury care bundle (ChIP) was developed for patients with blunt chest injury presenting to the emergency department. ChIP implementation resulted in increased health service use, decreased unplanned Intensive Care Unit admissions and non-invasive ventilation use. In this paper, we report on the financial implications of implementing ChIP and quantify costs/savings. METHODS This was a controlled pre-and post-test study with two intervention and two non-intervention sites. The primary outcome measure was the treatment cost of hospital admission. Costs are reported in Australian dollars (AUD). A generalised linear model (GLM) estimated patient episode treatment costs at ChIP intervention and non-intervention sites. Because healthcare cost data were positive-skewed, a gamma distribution and log-link function were applied. RESULTS A total of 1705 patients were included in the cost analysis. The interaction (Phase x Treatment) was positive but insignificant (p = 0.45). The incremental cost per patient episode at ChIP intervention sites was estimated at $964 (95 % CI, -966 - 2895). The very wide confidence intervals reflect substantial differences in cost changes between individual sites Conclusions: The point estimate of the cost of the ChIP care bundle indicated an appreciable increase compared to standard care, but there is considerable variability between sites, rendering the finding statistically non-significant. The impact on short- and longer-term costs requires further quantification.
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Affiliation(s)
- Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, VIC, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; University of Technology Sydney, NSW, Australia; Northern Sydney Local Health District, NSW, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Centre for Population Health, Western Sydney Local Health District, Westmead, NSW, Australia; New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, Australia
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5
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Baker E, Battle C, Lee G. Blunt mechanism chest wall injury: initial patient assessment and acute care priorities. Emerg Nurse 2024; 32:34-42. [PMID: 38468549 DOI: 10.7748/en.2024.e2181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/13/2024]
Abstract
Blunt mechanism chest wall injury (CWI) is commonly seen in the emergency department (ED), since it is present in around 15% of trauma patients. The thoracic cage protects the heart, lungs and trachea, thereby supporting respiration and circulation, so injury to the thorax can induce potentially life-threatening complications. Systematic care pathways have been shown to improve outcomes for patients presenting with blunt mechanism CWI, but care is not consistent across the UK. Emergency nurses have a crucial role in assessing and treating patients who present to the ED with blunt mechanism CWI. This article discusses the initial assessment and acute care priorities for this patient group. It also presents a prognostic model for predicting the probability of in-hospital complications following blunt mechanism CWI.
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Affiliation(s)
- Edward Baker
- King's College Hospital NHS Foundation Trust, London, England
| | - Ceri Battle
- Swansea Bay University Health Board, Swansea, Wales
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England
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Eriksson EA, Wijffels MME, Kaye A, Forrester JD, Moutinho M, Majerick S, Bauman ZM, Janowak CF, Patel B, Wullschleger M, Clevenger L, Van Lieshout EMM, Tung J, Woodfall M, Hill TR, White TW, Doben AR. Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1). Eur J Trauma Emerg Surg 2024; 50:417-423. [PMID: 37624405 DOI: 10.1007/s00068-023-02343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions. METHODS A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis. RESULTS Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001). CONCLUSION Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.
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Affiliation(s)
- Evert Austin Eriksson
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Drive CSB 420, MSC 613, Charleston, SC, 29425, USA.
| | - Mathieu Mathilde Eugene Wijffels
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Adam Kaye
- Department of Trauma, Overland Park Regional Medical Center, 10500 Quivira Rd., Overland Park, KS, 66215, USA
| | - Joseph Derek Forrester
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Manuel Moutinho
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
| | - Sarah Majerick
- Department of Trauma, Intermountain Health, Salt Lake City, USA
| | - Zachary Mitchel Bauman
- Trauma Surgery, Surgical Critical Care, Emergency General Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, TraumaOmaha, NE, 68198-3280, USA
| | - Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Bhavik Patel
- Gold Coast University Hospital, Gold Coast, QLD, 4215, Australia
| | - Martin Wullschleger
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Griffith University, Gold Coast, Australia
| | - Leanna Clevenger
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Drive CSB 420, MSC 613, Charleston, SC, 29425, USA
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jamie Tung
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Michelle Woodfall
- Department of Surgery, Stanford Healthcare, Chest Wall Injury Center, Stanford Healthcare, Center for Innovation in Global Health (CIGH), Stanford University, Stanford, USA
| | - Thomas Russell Hill
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
| | | | - Andrew Ross Doben
- Department of Surgery, Saint Francis Hospital and Medical Center, UConn School of Medicine, Hartford, CT, USA
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Proaño-Zamudio JA, Argandykov D, Renne A, Gebran A, Ouwerkerk JJJ, Dorken-Gallastegi A, de Roulet A, Velmahos GC, Kaafarani HMA, Hwabejire JO. Timing of regional analgesia in elderly patients with blunt chest-wall injury. Surgery 2023; 174:901-906. [PMID: 37582669 DOI: 10.1016/j.surg.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Rib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia. METHODS We retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed. RESULTS In the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9-17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36-0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041-0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04-1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34-1.04; P = .070). CONCLUSION Early regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Angela Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joep J J Ouwerkerk
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Amory de Roulet
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Larraga-García B, Castañeda López L, Monforte-Escobar F, Quintero Mínguez R, Quintana-Díaz M, Gutiérrez Á. Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management. Appl Clin Inform 2023; 14:714-724. [PMID: 37673097 PMCID: PMC10482499 DOI: 10.1055/s-0043-1771396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/15/2023] [Indexed: 09/08/2023] Open
Abstract
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.
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Affiliation(s)
- Blanca Larraga-García
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Luis Castañeda López
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | | | | | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain
| | - Álvaro Gutiérrez
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
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Beloy V, Dull M. Blunt chest wall trauma: Rib fractures and associated injuries. JAAPA 2022; 35:25-31. [PMID: 36219110 DOI: 10.1097/01.jaa.0000885136.91189.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.
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Affiliation(s)
- Victoria Beloy
- Victoria Beloy practices in general and trauma surgery at Intermountain Healthcare Good Samaritan Hospital in Lafayette, Colo. Matthew Dull is an acute care and trauma general surgeon at Spectrum Health Butterworth Hospital in Grand Rapids, Mich. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Larraga-García B, Quintana-Díaz M, Gutiérrez Á. The Need for Trauma Management Training and Evaluation on a Prehospital Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13188. [PMID: 36293767 PMCID: PMC9602774 DOI: 10.3390/ijerph192013188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Blanca Larraga-García
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, 28040 Madrid, Spain
| | | | - Álvaro Gutiérrez
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, 28040 Madrid, Spain
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11
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McGuinness MJ, Harmston C. Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study. Injury 2022; 53:2953-2959. [PMID: 35489820 DOI: 10.1016/j.injury.2022.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 02/02/2023]
Abstract
AIM Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ. METHODS A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia. RESULTS Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Māori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block. CONCLUSION This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.
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Affiliation(s)
- Matthew J McGuinness
- University of Auckland; Surgical Department, Whangārei Hospital, Manu Road, Whangārei, New Zealand.
| | - Christopher Harmston
- University of Auckland; Surgical Department, Whangārei Hospital, Manu Road, Whangārei, New Zealand
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Pelaez CA, Jackson JA, Hamilton MY, Omerza CR, Capella JM, Trump MW. High flow nasal cannula outside the ICU provides optimal care and maximizes hospital resources for patients with multiple rib fractures. Injury 2022; 53:2967-2973. [PMID: 35667887 DOI: 10.1016/j.injury.2022.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/14/2022] [Accepted: 05/04/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND High flow nasal cannula (HFNC) use reduces work of breathing and improves oxygenation for patients with hypoxemic respiratory failure. Limited prior work has explored protocolized use of HFNC for trauma patients outside the Intensive Care Unit (ICU). The purpose of this study is to describe and evaluate use of HFNC for patients with rib fractures when therapy was standard of care on all floors of the hospital. METHODS In 2018, the study hospital expanded use of HFNC (AIRVO; Fisher Paykel, Auckland, NZ) to all floors of the hospital, making it available in the ICU, Emergency Department (ED), and on general inpatient floors. The study group included adult patients with three or more rib fractures who received HFNC at any location in the hospital (Phase 2: January 2018-December 2019). The study group was compared to a historical control group when HFNC was available only in the ICU (Phase 1: March 2013-July 2015). Patients were excluded from the study if they received invasive mechanical ventilation prior to HFNC. Primary outcomes were mechanical ventilation rates, ICU days, length of hospitalization, and mortality. RESULTS During the study period, 63 patients received HFNC, with 35% of patients (n = 22) receiving the duration of therapy outside the ICU. When compared to the control group (N = 63), there were no significant differences in total hospital days (9 vs. 9, p=.64), mechanical ventilation (19% vs. 13%, p=.47), or mortality (3% vs. 5%, p = 1.00). Twenty-seven percent of patients (n = 17) in the study group avoided the ICU during hospitalization. CONCLUSIONS Findings suggest that HFNC therapy can be safely initiated and managed on all hospital floors for patients with multiple rib fractures. Making the therapy available outside the ICU may reduce healthcare resource use without adversely affecting patient outcomes.
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Affiliation(s)
- Carlos A Pelaez
- Trauma Surgery, The Iowa Clinic, 1200 Pleasant St, Des Moines, IA, United States of America; Trauma Services, UnityPoint Health, Des Moines, IA, United States of America.
| | - Julie A Jackson
- Respiratory Therapy, UnityPoint Health, 1200 Pleasant St, Des Moines, IA, United States of America
| | - Mikayla Y Hamilton
- Doctor of Osteopathic Medicine Program, Des Moines University, 3200 Grand Ave, Des Moines, IA, United States of America
| | - Christopher R Omerza
- General Surgery Residency Program, 1415 Woodland Ave, UnityPoint Health, Des Moines, IA, United States of America
| | - Jeannette M Capella
- Trauma Surgery, The Iowa Clinic, 1200 Pleasant St, Des Moines, IA, United States of America; Trauma Services, UnityPoint Health, Des Moines, IA, United States of America
| | - Matthew W Trump
- Pulmonary and Critical Care Medicine, The Iowa Clinic, 1200 Pleasant St, Des Moines, IA, United States of America
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13
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Curtis K, Kourouche S, Asha S, Buckley T, Considine J, Middleton S, Mitchell R, Munroe B, Shaban RZ, Lam M, Fry M. Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes. Injury 2022; 53:2939-2946. [PMID: 35644642 DOI: 10.1016/j.injury.2022.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/05/2022] [Accepted: 04/29/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury. METHODS ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes. RESULTS There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites. CONCLUSION Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery. TRIAL REGISTRATION ANZCTR: ACTRN12618001548224, approved 17/09/2018.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia; Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Northfields Avenue, Wollongong NSW, Australia.
| | - Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Stephen Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia; St George Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia.
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; Centre for Quality and Patient Safety Experience, Eastern Health Partnership, Box Hill, VIC, Australia.
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; Australian Catholic University, NSW Australia.
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2113, Australia.
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia.
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW 2006, Australia; Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, 2145, Australia; New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, 2145, Australia.
| | - Mary Lam
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia.
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; University of Technology Sydney, Faculty of Health, NSW, Australia; Northern Sydney Local Health District, NSW, Australia.
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Shanahan TAG, Cottey L, Darbyshire D, Hirst R, Naquib M, Oliver G, Prager G. Journal update monthly top five. J Accid Emerg Med 2022. [PMID: 35858683 DOI: 10.1136/emermed-2022-212672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Thomas Alexander Gerrard Shanahan
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK .,Division of Cardiovascular Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Laura Cottey
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Daniel Darbyshire
- Lancaster Medical School, Lancaster University, Lancaster, UK.,Emergency Department, The Royal Oldham Hospital, Oldham, UK
| | - Robert Hirst
- Children's Emergency Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,Trainee Emergency Research Network (TERN), The Royal College of Emergency Medicine, London, UK
| | - Mina Naquib
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Govind Oliver
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gabrielle Prager
- Emergency Department, Wythenshawe Hospital, Manchester, UK.,Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
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The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury. Injury 2022; 53:1073-1080. [PMID: 34625240 DOI: 10.1016/j.injury.2021.09.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 05/12/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury. METHODS Patients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality. RESULTS A total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%). CONCLUSIONS Lethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic "lethal triad", there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.
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Gao Y, Liao LP, Chen P, Wang K, Huang C, Chen Y, Mou SY. Application effect for a care bundle in optimizing nursing of patients with severe craniocerebral injury. World J Clin Cases 2021; 9:11265-11275. [PMID: 35071557 PMCID: PMC8717492 DOI: 10.12998/wjcc.v9.i36.11265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/17/2021] [Accepted: 11/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe craniocerebral injury (STBI) is a critical physical trauma caused by a sudden external force acting on the head. The condition is complex and changeable, and disability and mortality rates are high. Although the life of STBI patients can be saved through treatment, the sequelae of consciousness, speech, cognitive impairment, stiffness, spasm, pain and abnormal behavior in the early rehabilitation stage can be a heavy burden to a family. In the past, routine nursing was often used to treat/manage STBI; however, problems, such as improper cooperation and untimely communication, reduced therapeutic effectiveness. AIM To investigate the effect of a proposed care bundle to optimize the first aid process and assess its effectiveness on the early rehabilitation nursing of patients with STBI. METHODS From January 2019 to December 2020, 126 STBI patients were admitted to the emergency department of Chongqing Emergency Medical Center. These patients were retrospectively selected as the research participants in the current study. The study participants were then divided into a control group (61 cases) and a study group (65 cases). The control group was treated with routine nursing. The study group adopted the proposed care bundle. The National Institutes of Health Stroke Scale/Score and Glasgow Coma Scale (GCS) were used to evaluate neurological function before and after emergency treatment. After 3 mo of rehabilitation, experimental outcomes were assessed. These included the GCS, Barthel Index, complication rate, muscle strength grade and satisfaction. RESULTS There was no significant difference in gender, age, cause of injury and GCS between the two groups. After emergency, the National Institutes of Health Stroke Scale/Score of the study group (10.23 ± 3.26) was lower than that of the control group (14.79 ± 3.14). The GCS score of the study group (12.48 ± 2.38) was higher than that of the control group (9.32 ± 2.01). The arrival time of consultation in the study group was 20.56 ± 19.12, and the retention time in the emergency room was 45.12 ± 10.21, which were significantly shorter than those in the control group. After 3 mo of rehabilitation management, the GCS and Barthel Index of the study group were 14.56 ± 3.75 and 58.14 ± 12.14, respectively, which were significantly higher than those of the control group. The incidence of complications in the study group (15.38%) was significantly lower than that in the control group (32.79%). The proportion of muscle strength ≥ grade III in the study group (89.23%) was significantly higher than that in the control group (50.82%). The satisfaction of patients in the study group was significantly higher than that in the control group. CONCLUSION Care bundles are used to optimize the nursing process. During first-aid, care bundles can effectively improve the rescue effect and improve neurological function of STBI patients as well as shorten the treatment time. In early rehabilitation, they can effectively improve the consciousness of STBI patients, improve the activities of daily living, reduce the risk of complications, accelerate the recovery of muscle strength and improve their satisfaction.
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Affiliation(s)
- Ying Gao
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Li-Ping Liao
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Peng Chen
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Ke Wang
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Cui Huang
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Ying Chen
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Shao-Yu Mou
- School of Nursing, Chongqing Medical University, Chongqing 400016, China
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Curtis K, Kourouche S, Asha S, Considine J, Fry M, Middleton S, Mitchell R, Munroe B, Shaban RZ, D’Amato A, Skinner C, Wiseman G, Buckley T. Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation. PLoS One 2021; 16:e0256027. [PMID: 34618825 PMCID: PMC8496821 DOI: 10.1371/journal.pone.0256027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/28/2021] [Indexed: 12/03/2022] Open
Abstract
Background Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. Methods This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. Results There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period. Conclusion The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. Trial registration ANZCTR: ACTRN12618001548224, approved 17/09/2018
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, NSW, Australia
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
- * E-mail:
| | - Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Stephen Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia
- St George Clinical School, Faculty of Medicine, University of New South Wales, Kogarah, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Experience–Eastern Health Partnership, Box Hill, VIC, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Northern Sydney Local Health District, Hornsby, NSW, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne, Fitzroy, Australia
- Australian Catholic University, Sydney, NSW, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, NSW, Australia
| | - Ramon Z. Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
- Division of Infectious Diseases and Sexual Health, Department of Infection Prevention and Control, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, Australia
- New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Warwick Farm, NSW, Australia
| | - Alfa D’Amato
- NSW Activity Based Funding Taskforce, NSW Ministry of Health, Sydney, Australia
| | - Clare Skinner
- Emergency Department, Hornsby Ku-ring-ai Hospital, Hornsby, NSW, Australia
| | - Glen Wiseman
- Emergency Services, Canterbury Hospital, Campsie, NSW, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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Baker E, Xyrichis A, Norton C, Hopkins P, Lee G. Building consensus on inpatient discharge pathway components in the management of blunt thoracic injuries: An e-Delphi study amongst an international professional expert panel. Injury 2021; 52:2551-2559. [PMID: 33849725 DOI: 10.1016/j.injury.2021.03.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/02/2021] [Accepted: 03/30/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Access to a standardised and evidence informed approach to blunt thoracic injury (BTI) management remains challenging across organised trauma systems globally. It remains important to optimise recovery through pathway-based interventions. The aim of this study was to identify components of care that are important in the effective discharge process for patients with BTI and pinpoint core and optional components for a patient pathway-based intervention. METHODS Components of care within the hospital discharge process after BTI were identified using existing literature and expert opinion. These initial data were entered into a three-round e-Delphi consensus method where round one involved further integrating and categorising components of discharge care from the expert panel. The panel comprised of an international interdisciplinary group of healthcare professionals with experience in the management of BTI. All questionnaires were completed anonymously using an online survey and involved rating care components using Likert scales (Range: 1-6). The final consensus threshold for pathway components were defined as a group rating of greater than 70% scoring in either the moderate importance (3-4) or high importance category (5-6) and less than 15% of the panel scoring within the low importance category (1-2). RESULTS Of 88 recruited participants, 67 (76%) participated in round one. Statements were categorised into nine themes: (i) Discharge criteria; (ii) Physical function and Self-care; (iii) Pain management components; (iv) Respiratory function components; (v) General care components; (vi) Follow-up; (vii) Psychological care components; (viii) Patient, family and communication; (ix) 'Red Flag' signs and symptoms. Overall, 70 statements were introduced into the consensus building exercise in round two. In round three, 40 statements from across these categorises achieved consensus amongst the expert panel, forming a framework of core and optional care components within the discharge process after BTI. CONCLUSIONS These data will be used to build a toolkit containing guidance on developing discharge pathways for patients with BTI and for the development of audit benchmarks for analysing healthcare provision in this area. It is important that interventions developed using this framework are validated locally and evaluated for efficacy using appropriate research methodology.
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Key Words
- Consensus study abbreviations BTI, Blunt thoracic injury
- Delphi method
- FEV1, Forced expiratory volume in 1 second
- IQR, Interquartile range
- Injury
- MDT, Multidisciplinary team
- MTC, Major trauma centre
- OPD, Outpatient department
- OT, Occupational therapist
- PT, Physiotherapist
- Pathway development
- Rib fracture
- SD, Standard deviation
- Trauma
- VAS, Visual analogue scale
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Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK; Emergency Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK.
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK.
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK.
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Kourouche S, Curtis K, Munroe B, Watts M, Balzer S, Buckley T. Implementation strategy fidelity evaluation for a multidisciplinary Chest Injury Protocol (ChIP). Implement Sci Commun 2021; 2:86. [PMID: 34376254 PMCID: PMC8353870 DOI: 10.1186/s43058-021-00189-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 07/25/2021] [Indexed: 12/19/2022] Open
Abstract
Background Blunt chest wall injuries can lead to complications, especially without early intervention. A blunt Chest Injury Protocol (ChIP) was developed to help improve the consistency of evidence-based care following admission to the emergency department. Implementation strategy fidelity is the extent to which the strategies of implementation are delivered in line with the intended plan. The aim of this study was to assess fidelity to the strategies of the implementation plan developed for ChIP. Methods A retrospective evaluation of strategies used for implementation was performed, specifically the behaviour change techniques (BCTs). BCTs were used as part of an implementation plan derived based on the Behaviour Change Wheel from results from a staff survey at two hospitals. Levels of implementation or adaptation for BCTs were scored by implementers as follows: ‘Were the behaviour change interventions implemented?’ (0 = ‘not implemented’, 1 = partially implemented, and 2 = fully implemented); ‘Were adaptations made to the implementation plan?’, scored 1 (many changes from plan) to 4 (just as planned). Free text explanation to their responses was also collected with supporting evidence and documentation (such as emails, implementation checklists, audit reports, and incident reports). Results There was high overall fidelity of 97.6% for BCTs partially or fully implemented. More than three quarters (32/42, 76.2%) of the BCTs were fully implemented with an additional 9/42 (21.4%) partially implemented. BCTs that were not fully implemented were social support, feedback on behaviour, feedback on outcomes of behaviour, adding objects to the environment, and restructuring the environment. The modes of delivery with poorer implementation or increased adaptations were clinical champions and audit/feedback. Conclusions This study describes the evaluation of implementation strategy fidelity in the acute care context. The systematic use and application of the behaviour change wheel was used to develop an implementation plan and was associated with high implementation strategy fidelity. A fidelity checklist developed during the implementation process may help implementers assess fidelity. Trial registration Trial registered on ANZCTR. Registration number ACTRN12618001548224, date approved 17/09/2018 Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00189-8.
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Affiliation(s)
- Sarah Kourouche
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney Susan Wakil School of Nursing and Midwifery, 88 Mallet St, Camperdown, NSW, Australia.
| | - Kate Curtis
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney Susan Wakil School of Nursing and Midwifery, 88 Mallet St, Camperdown, NSW, Australia.,Director of Critical Care Research, Illawarra Shoalhaven Local Health District, Warrawong, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Belinda Munroe
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney Susan Wakil School of Nursing and Midwifery, 88 Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
| | - Michael Watts
- Intensive Care, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
| | - Sharyn Balzer
- Emergency Services, Shoalhaven Memorial District Hospital, Shoalhaven, NSW, Australia
| | - Thomas Buckley
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney Susan Wakil School of Nursing and Midwifery, 88 Mallet St, Camperdown, NSW, Australia
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Baker E, Battle C, Banjeri A, Carlton E, Dixon C, Ferry J, Hopkins P, Jones R, Murrells T, Norton C, Patient L, Rasheed A, Skene I, Tabner A, Tunnicliff M, Young L, Xyrichis A, Lee G. Prospective observational study to examine health-related quality of life and develop models to predict long-term patient-reported outcomes 6 months after hospital discharge with blunt thoracic injuries. BMJ Open 2021; 11:e049292. [PMID: 34244278 PMCID: PMC8268921 DOI: 10.1136/bmjopen-2021-049292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE This study aimed to examine the long-term outcomes and health-related quality of life in patients with blunt thoracic injuries over 6 months from hospital discharge and develop models to predict long-term patient-reported outcomes. DESIGN A prospective observational study using longitudinal survey design. SETTING The study recruitment was undertaken at 12 UK hospitals which represented diverse geographical locations and covered urban, suburban and rural areas across England and Wales. PARTICIPANTS 337 patients admitted to hospital with blunt thoracic injuries were recruited between June 2018-October 2020. METHODS Participants completed a bank of two quality of life surveys (Short Form-12 (SF-12) and EuroQol 5-Dimensions 5-Levels) and two pain questionnaires (Brief Pain Inventory and painDETECT Questionnaire) at four time points over the first 6 months after discharge from hospital. A total of 211 (63%) participants completed the outcomes data at 6 months after hospital discharge. OUTCOMES MEASURES Three outcomes were measured using pre-existing and validated patient-reported outcome measures. Outcomes included: Poor physical function (SF-12 Physical Component Score); chronic pain (Brief Pain Inventory Pain Severity Score); and neuropathic pain (painDETECT Questionnaire). RESULTS Despite a trend towards improving physical functional and pain at 6 months, outcomes did not return to participants perceived baseline level of function. At 6 months after hospital discharge, 37% (n=77) of participants reported poor physical function; 36.5% (n=77) reported a chronic pain state; and 22% (n=47) reported pain with a neuropathic component. Predictive models were developed for each outcome highlighting important data collection requirements for predicting long-term outcomes in this population. Model diagnostics including calibration and discrimination statistics suggested good model fit in this development cohort. CONCLUSIONS This study identified the recovery trajectories for patients with blunt thoracic injuries over the first 6 months after hospital discharge and present prognostic models for three important outcomes which after external validation could be used as clinical risk stratification scores.
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Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
- Emergency Department, King's College Hospital, London, UK
| | - Ceri Battle
- Welsh Institute of Biomedical and Emergency Medicine Research, Swansea Bay University Health Board, Port Talbot, Neath Port Talbot, UK
| | - Abhishek Banjeri
- Emergency Department, Buckingham Healthcare NHS Trust, Amersham, UK
| | - Edward Carlton
- Emergency Department, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Christine Dixon
- Emergency Department, Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, UK
| | - Jennifer Ferry
- Department of Anesthetics, Aneurin Bevan Health Board, Newport, UK
| | - Philip Hopkins
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Robert Jones
- Emergency Department, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Lee Patient
- Emergency Department, St George's Healthcare NHS Trust, London, UK
| | - Ashraf Rasheed
- General Surgery, Aneurin Bevan Health Board, Newport, UK
| | - Imogen Skene
- Emergency Department, Barts Health NHS Trust, London, UK
| | - Andrew Tabner
- Emergency Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Malcolm Tunnicliff
- Emergency Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Louise Young
- Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Gerry Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Kourouche S, Curtis K, Munroe B, Asha SE, Carey I, Considine J, Fry M, Lyons J, Middleton S, Mitchell R, Shaban RZ, Unsworth A, Buckley T. Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation. Aust Crit Care 2021; 35:113-122. [PMID: 34144864 DOI: 10.1016/j.aucc.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. OBJECTIVE The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. METHODS This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test. RESULTS/FINDINGS Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]). CONCLUSIONS High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.
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Affiliation(s)
- Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia; Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Northfields Avenue, Wollongong NSW, Australia.
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia.
| | - Stephen Edward Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia; St George Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia.
| | - Ian Carey
- School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; Centre for Quality and Patient Safety Experience - Eastern Health Partnership, Box Hill, VIC, Australia.
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; University of Technology Sydney Faculty of Health, NSW, Australia; Northern Sydney Local Health District, NSW, Australia.
| | - Jack Lyons
- School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, NSW Australia.
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2113.
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW 2006, Australia; Department of Infection Prevention and Control, Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, 2145, Australia; New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, 2145, Australia.
| | - Annalise Unsworth
- South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, NSW 2006, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
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Baker E, Xyrichis A, Norton C, Hopkins P, Lee G. The processes of hospital discharge and recovery after blunt thoracic injuries: The patient's perspective. Nurs Open 2021; 9:1832-1843. [PMID: 34002948 PMCID: PMC8994942 DOI: 10.1002/nop2.929] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
AIMS The aim of this study was to explore hospital discharge processes and the self-management of recovery in the early post-discharge period after blunt thoracic injury from a patient perspective. DESIGN Qualitative interview study. METHODS Interviews were conducted with participants recruited from 8 sites across England and Wales between November 2019-May 2020. Semi-structured interviews were conducted between 5-8 weeks after hospital discharge, and in total, 14 interviews were undertaken. These interviews were recorded, transcribed and analysed using thematic coding. RESULTS Three main themes were identified from the analysis: (a) challenges in the discharge process, (b) coping at home after discharge and (c) managing medications at home. Pain was a dominant thread running throughout all themes which represented an important quality and safety concern for all participants. Associated concerns included insufficient preparation and education for hospital discharge, ineffective communication and subsequent unsafe use of opioids at home highlighting unmet patient care needs.
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Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Emergency Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Griffard J, Daley B, Campbell M, Martins D, Beam Z, Rowe S, Taylor J. Plate of ribs: single institution's matched comparison of patients managed operatively and non-operatively for rib fractures. Trauma Surg Acute Care Open 2020; 5:e000519. [PMID: 33178892 PMCID: PMC7646357 DOI: 10.1136/tsaco-2020-000519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/27/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background Rib fractures are associated with significant morbidity and mortality in polytraumatized patients. There is considerable variability in the management (operative vs. non-operative) and timing of operative intervention. Although Eastern Association for the Surgery of Trauma (EAST) guidelines recommend early operative intervention in patients with flail chest, there are no strong recommendations regarding operative fixation in patients with a non-flail chest rib fracture pattern. Methods We reviewed our Trauma Quality Improvement Program database for patients aged 18 to 99 who underwent operative intervention of ribs from January 2016 to July 2019. We examined hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, Injury Severity Score, age, discharge disposition and packed red blood cell transfusions. Similarly, we collected data from patients aged 18 to 99 who had one or more rib fractures in this time frame. We compared results in a 4:1 ratio of patients managed non-operatively to patients managed operatively. The patient groups were matched based on age, number of rib fractures and presence of bilateral rib fractures. Results Between January 2016 and July 2019, 33 of 4189 total patients diagnosed with rib fractures underwent operative fixation; the matched non-operative group consisted of 132 patients. The statistically significant differences included presence of bilateral rib fractures, displaced rib fractures and flail chest segments. The median ICU days were longer in the operative group (6.0 vs. 3.5 days). A subgroup analysis of patients without flail segments demonstrated a significant presence of displaced rib fractures.Our single-institution matched comparison of outcomes in operative intervention versus Non-operative Management (NOM) of rib fractures found an increased median number of ICU days. Patients who underwent operative intervention often stayed in the ICU preoperatively and postoperatively for aggressive pulmonary hygiene and pain control, suggesting observer bias. The increased incidence of displaced rib fractures and the presence of a flail segment in the operative group demonstrate congruence with EAST guidelines. A subgroup analysis of patients without flail segment did not demonstrate differences in outcomes nor shoulder girdle injury characteristics. Level of evidence This article presents level III evidence that can be used by other clinicians to analyze eligibility for patients to undergo surgical stabilization of rib fracture (SSRF) and to provide counterarguments for performing SSRF in a heterogenous group of patients.
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Affiliation(s)
- Jared Griffard
- Surgery, The University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Brian Daley
- Surgical Critical Care, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Marc Campbell
- Surgical Critical Care, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | | | - Zach Beam
- Surgical Critical Care, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Sean Rowe
- Pharmacy, The University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Jessica Taylor
- Surgical Critical Care, University of Tennessee Medical Center, Knoxville, Tennessee, USA
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Measuring nurses' perceptions of their work environment and linking with behaviour change theories and implementation strategies to support evidence based practice change. Appl Nurs Res 2020; 56:151374. [PMID: 33280792 DOI: 10.1016/j.apnr.2020.151374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/28/2020] [Accepted: 10/09/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Survey tools, such as the Alberta Context Tool, reliably measure context but researchers have no process to map context to clinician behaviour and develop strategies to support practice change. Therefore, we aimed to map the Alberta Context Tool to the Theoretical Domains Framework and the Behaviour Change Wheel. METHOD The multi-centre study used the Alberta Context Tool to collect data from a convenience sample of nurses working in two emergency departments. These findings were categorised as barriers and enablers, and then mapped to the Theoretical Domains Framework to examine for behavioural domains. Using the Behaviour Change Wheel functions, strategies were developed to target clinician behaviour change. RESULTS Survey response rate was 42% (n = 68). Nurses perceived a positive work environment in the dimensions of Social Capital (median 4.00, IQR 0.33), Culture (median 3.83, IQR 1.16) and Leadership (median 3.60, IQR 1.1). Low scoring dimensions included Formal Interactions (median 2.75, IQR 1.00); Time (median 2.60, IQR 1.00) Staffing (median 3.0, IQR 2.00) and Space (median 3.0, IQR 2.00). Enablers (n = 77) and barriers (n = 25) were identified in both sites. The Theoretical Domains Framework was mapped to Alberta Context Tool barriers and enablers. The behaviour change strengths included: social and professional role; beliefs about capability; goals; and emotions. Using the Behaviour Change Wheel functions, 67 strategies were developed to address barriers and enablers. CONCLUSIONS The Alberta Context Tool successfully measured two emergency environments identifying barriers and enablers. This approach enabled environment dimensions to be targeted with practical solutions to support evidence-based practice implementation.
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Curtis K, Nahidi S, Gabbe B, Vallmuur K, Martin K, Shaban RZ, Christey G. Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians. Injury 2020; 51:2053-2058. [PMID: 32698960 DOI: 10.1016/j.injury.2020.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/09/2020] [Accepted: 07/14/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Injury is a leading cause of death and disability world-wide. Little is known about the day-to-day challenges the trauma clinicians face in their practice that they feel could be improved through an increased evidence base. This study explored and ranked the trauma clinical practice research priorities of trauma care professionals across Australia and New Zealand. METHODS A modified-Delphi study was conducted between September 2019 and January 2020. The study employed two rounds of online survey of trauma professionals from relevant Australia and New Zealand professional organisations using snowballing method. Participants were asked to rank the importance of 29 recommendations, each corresponding to a key challenge in trauma care delivery. Decisions on the priorities of the challenges were determined by a consensus of >70% of respondents ranking the challenge as important or very important. RESULTS One hundred and fifty-five participants completed Round One, and 106 participants completed Round Two. A total of 15 recommendations reached >70% in Round One. Nine recommendations also reached >70% consensus in Round Two. Recommendations ranked highest were 'Caring for elderly trauma patients', 'Identifying and validating key performance indicators for trauma system benchmarking and improvement', and 'Management of traumatic brain injury'. CONCLUSION This study identified the priority areas for trauma research as determined by clinician ranking of the most important for informing and improving their practice. Addressing these areas generates potential to improve the quality and safety of trauma care in Australian and New Zealand.
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Affiliation(s)
- Kate Curtis
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, Sydney, Australia; Trauma Quality Improvement Sub-Committee, Royal Australasian College of Surgeons, Australia; Australasian Trauma Society, Australia; Australian Trauma Quality Improvement Program (AusTQIP), Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; University of Wollongong, Faculty of Science, Medicine and Health, Wollongong, Australia.
| | - Shizar Nahidi
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, Sydney, Australia
| | - Belinda Gabbe
- Australasian Trauma Society, Australia; Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - Kirsten Vallmuur
- Australian Trauma Quality Improvement Program (AusTQIP), Australia; Queensland University of Technology, Australian Centre for Health Services Innovation, Faculty of Health, School of Public Health and Social Work, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Queensland Health, Australia
| | - Katherine Martin
- Trauma Quality Improvement Sub-Committee, Royal Australasian College of Surgeons, Australia; Australasian Trauma Society, Australia
| | - Ramon Z Shaban
- The University of Sydney, Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, Sydney, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Camperdown, NSW, Australia; Centre for Infectious Diseases and Microbiology and the Directorate of Nursing, Midwifery and Clinical Governance, Western Sydney Local Health District, Westmead, NSW, Australia
| | - Grant Christey
- Trauma Quality Improvement Sub-Committee, Royal Australasian College of Surgeons, Australia; Australasian Trauma Society, Australia; Australian Trauma Quality Improvement Program (AusTQIP), Australia; Centre for Infectious Diseases and Microbiology and the Directorate of Nursing, Midwifery and Clinical Governance, Western Sydney Local Health District, Westmead, NSW, Australia; Waikato District Health Board, Hamilton, New Zealand; Waikato Clinical School, University of Auckland, Auckland, New Zealand
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Macheel C, Reicks P, Sybrant C, Evans C, Farhat J, West MA, Tignanelli CJ. Clinical Decision Support Intervention for Rib Fracture Treatment. J Am Coll Surg 2020; 231:249-256.e2. [DOI: 10.1016/j.jamcollsurg.2020.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/01/2020] [Accepted: 04/06/2020] [Indexed: 01/22/2023]
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Baker E, Woolley A, Xyrichis A, Norton C, Hopkins P, Lee G. 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. Injury 2020; 51:1733-1743. [PMID: 32576379 PMCID: PMC7399576 DOI: 10.1016/j.injury.2020.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK; Emergency Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Alison Woolley
- Department of Cardio-thoracic Surgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
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van Aswegen H. Physiotherapy management of patients with trunk trauma: A state-of-the-art review. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2020; 76:1406. [PMID: 32671276 PMCID: PMC7343940 DOI: 10.4102/sajp.v76i1.1406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/27/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma. OBJECTIVES To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management. METHOD A non-systematic narrative review of published literature was performed. RESULTS Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice. CONCLUSION Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used. CLINICAL IMPLICATIONS Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma.
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Affiliation(s)
- Helena van Aswegen
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020; 23:125-138. [PMID: 32417043 PMCID: PMC7296362 DOI: 10.1016/j.cjtee.2020.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
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.
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Tignanelli CJ, Rix A, Napolitano LM, Hemmila MR, Ma S, Kummerfeld E. Association Between Adherence to Evidence-Based Practices for Treatment of Patients With Traumatic Rib Fractures and Mortality Rates Among US Trauma Centers. JAMA Netw Open 2020; 3:e201316. [PMID: 32215632 PMCID: PMC7707110 DOI: 10.1001/jamanetworkopen.2020.1316] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Rib fractures are sustained by nearly 15% of patients who experience trauma and are associated with significant morbidity and mortality. Evidence-based practice (EBP) rib fracture management guidelines and treatment algorithms have been published. However, few studies have evaluated trauma center adherence to EBP or the clinical outcomes of each practice within a national cohort. OBJECTIVE To examine adherence to 6 EBPs for rib fractures across US trauma centers and the association with in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from January 1, 2007, to December 31, 2014, of 777 US trauma centers participating in the National Trauma Data Bank. A total of 625 617 patients (age, ≥16 years) were evaluated. Patients without rib fractures and those with no signs of life or institutions with poor data quality were excluded. Data analysis was performed from January 1, 2007, to December 31, 2014. MAIN OUTCOMES AND MEASURES Six EBPs were defined: (1) neuraxial blockade, (2) intensive care unit admission, (3) pneumatic stabilization, (4) chest computed tomographic scans for older adults (≥65 years) with 3 or more rib fractures, (5) surgical rib fixation for flail chest, and (6) tube thoracostomy placement for hemothorax and/or pneumothorax. Multiple imputation was used to account for missing data. Patients were propensity score matched in a 1:1 fashion based on demographic characteristics; injury severity parameters, including the Injury Severity Score (range, 0-75; higher scores indicate more severe injuries); and comorbidities. Logistic regression was used to determine the association of each practice with all-cause in-hospital mortality. RESULTS Of the 625 617 patients with rib fractures included in this analysis, 456 196 patients (73%) were white and 432 229 patients (69%) were male; the median age of the patients was 51 (interquartile range, 37-65) years, and the mean (SD) Injury Severity Score was 18.3 (11.1). The mean (SD) number of rib fractures was 4.2 (2.6). On univariate analysis, patients treated at verified level I trauma centers were more likely to receive 5 or 6 EBPs (all but pneumatic stabilization). Of those who met eligibility, only 4578 of 111 589 patients (4%) received neuraxial blockade, 46 456 of 111 589 patients (42%) were admitted to the intensive care unit, 3302 of 24 319 patients (14%) received surgical rib fixation, 1240 of 111 589 patients (1%) received pneumatic stabilization, 109 160 of 258 334 patients (42%) received tube thoracostomy, and 32 405 of 81 417 patients (40%) received chest computed tomographic scans. Three EBPs were associated with decreased mortality: neuraxial blockade (odds ratio [OR], 0.64; 95% CI, 0.51-0.79; P < .001) for patients aged 65 years or older with 3 or more rib fractures, surgical rib fixation (OR, 0.13; 95% CI, 0.01-0.18; P < .001), and intensive care unit admission (OR, 0.93; 95% CI, 0.86-1.00; P = .04) for patients aged 65 years or older with 3 or more rib fractures. Pneumatic stabilization (OR, 1.71; 95% CI, 1.25-2.35; P < .001) and chest tube placement (OR, 1.27; 95% CI, 1.21-1.33; P < .001) were associated with increased mortality in older patients with 3 or more rib fractures. On multivariable analysis, insurance status, race/ethnicity, injury severity, hospital bed size, and trauma center verification level were associated with receiving EBPs for rib fractures. CONCLUSIONS AND RELEVANCE Significant variation appears to exist in the delivery of EBPs for rib fractures across US trauma centers. Three EBPs were associated with reduced mortality, but EBP adherence was poor. Multiple factors, including trauma center verification level, appear to be associated with patients receiving EBPs for rib fractures.
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Affiliation(s)
- Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
| | - Alexander Rix
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
| | | | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor
| | - Sisi Ma
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
| | - Erich Kummerfeld
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
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Kourouche S, Buckley T, Van C, Munroe B, Curtis K. Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study. BMC Health Serv Res 2019; 19:461. [PMID: 31286954 PMCID: PMC6615309 DOI: 10.1186/s12913-019-4177-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care. Aim To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation. Methods 1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria. Results One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term ‘care bundle’ (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions. Conclusions Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway. Electronic supplementary material The online version of this article (10.1186/s12913-019-4177-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Kourouche
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.
| | - Tom Buckley
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Connie Van
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Belinda Munroe
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
| | - Kate Curtis
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
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Janssen TL, Hosseinzoi E, Vos DI, Veen EJ, Mulder PGH, van der Holst AM, van der Laan L. The importance of increased awareness for delirium in elderly patients with rib fractures after blunt chest wall trauma: a retrospective cohort study on risk factors and outcomes. BMC Emerg Med 2019; 19:34. [PMID: 31195982 PMCID: PMC6567595 DOI: 10.1186/s12873-019-0248-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 06/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma. METHODS A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months. RESULTS Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance. CONCLUSION Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.
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Affiliation(s)
- Ties L Janssen
- Department of surgery, Amphia Hospital Breda, P.O. Box 90518, 4800 RK, Breda, The Netherlands.
| | - Elmand Hosseinzoi
- Department of surgery, Amphia Hospital Breda, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Dagmar I Vos
- Department of surgery, Amphia Hospital Breda, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Eelco J Veen
- Department of surgery, Amphia Hospital Breda, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Paul G H Mulder
- Amphia Academy, Amphia Hospital Breda, Breda, The Netherlands
| | | | - Lijckle van der Laan
- Department of surgery, Amphia Hospital Breda, P.O. Box 90518, 4800 RK, Breda, The Netherlands
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Wen Z, Zhang X, Liu Y, Li Y, Li X, Wei L. Humidified versus nonhumidified low-flow oxygen therapy in children with Pierre-Robin syndrome: Study protocol for a randomised controlled trial. J Clin Nurs 2019; 28:3522-3528. [PMID: 31162860 DOI: 10.1111/jocn.14943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/08/2019] [Accepted: 05/26/2019] [Indexed: 12/27/2022]
Abstract
AIMS AND OBJECTIVES To evaluate the necessity of oxygen humidification for low-flow oxygen therapy in children with Pierre-Robin syndrome. BACKGROUND Whether to carry out humidification or not in the low-flow oxygen delivery remains unclear, and currently, there is no published study on this issue in the population of children. Therefore, it is necessary to conduct more studies to elucidate this issue. DESIGN A randomised controlled trial. METHODS We attempt to report this randomised controlled trial to comply with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT). 188 children with Pierre-Robin syndrome will be expected to inclusion. The participants will be randomly divided into the humidified group (n = 94) and nonhumidified group (n = 94) at a ratio of 1:1. For humidified group, the oxygen will be routinely humidified with disposable bottle containing sterile water, whereas for nonhumidified group, the oxygen will not be humidified. Average arterial oxygen partial pressure (PaO2 ) and carbon dioxide partial pressure (PaCO2 ), incidence of ventilator-associated pneumonia (VAP), nasal cavity dryness, nasal mucosal bleeding and bacterial contamination of the humidified bottle, the cost of nasal oxygen therapy and duration of ICU stay are collected and analysed. RESULTS The study is planned to start in May 2019, and the results will be expected in July 2020. CONCLUSIONS This study is expected to provide a credible evidence on the necessity of routine oxygen humidification in low-flow oxygen delivery. RELEVANCE TO CLINICAL PRACTICE Understanding the role of oxygen humidification and no humidification for low-flow oxygen therapy in the population of children is beneficial to the nursing care of healthcare providers in clinical setting.
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Affiliation(s)
- Zunjia Wen
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xin Zhang
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yingfei Liu
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Li
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoyan Li
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Li Wei
- Children's Hospital of Nanjing Medical University, Nanjing, China
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Coggins A, Ebrahimi N, Kemp U, O'Shea K, Fusi M, Murphy M. A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department. Australas Emerg Care 2019; 22:69-75. [PMID: 31053486 DOI: 10.1016/j.auec.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients. METHODS A prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding. RESULTS The response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41). Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%). CONCLUSIONS Despite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.
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Affiliation(s)
- Andrew Coggins
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia.
| | - Nargus Ebrahimi
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | - Ursula Kemp
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | - Kelly O'Shea
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | | | - Margaret Murphy
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
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Harde M, Aditya G, Dave S. Prediction of outcomes in chest trauma patients using chest trauma scoring system: A prospective observational study. Indian J Anaesth 2019; 63:194-199. [PMID: 30988533 PMCID: PMC6423939 DOI: 10.4103/ija.ija_750_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background and Aims: Prognostication of chest trauma patients by scoring systems is of vital importance to predict morbidity and mortality. We aimed to predict outcomes in chest trauma patients using chest trauma scoring system (CTS) in Indian patients. Methods: This was a prospective observational study done in a trauma care centre at a tertiary care teaching public hospital. CTS was calculated by scores of age, severity of pulmonary contusion, number of rib fractures and presence of bilateral rib fractures. Final CTS ranges from 2 to 12. We evaluated CTS to predict outcome that is mortality as primary objective and development of complications like pneumonia and need for ventilator support as secondary objective in Indian population. Results: Data were collected from 30 patients and they were divided into two groups, CTS <5 (15) and CTS ≥5 (15). High CTS ≥5 was statistically significantly associated with high incidence of pneumonia (P = 0.046), increased requirement of mechanical ventilation (P = 0.025) and mortality (P = 0.035) in chest trauma. Area under the ROC for mortality shows that the test is acceptable (0.75) and at CTS score 5.5 maximum sensitivity is 87.5% and specificity is 68%. Conclusion: This study concludes that a CTS ≥5 is associated with poor outcomes. This scoring system may be used to identify patients at risk of complications and institute early intensive focussed care.
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Affiliation(s)
- Minal Harde
- Department of Anaesthesiology, Topiwala National Medical College and B.Y.L. Nair Ch. Hospital, Mumbai Central, Mumbai, Maharashtra, India
| | - G Aditya
- Department of Anaesthesiology, Topiwala National Medical College and B.Y.L. Nair Ch. Hospital, Mumbai Central, Mumbai, Maharashtra, India
| | - Sona Dave
- Department of Anaesthesiology, Topiwala National Medical College and B.Y.L. Nair Ch. Hospital, Mumbai Central, Mumbai, Maharashtra, India
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