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Chen C, Sehgal A, Battle C, Hardman J, Ollivere B, Hewson DW. Acute management of adults following chest wall injury: An assessment of institutional clinical practice guidelines across the UK and synthesis of care recommendations. Injury 2024:112077. [PMID: 39665971 DOI: 10.1016/j.injury.2024.112077] [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: 09/21/2024] [Revised: 11/26/2024] [Accepted: 12/03/2024] [Indexed: 12/13/2024]
Abstract
OBJECTIVE Chest wall injury causes significant morbidity and mortality. There is uncertainty regarding many aspects of clinical care for these patients, including optimal analgesia, acuity of monitoring and surgical fixation. Our aim in this work is to [1] objectively appraise the quality and extent of heterogeneity in UK major trauma centre (MTC) clinical practice guidelines regarding the management of chest wall injury; and [2] narratively summarise clinical and care process recommendations from these guidelines to provide a comparative description of recommendations between institutions. METHODS All major trauma centres in England and Wales were contacted for their institutional clinical practice guidelines relevant to chest wall injury. A literature search was executed seeking eligible supra-regional, national or international consensus documents or guidelines to serve as reference standards. Interrogation of the reference standard guidelines was performed to identify key clinical and care processes against which two blinded assessors judged the clinical validity of institutional clinical practice guidelines as part of the Appraisal of Guidelines for Research & Evaluation II Global Rating Scale (AGREE II-GRS) tool. RESULTS We received 17 institutional clinical practice guidelines and identified themes of care from seven reference standards identified during our literature search. Four institutional clinical practice guidelines were assessed as high-quality by pre-specified AGREE II-GRS criteria. Guidelines scored highly for the quality of their presentation of information (median (interquartile range [IQR]) AGREE II-GRS Item5 score 5 (4.5-5.5)); however, the quality of guideline development methodology and the guideline completeness in comprehensively addressing the needs of this population was generally poor (median (IQR) AGREE II-GRS Item1 methodology score 2.92 (2.33-5.25); AGREE II-GRS Item3 completeness score 2.63 (1.75-5.25) respectively). CONCLUSIONS This work highlights the paucity of high-quality local clinical practice guidelines to inform the management of adults with chest wall injury admitted to UK MTCs. Although some degree of variation between local guidelines is acceptable, we have identified substantial heterogeneity in the clinical care recommendations between institutions.
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Affiliation(s)
- Caleb Chen
- Department of General Surgery, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Lincoln LN2 5QY, UK
| | - Apurv Sehgal
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 6NL, UK
| | - Jonathan Hardman
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Benjamin Ollivere
- Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK; Department of Trauma and Orthopaedic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - David W Hewson
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK.
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Battle C, Driscoll T, Fitzsimmons D, Harris S, Lecky F, O'Neill C, Watkins A, Barnett J, Davies S, Hutchings HA. EarLy Exercise in blunt Chest wall Trauma: A multi-centre, parallel randomised controlled trial (ELECT2 Trial). Injury 2024:112075. [PMID: 39674711 DOI: 10.1016/j.injury.2024.112075] [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: 05/13/2024] [Revised: 11/01/2024] [Accepted: 11/29/2024] [Indexed: 12/16/2024]
Abstract
INTRODUCTION The aim of this trial was to investigate the impact of early thoracic and shoulder girdle exercises on chronic pain and Health-Related Quality of Life in patients with blunt chest wall trauma, when compared to normal care. METHODS A multi-centre, parallel, randomised controlled trial, in which adult patients presenting to hospital with blunt chest wall trauma were allocated to either control or intervention group. The intervention was an exercise programme consisting of four simple thoracic and shoulder girdle exercises, completed for one week. Outcomes measures included prevalence and severity of chronic pain using the Brief Pain Inventory, health-related quality of life using EQ-5D-5 L, and cost effectiveness, measured at initial presentation and three months post-injury. RESULTS 360 participants were recruited. Participants' mean age was 63.6 years (standard deviation (SD): 17.9 years) and 213 (59.8 %) were men. After loss-to-follow-up, the survey response rate at three months was 73.0 % (251/344 participants). The primary analysis, for chronic pain prevalence at three months post-injury, found no statistically significant differences between intervention and control groups, with lower rates in the control (intervention: 35/126 (27.8 %), control: 20/117 (17.1 %); adjusted odds ratio 1.862; 95 % CI: 0.892 to 3.893, p = 0.098). There were no statistically significant differences between intervention and control groups for pain severity at three months post-injury, (intervention mean (SD): 2.15 (2.49), control: 1.81 (2.10); adjusted difference 0.196, 95 % CI:0.340 to 0.731; p = 0.473); or Health-Related Quality of Life (intervention mean (SD): 0.715 (0.291), control: 0.704 (0.265); adjusted difference: 0.030; 95 % CI:0.033 to 0.094; p = 0.350). The health economic analysis found the intervention was associated with higher costs compared to normal care. CONCLUSION The results of this trial did not support a 'one-size fits all' simple, early exercise programme for patients with blunt chest wall trauma. Future research should consider the impact of a personalised exercise programme, commenced by the patient at least one week post-injury.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Dept, Morriston Hospital, Swansea, Wales, UK; Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK.
| | - Timothy Driscoll
- Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK.
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, Faculty of Medicine, Health and Lifesciences, Swansea University, UK.
| | - Shaun Harris
- Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK; Swansea Centre for Health Economics, Faculty of Medicine, Health and Lifesciences, Swansea University, UK
| | - Fiona Lecky
- School of Health and Related Research, Sheffield University, UK; Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.
| | - Claire O'Neill
- Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK.
| | - Alan Watkins
- Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK.
| | - Jane Barnett
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Western Avenue, Cardiff, UK.
| | - Susan Davies
- Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK.
| | - Hayley Anne Hutchings
- Swansea Trials Unit. Swansea University Medical School, Swansea University, Swansea, UK.
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Battle C, Cole E, Carter K, Baker E. Clinical prediction models for the management of blunt chest trauma in the emergency department: a systematic review. BMC Emerg Med 2024; 24:189. [PMID: 39395934 PMCID: PMC11470733 DOI: 10.1186/s12873-024-01107-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Accepted: 10/08/2024] [Indexed: 10/14/2024] Open
Abstract
BACKGROUND The aim of this systematic review was to investigate how clinical prediction models compare in terms of their methodological development, validation, and predictive capabilities, for patients with blunt chest trauma presenting to the Emergency Department. METHODS A systematic review was conducted across databases from 1st Jan 2000 until 1st April 2024. Studies were categorised into three types of multivariable prediction research and data extracted regarding methodological issues and the predictive capabilities of each model. Risk of bias and applicability were assessed. RESULTS 41 studies were included that discussed 22 different models. The most commonly observed study design was a single-centre, retrospective, chart review. The most widely externally validated clinical prediction models with moderate to good discrimination were the Thoracic Trauma Severity Score and the STUMBL Score. DISCUSSION This review demonstrates that the predictive ability of some of the existing clinical prediction models is acceptable, but high risk of bias and lack of subsequent external validation limits the extensive application of the models. The Thoracic Trauma Severity Score and STUMBL Score demonstrate better predictive accuracy in both development and external validation studies than the other models, but require recalibration and / or update and evaluation of their clinical and cost effectiveness. REVIEW REGISTRATION PROSPERO database ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=351638 ).
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Affiliation(s)
- Ceri Battle
- Physiotherapy Dept, Morriston Hospital, Swansea Bay University Health Board, Swansea, Wales, SA6 6NL, UK.
- Swansea Trials Unit, Swansea University Medical School, Swansea University, Swansea, UK.
| | - Elaine Cole
- Centre of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Kym Carter
- Swansea Trials Unit, Swansea University Medical School, Swansea University, Swansea, UK
| | - Edward Baker
- Emergency Dept, Kings College Hospital, London, UK
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Battle C, O'Neill M, Barnett J, Hutchings H, Uzzell B, Toghill H, O'Neill C. Patient and clinician perceptions of blunt chest trauma management and recovery: a qualitative study. Disabil Rehabil 2024:1-7. [PMID: 38738835 DOI: 10.1080/09638288.2024.2353246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/04/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE To explore patient and clinician perceptions of blunt chest trauma management and recovery, when discharged directly home from the Emergency Department (ED). METHODS This was a qualitative study, completed in a trauma unit in Wales. Blunt chest trauma was defined as an isolated blunt injury to the chest wall, resulting in bruising or rib fractures. Data collection involved semi-structured telephone interviews and focus groups with patients and clinicians respectively. Data analysis was completed using reflexive thematic coding. RESULTS Twelve patient interviews and three focus groups (23 clinicians) were conducted. In the interviews, seven males and five females participated, with a mean age of 54 years (range 28-74). Clinicians included nurses, doctors, and therapists. Two main themes emerged; 1) the ED experience and 2) recovery once home; each with a number of sub-themes. Results highlighted the significant impact of pain on recovery, and that there is a disjuncture between organisational perspectives of clinicians, and the individual personal perspective of patients. DISCUSSION Recovery from blunt chest trauma for patients discharged directly home from the ED is a challenging and complex process. Protocol-driven care does not always lead to good patient experience, as it focuses primarily on hospital services and resources.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, UK
| | - Martin O'Neill
- Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK
| | - Jane Barnett
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | | | - Bethan Uzzell
- Physiotherapy Department, Morriston Hospital, Swansea, UK
| | - Hannah Toghill
- Physiotherapy Department, Morriston Hospital, Swansea, UK
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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; 54:110796. [PMID: 37208252 DOI: 10.1016/j.injury.2023.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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Battle C, Carter K, Newey L, Giamello JD, Melchio R, Hutchings H. Risk factors that predict mortality in patients with blunt chest wall trauma: an updated systematic review and meta-analysis. Emerg Med J 2023; 40:369-378. [PMID: 36241371 DOI: 10.1136/emermed-2021-212184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 10/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Over the last 10 years, research has highlighted emerging potential risk factors for poor outcomes following blunt chest wall trauma. The aim was to update a previous systematic review and meta-analysis of the risk factors for mortality in blunt chest wall trauma patients. METHODS A systematic review of English and non-English articles using MEDLINE, Embase and Cochrane Library from January 2010 to March 2022 was completed. Broad search terms and inclusion criteria were used. All observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. Where sufficient data were available, ORs with 95% CIs were calculated using a Mantel-Haenszel method. Heterogeneity was assessed using the I2 statistic. RESULTS 73 studies were identified which were of variable quality (including 29 from original review). Identified risk factors for mortality following blunt chest wall trauma were: age 65 years or more (OR: 2.11; 95% CI 1.85 to 2.41), three or more rib fractures (OR: 1.96; 95% CI 1.69 to 2.26) and presence of pre-existing disease (OR: 2.86; 95% CI 1.34 to 6.09). Other new risk factors identified were: increasing Injury Severity Score, need for mechanical ventilation, extremes of body mass index and smoking status. Meta-analysis was not possible for these variables due to insufficient studies and high levels of heterogeneity. CONCLUSIONS The results of this updated review suggest that despite a change in demographics of trauma patients and subsequent emerging evidence over the last 10 years, the main risk factors for mortality in patients sustaining blunt chest wall trauma remained largely unchanged. A number of new risk factors however have been reported that need consideration when updating current risk prediction models used in the ED. PROSPERO REGISTRATION NUMBER CRD42021242063. Date registered: 29 March 2021. https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Kym Carter
- Swansea Trials Unit, Swansea University, Swansea, UK
| | - Luke Newey
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jacopo Davide Giamello
- School of Emergency Medicine, Università degli Studi di Torino Dipartimento di Scienze Mediche, Torino, Italy
- Department of Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Remo Melchio
- Department of Internal Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
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Battle C, Charnock A, Davies S, Davies S, Dawson T, Driscoll T, Evans PA, Fitzsimmons D, Harris S, Jones K, Lecky FE, O'Neill C, Prosser J, Toghill H, Watkins A, Hutchings HA. Early exercise in blunt chest wall trauma: protocol for a mixed-methods, multicentre, parallel randomised controlled trial (ELECT2 trial). BMJ Open 2022; 12:e060055. [PMID: 35393332 PMCID: PMC8991047 DOI: 10.1136/bmjopen-2021-060055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Chronic pain and disability are now well-recognised long-term complications of blunt chest wall trauma. Limited research exists regarding therapeutic interventions that can be used to address these complications. A recent feasibility study was completed testing the methods of a definitive trial. This protocol describes the proposed definitive trial, the aim of which is to investigate the impact of an early exercise programme on chronic pain and disability in patients with blunt chest wall trauma. METHODS/ANALYSIS This mixed-methods, multicentre, parallel randomised controlled trial will run in four hospitals in Wales and one in England over 12-month recruitment period. Patients will be randomised to either the control group (routine physiotherapy input) or the intervention group (routine physiotherapy input plus a simple exercise programme completed individually by the patient). Baseline measurements including completion of two surveys (Brief Pain Inventory and EuroQol 5-dimensions, 5-Levels) will be obtained on initial assessment. These measures and a client services receipt inventory will be repeated at 3-month postinjury. Analysis of outcomes will focus on rate and severity of chronic pain and disability, cost-effectiveness and acceptability of the programme by patients and clinicians. Qualitative feedback regarding acceptability will be obtained through patient and clinician focus groups. ETHICS/DISSEMINATION London Riverside Research Ethics Committee (Reference number: 21/LO/0782) and the Health Research Authority granted approval for the trial in December 2021. Patient recruitment will commence in February 2022. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at professional meetings. TRIAL REGISTRATION NUMBER ISRCTN65829737; Pre-results.
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Affiliation(s)
- Ceri Battle
- Welsh Institute of Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK
| | - Amy Charnock
- Physiotherapy Dept, Wrexham Maelor Hospital, Wrexham, UK
| | - Sara Davies
- Physiotherapy Dept, Llanfrechfa Grange Hospital, Cwmbran, UK
| | - Susan Davies
- (PPI rep) Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Thomas Dawson
- Physiotherapy Dept, Salford Royal Hospital, Salford, UK
| | - Timothy Driscoll
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Phillip A Evans
- Welsh Institute of Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, Faculty of Medicine, Health and Lifesciences, Swansea University, Swansea, UK
| | - Shaun Harris
- Swansea Centre for Health Economics, Faculty of Medicine, Health and Lifesciences, Swansea University, Swansea, UK
| | - Kate Jones
- Physiotherapy Dept, University of Wales Cardiff, Cardiff, UK
| | - Fiona Elizabeth Lecky
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- Salford Royal Hospitals NHS Trust, Salford, UK
| | - Claire O'Neill
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Joanne Prosser
- (PPI rep) Physiotherapy Dept, Princess of Wales Hospital, Bridgend, UK
| | | | - Alan Watkins
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
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