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Kourouche S, Wiseman T, Lam MK, Mitchell R, Sarrami P, Dinh M, Singh H, Curtis K. Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study. Injury 2024; 55:111538. [PMID: 38599952 DOI: 10.1016/j.injury.2024.111538] [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: 11/09/2023] [Revised: 02/26/2024] [Accepted: 04/01/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults. AIMS i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma. METHODS A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019. RESULTS After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days. CONCLUSION Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.
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Affiliation(s)
- S Kourouche
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia.
| | - T Wiseman
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia
| | - M K Lam
- School of Health and Biomedical Sciences, RMIT University, Australia
| | - R Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - P Sarrami
- New South Wales Institute of Trauma and Injury Management, South Western Sydney Clinical School, University of New South Wales, Australia
| | - M Dinh
- Sydney Local Health District, New South Wales Institute of Trauma and Injury Management, Australia; Sydney Medical School, the University of Sydney, Australia
| | - H Singh
- New South Wales Institute of Trauma and Injury Management, Australia
| | - K Curtis
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia; Emergency Services, Illawarra Shoalhaven LHD, NSW, Australia
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Strachan D, Baker E. Building consensus on the selection criteria used when providing regional anaesthesia for rib fractures. An e-Delphi study amongst a UK-wide expert panel. Injury 2024; 55:110967. [PMID: 37563045 DOI: 10.1016/j.injury.2023.110967] [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: 06/16/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Rib fractures are associated with significant morbidity and mortality, and providing adequate analgesia is paramount in preventing early complications from these injuries. Multiple regional anaesthetic techniques can be used to provide analgesia for these injuries; however, few evidence-based guidelines exist for their use. The aim of this study was to establish consensus within an expert group on the selection criteria used when choosing regional anaesthetic techniques for rib fractures. METHODS The Delphi technique is a mixed-methods study format which uses a longitudinal survey process to develop consensus opinion amongst an expert group. A three-round modified e-Delphi study was undertaken using an online survey platform. Round one established cohort characteristics and identified key factors considered important by the group when selecting regional anaesthetic techniques for rib fractures. Subsequent rounds used Likert scales and free text comments to rate the participants' level of agreement with various statements generated from the first-round responses. The final consensus threshold was established as at least 70% of respondents stating, 'Strongly Disagree' or 'Disagree' or alternatively 'Agree' or 'Strongly Agree'. RESULTS An expert panel of UK-based consultants in anaesthesia and/or intensive care medicine was recruited. Participants worked in a variety of tertiary- and non-tertiary trauma care settings and were varied in their years of experience, approximate annual rib fracture caseload and preference for various anaesthetic techniques in rib fracture management. 54 participants took part in round one and generated 60 statements which were further analysed in an iterative process involving a total of three rounds. A total of 28 statements ultimately reached the pre-defined threshold for consensus within the expert group. CONCLUSIONS This e-Delphi study succeeded in building consensus across multiple statements relating to the selection criteria for regional anaesthesia in patients with rib fractures. These consensus statements can inform clinical practice, guide future research priorities and can be integrated into decision-making pathways across multiple hospital settings.
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Affiliation(s)
- Dominic Strachan
- Department of Anaesthesia, NHS Lanarkshire, University Hospital Wishaw, Netherton Street, Wishaw ML20DP, UK; Centre for Trauma Science Queen Mary University of London Blizard Institute, 4 Newark Street, London E1 2AT, England, UK.
| | - Edward Baker
- Emergency Department King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, England, UK; Centre for Trauma Science Queen Mary University of London Blizard Institute, 4 Newark Street, London E1 2AT, England, UK
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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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Battle C, Cole E, Whelan R, Baker E. Scoping review of the literature to ascertain how the STUMBL Score clinical prediction model is used to manage patients with blunt chest wall trauma in emergency care. Injury 2023:S0020-1383(23)00436-9. [PMID: 37208252 DOI: 10.1016/j.injury.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION The STUMBL Score clinical prediction model was originally developed and externally validated to support clinical decision-making of patients with blunt chest wall trauma in the Emergency Department. The aim of this scoping review was to understand the extent and type of evidence in relation to the STUMBL Score clinical prediction model as a component of the management of patients with blunt chest wall trauma managed in the Emergency Care setting. METHODS A systematic search was conducted across databases, including Medline, Embase and the Cochrane Central Register of Controlled Trials from Jan 2014 to Feb 2023. In addition, a search of the grey literature was undertaken along with citation searching of relevant studies. Published and non-published sources of all research designs were included. Data extracted included specific details about the participants, concept, context, study methods and key findings relevant to the review question. Data extraction followed the JBI guidance and results presented in tabular format accompanied with a narrative summary. RESULTS A total of 44 sources originating from eight countries were identified, 28 were published and 16 grey literature. Sources were grouped into four separate categories: 1) external validation studies, 2) guidance documents, 3) practice reviews and educational resources 3) research studies and quality improvement projects, 4) grey literature unpublished resources. This body of evidence describes the clinical utility of the STUMBL Score and has identify how the score is being implemented and used differently in different settings including analgesic selection and participant eligibility for including in chest wall injury research studies. DISCUSSION This review demonstrates how the STUMBL Score has evolved from solely predicting risk of respiratory complications to a measure which supports clinical decision making for the use of complex analgesic modes and as a guide for eligibility in chest wall injury trauma research studies. Despite external validation of the STUMBL Score, there is a need for further calibration and evaluation, particularly relating to these repurposed functions of the score. Overall, the clinical benefit of the score remains clear and its wide usage demonstrates the impact it has on clinical care, patient experience and clinician decision making.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Dept, Morriston Hospital, Swansea Bay University Health Board, Swansea. Wales SA6 6NL, United Kingdom.
| | - Elaine Cole
- Centre of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom.
| | - Rhys Whelan
- Library and Knowledge Services, Morriston Hospital, Swansea Bay University Health Board, Swansea, Wales, United Kingdom.
| | - Edward Baker
- Emergency Dept, Kings College Hospital, London, United Kingdom.
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Lee G, Baker E, Collins R, Merino JL, Desteghe L, Heidbuchel H. The challenge of managing multimorbid atrial fibrillation: a pan-European European Heart Rhythm Association (EHRA) member survey of current management practices and clinical priorities. Europace 2022; 24:2004-2014. [PMID: 36036694 PMCID: PMC9733957 DOI: 10.1093/europace/euac136] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/19/2022] [Indexed: 12/15/2022] Open
Abstract
As part of the EHRS-PATHS study examining comorbidities in atrial fibrillation (AF) across Europe, the aim was (i) to evaluate how multimorbidity is currently addressed by clinicians during AF treatment to characterize the treatment structure and (ii) to assess how the interdisciplinary management of multimorbid AF is currently conducted. An online survey was distributed among European Heart Rhythm Association (EHRA) members in Europe that included 21 questions and a free-text option for comments on detection, assessment, and management of AF-related comorbidities. A total of 451 responses were received with 339 responses eligible for inclusion. Of these, 221 were male (66%), 300 (91.5%) were physicians, and 196 (57.8%) were working in academic university teaching hospitals. Half of the respondents managed between 20 and 50 patients per month with multimorbid AF. Varying rates of specialist services and referral to these services were available at each location (e.g. heart failure and diabetes), with a greater number of specialist services available at academic university teaching hospitals compared with non-teaching hospitals [e.g. anticoagulation clinic 92 (47%) vs. 50 (35%), P < 0.03]. Barriers to referring to specialist services for AF comorbidities included lack of integrated care model (n = 174, 51%), organizational or institutional issues (n = 145, 43%), and issues with patient adherence (n = 126, 37%), highlighting the need for organizational restructuring and developing an integrated collaborative evidenced-based approach to multimorbid AF care. The survey and analyses of free-text comments demonstrated the need for systematic, integrated management of AF-related comorbidities, and these results will inform the next phases of the EHRA-PATHS study.
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Affiliation(s)
- Geraldine Lee
- Division of Applied Technology for Clinical Care, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK
| | - Edward Baker
- Division of Applied Technology for Clinical Care, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital Dublin, Dublin, Ireland
- Department of Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Jose L Merino
- Department of Cardiology, La Paz University Hospital, IdiPaz, Universidad Autonoma, Madrid, Spain
| | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Hein Heidbuchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
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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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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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Sborov KD, Dennis BM, de Oliveira Filho GR, Bellister SA, Statzer N, Stonko DP, Guyer RA, Wanderer JP, Beyene RT, McEvoy MD, Allen BFS. Acute pain consult and management is associated with improved mortality in rib fracture patients. Reg Anesth Pain Med 2022; 47:rapm-2022-103527. [PMID: 35882429 DOI: 10.1136/rapm-2022-103527] [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: 02/02/2022] [Accepted: 07/09/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Traumatic rib fractures result in significant patient morbidity and mortality, which increases with patient age and number of rib fractures. A dedicated acute pain service (APS) providing expertize in multimodal pain management may reduce these risks and improve outcomes. We aimed to test the hypothesis that protocolized APS consultation decreases mortality and morbidity in traumatic rib fracture patients. METHODS This is a retrospective observational, propensity-matched cohort study of adult patients with trauma with rib fractures from 2012 to 2015, at a single, large level 1 trauma center corresponding to introduction and incorporation of APS consultation into the institutional rib fracture pathway. Using electronic medical records and trauma registry data, we identified adult patients presenting with traumatic rib fractures. Patients with hospital length of stay (LOS) ≥2 days were split into two cohorts based on presence of APS consult using 1:1 propensity matching of age, gender, comorbidities and injury severity. The primary outcome was difference in hospital mortality. Secondary outcomes included LOS and pulmonary morbidity. RESULTS 2486 patients were identified, with a final matched cohort of 621 patients receiving APS consult and 621 control patients. The mortality rate was 1.8% among consult patients and 6.6% among control patients (adjusted OR 0.25, 95% CI 0.13 to 0.50; p=0.001). The average treatment effect of consult on mortality was 4.8% (95% CI 1.2% to 8.5%;. p<0.001). APS consultation was associated with increased intensive care unit (ICU) LOS (1.19 day; 95% CI 0.48 to 1.90; p=0.001) and hospital LOS (1.61 days; 95% CI 0.81 to 2.41 days; p<0.001). No difference in pulmonary complications was observed. DISCUSSION An APS consult in rib fracture patients is associated with decreased mortality and no difference in pulmonary complications yet increased ICU and hospital LOS.
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Affiliation(s)
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Seth A Bellister
- Department of Acute Care Surgery, CHRISTUS Trinity Mother Frances Health System, Tyler, Texas, USA
| | - Nicholas Statzer
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Richard A Guyer
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan P Wanderer
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robel T Beyene
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D McEvoy
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Gartner JB, Abasse KS, Bergeron F, Landa P, Lemaire C, Côté A. Definition and conceptualization of the patient-centered care pathway, a proposed integrative framework for consensus: a Concept analysis and systematic review. BMC Health Serv Res 2022; 22:558. [PMID: 35473632 PMCID: PMC9040248 DOI: 10.1186/s12913-022-07960-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/13/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Confusion exists over the definition of the care pathway concept and existing conceptual frameworks contain various inadequacies which have led to implementation difficulties. In the current global context of rapidly changing health care systems, there is great need for a standardized definition and integrative framework that can guide implementation. This study aims to propose an accurate and up-to-date definition of care pathway and an integrative conceptual framework. METHODS An innovative hybrid method combining systematic review, concept analysis and bibliometric analysis was undertaken to summarize qualitative, quantitative, and mixed-method studies. Databases searched were PubMed, Embase and ABI/Inform. Methodological quality of included studies was then assessed. RESULTS Forty-four studies met the inclusion criteria. Using concept analysis, we developed a fine-grained understanding, an integrative conceptual framework, and an up-to-date definition of patient-centered care pathway by proposing 28 subcategories grouped into seven attributes. This conceptual framework considers both operational and social realities and supports the improvement and sustainable transformation of clinical, administrative, and organizational practices for the benefit of patients and caregivers, while considering professional experience, organizational constraints, and social dynamics. The proposed attributes of a fluid and effective pathway are (i) the centricity of patients and caregivers, (ii) the positioning of professional actors involved in the care pathway, (iii) the operation management through the care delivery process, (iv) the particularities of coordination structures, (v) the structural context of the system and organizations, (vi) the role of the information system and data management and (vii) the advent of the learning system. Antecedents are presented as key success factors of pathway implementation. By using the consequences and empirical referents, such as outcomes and evidence of care pathway interventions, we went beyond the single theoretical aim, proposing the application of the conceptual framework to healthcare management. CONCLUSIONS This study has developed an up-to-date definition of patient-centered care pathway and an integrative conceptual framework. Our framework encompasses 28 subcategories grouped into seven attributes that should be considered in complex care pathway intervention. The formulation of these attributes, antecedents as success factors and consequences as potential outcomes, allows the operationalization of this model for any pathway in any context.
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Affiliation(s)
- Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, Canada.
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada.
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada.
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada.
| | - Kassim Said Abasse
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
| | - Frédéric Bergeron
- Bibliothèque-Direction des services-conseils, Université Laval, Québec, QC, Canada
| | - Paolo Landa
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Département d'opérations et systèmes de décision, Université Laval, Québec, QC, Canada
| | - Célia Lemaire
- Université de Strasbourg, EM Strasbourg-Business School, HuManiS, Strasbourg, France
| | - André Côté
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
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Caldwell L, Papermaster AE, Halder GE, White AB, Young A, Rogers RG. Evidence-based pelvic floor disorder care pathways optimize shared decision making between patients and surgeons. Int Urogynecol J 2022; 33:2841-2847. [PMID: 35001160 PMCID: PMC8743070 DOI: 10.1007/s00192-021-05021-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
Introduction and hypothesis Evidence-based care pathways improve care standardization and patient outcomes. We created pelvic organ prolapse (POP) and stress urinary incontinence (SUI) care pathways as decision aids for our multidisciplinary team to use when counseling patients. Methods Using a modified Delphi process, an expert team reviewed existing guidelines and literature to reach consensus on pathway definitions and components. Results Entry to the care pathways occurs via an advanced practice provider visit. Symptom and quality-of-life questionnaires as well as open-ended patient goals are used to guide patient–provider shared decision making. All treatment choices, including surgical and nonsurgical management, are presented to patients by advanced practice providers. Patients electing nonsurgical management follow-up by telehealth (preferred) or in-person visits as determined by the care pathway. Surgeon consultations are scheduled for patients desiring surgery. Surgical patients undergo urodynamics, simple cystometrics or deferred bladder testing according to the urodynamics clinical pathway. Postoperative follow-up includes telehealth visits and minimizes in-person visits for women with uncomplicated postoperative courses. Patients with resolution of symptoms are graduated from clinic and return to their referring physician. The pathways are revised following publication of new compelling evidence. Conclusions We developed POP and SUI care pathways to standardize care across a diverse provider group. Advanced practice providers use care pathways with patients as shared decision-making tools for initial evaluation of patients with prolapse and incontinence. These pathways serve as components of value-based care and encourage team members to function independently while utilizing the full scope of their training.
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Affiliation(s)
- Lauren Caldwell
- University of Texas Dell Medical School, 1301 W. 38th Street, Suite 705, Austin, TX, 78705, USA.
| | - Amy E Papermaster
- University of Texas Dell Medical School, 1301 W. 38th Street, Suite 705, Austin, TX, 78705, USA
| | | | - Amanda B White
- University of Texas Dell Medical School, 1301 W. 38th Street, Suite 705, Austin, TX, 78705, USA
| | - Amy Young
- University of Texas Dell Medical School, 1301 W. 38th Street, Suite 705, Austin, TX, 78705, USA
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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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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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14
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Baker E, Xyrichis A, Norton C, Hopkins P, Lee G. Challenges associated with recovery from blunt thoracic injuries from hospital admission to six-months after discharge: A qualitative interview study. Int Emerg Nurs 2021; 57:101045. [PMID: 34243106 DOI: 10.1016/j.ienj.2021.101045] [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: 01/19/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Recovery for patients presenting to trauma services globally with blunt thoracic injury (BTI) remains challenging with substantial levels of physical, psychological socio-economic burden. The aim of this study is to examine the challenges experienced by patients with BTI from hospital admission to 6-months after hospital discharge. METHODS Participants were recruited from trauma patients admitted with BTI and were recruited from 7 sites across England and Wales between March and June 2019. Semi-structured interviews were conducted at six-months after discharge from hospital, and in total 11 interviews were undertaken. Interviews were recorded, transcribed, and analysed with reflexive thematic analysis. RESULTS Two themes were identified within the data: (i) Challenges within the acute hospital admission where pain and analgesic management and the processes of investigation and treatment were the sources of most challenges to recovery. (ii) Challenges within the post-discharge recovery journey, where managing pain at home, unidentified injuries, and mental well-being impacted most on recovery. CONCLUSIONS This study adds to the body of qualitative evidence surrounding recovery from major trauma and the patient experience within the recovery journey after BTI and It is important that clinicians consider the whole recovery journey as a continuous process rather than two isolated processes.
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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, United Kingdom; Emergency Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, United Kingdom.
| | - 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, United Kingdom.
| | - 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, United Kingdom.
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, United Kingdom.
| | - 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, United Kingdom.
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15
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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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