A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial

Sex and gender reporting in UK emergency medicine trials from 2010 to 2023: a systematic review

BACKGROUND

Female participants are underrepresented in randomised control trials conducted in urgent care settings. Although sex and gender are frequently reported within demographic data, it is less common for primary outcomes to be disaggregated by sex or gender. The aim of this review is to report sex and gender of participants in the primary papers published on research listed on the National Institute of Health and Care Research (NIHR) Trauma and Emergency Care (TEC) portfolio and how these data are presented.

METHODS

This is a systematic review of the published outputs of interventional trials conducted in UK EDs. Interventional trials were eligible to be included in the review if they were registered on the NIHR TEC research portfolio from January 2010, if the primary paper was published before 31 December 2023 and if the research was delivered primarily in the ED. Trials were identified through the NIHR open data platform and the primary papers were identified through specific searches using MedLine, EMBASE and PubMed. The primary objective of the review is to quantify the proportion of sex-disaggregated or gender-disaggregated primary outcomes in clinical trials within UK emergency medicine.

RESULTS

The initial search revealed 169 registered research projects on the NIHR TEC portfolio during the study period, of which 24 met the inclusion criteria. Overall, 76 719 participants were included, of which 31 374 (40%) were female. Only one trial (CRYOSTAT-2) reported a sex-disaggregated analysis of the effect of the intervention on either primary or secondary outcomes, and no sex-based difference in treatment effect was detected.

CONCLUSIONS

Fewer females than males were included in TEC trials from 2010 to 2023. One trial reported the primary outcome stratified by sex. There is significant scope to increase the scientific value of TEC trials to females by funders.

Blunt mechanism chest wall injury: initial patient assessment and acute care priorities

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.

Analgesia for rib fractures: a narrative review

PURPOSE

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.

SOURCE

Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.

PRINCIPAL FINDINGS

Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.

CONCLUSION

Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

The first hour of trauma reception is critical for patients with major thoracic trauma: A retrospective analysis from the TraumaRegister DGU

BACKGROUND

Up to 25% of trauma deaths are related to thoracic injuries.

OBJECTIVE

The primary goal was to analyse the incidence and time distribution of death in adult patients with major thoracic injuries. The secondary goal was to determine if potentially preventable deaths occurred within this time distribution and, if so, identify an associated therapeutic window.

DESIGN

Retrospective observational analysis.

SETTING

TraumaRegister DGU.

PATIENTS

Major thoracic injury was defined as an Abbreviated Injury Scale (AIS) 3 or greater. Patients with severe head injury (AIS ≥ 4) or injuries to other body regions with AIS being greater than the thoracic injury (AIS other >AIS thorax) were excluded to ensure that the most severe injury described was primarily thoracic related.

MAIN OUTCOME MEASURES

Incidence and time distribution of mortality were considered the primary outcome measures. Patient and clinical characteristics and resuscitative interventions were analysed in relation to the time distribution of death.

RESULTS

Among adult major trauma cases with direct admission from the accident scene, 45% had thoracic injuries and overall mortality was 9.3%. In those with major thoracic trauma ( n  = 24 332) mortality was 5.9% ( n  = 1437). About 25% of these deaths occurred within the first hour after admission and 48% within the first day. No peak in late mortality was seen. The highest incidences of hypoxia and shock were seen in non-survivors with immediate death within 1 h and early death (1 to 6 h). These groups received the largest number of resuscitative interventions. Haemorrhage was the leading cause of death in these groups, whereas organ failure was the leading cause of death amongst those who survived the first 6 h after admission.

CONCLUSION

About half of adult major trauma cases had thoracic injuries. In non-survivors with primarily major thoracic trauma, most deaths occurred immediately (<1h) or within the first 6 h after injury. Further research should analyse if improvements in trauma resuscitation performed within this time frame will reduce preventable deaths.

TRIAL REGISTRATION

The present study is reported within the publication guidelines of the TraumaRegister DGU® and registered as TR-DGU project ID 2020-022.

A retrospective validation study of the STUMBL score for emergency department patients with blunt thoracic trauma

INTRODUCTION

Blunt thoracic trauma (BTT) is a leading cause of emergency department (ED) trauma-related attendance. Risk prediction tools are commonly to predict patients' outcomes and assign them to the most appropriate care setting. The STUMBL score is a prognostic model for BTT, derived and validated in the United Kingdom; items comprising the score are age, number of rib fractures, use of pre-injury anticoagulants, chronic lung disease and oxygen saturation levels. This study's aim was to validate the STUMBL score in an Italian ED.

METHODS

This single-centre retrospective validation study was conducted in the ED of Santa Croce and Carle hub hospital in Cuneo, north-western Italy. All patients with an ED attendance for isolated BTT from 2018 to 2021 were included. Exclusion criteria were an age of under eighteen and the presence of any immediately life-threatening lesion. The primary outcome was the development of trauma-related complications, defined by the occurrence of one or more of the following: in-hospital mortality, pulmonary complications (infection, pleural effusion, haemothorax, pneumothorax, pleural empyema), need for intensive care unit admission, hospital length of stay equal to or greater than seven days. The performance of the STUMBL score was analysed in terms of discrimination with the evaluation of the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow test and with the calibration belt.

RESULTS

745 patients were enroled (median age 64 [25th;75th percentile: 50;78], male/female ratio 1:4, median Charlson comorbidity index 2 [1;4], median STUMBL score 11 [6;17]). 65.2% of patients were discharged home after ED evaluation. 203 patients (27.2%) developed the primary outcome. The STUMBL score was significantly different in patients with complications compared to those without complications (9 [5;13] vs 21 [17;25], p < 0.001). The C index of the score for the primary outcome was 0.90 (95% CI 0.88-0.93), and the result of the Hosmer-Lemeshow test was 9.01 (p = 0.34). STUMBL score = 16 has a sensitivity of 0.80 (95% CI 0.75-0.85), specificity of 0.87 (95% CI 0.84-0.90), a positive predictive value of 0.70 (95% CI 0.64-0.76), and a negative predictive value of 0.92 (95% CI 0.90-0.94).

CONCLUSION

In this validation study, the STUMBL score demonstrated excellent discrimination and calibration in predicting the outcome of patients attending the ED with a BTT.

Implementation of a chest injury pathway in the emergency department

Rib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long-standing consequences, such as reduced functional capabilities and loss of employment. Over recent years, there has been an increase in the awareness of the importance of early identification, aggressive pain management and adequate safety netting for patients with chest injuries. Substandard management leads to increased rates of morbidity and mortality. The development of protocols in the emergency department (ED) for management of patients with chest wall injuries has demonstrated reduction of complication rates.

Our aim was to develop an evidence-based, multidisciplinary chest injury pathway for the management of patients presenting with rib injury to our ED.

Prior to implementation of the pathway in our department, only 39% of patients were documented as having received analgesia and only 7% of discharged patients had documented written verbal advice. There was no standardised method to perform regional anaesthetic blocks. Using quality improvement methods, we standardised imaging modality, risk stratification with a scoring system, analgesia with emphasis on regional anaesthesia blocks and disposition with information leaflets for those discharged.

Implementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional anaesthetic blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. Compliance of doctors and nurses with the pathway was 63%.

Our previous audits showed substandard management of patients with chest injuries in our department. Through this quality improvement project, we were able to improve the quality of care provided to patients attending with rib fractures by increasing rate of analgesia received, regional blocks performed and discharge advice given.

Early exercise in blunt chest wall trauma: protocol for a mixed-methods, multicentre, parallel randomised controlled trial (ELECT2 trial)

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.

Building consensus on inpatient discharge pathway components in the management of blunt thoracic injuries: An e-Delphi study amongst an international professional expert panel

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.

EarLy Exercise in blunt Chest wall Trauma: a feasibility trial (ELECT Trial)

BACKGROUND

The aim was to complete a feasibility study that would test the methods of the main trial, that will investigate whether early thoracic and shoulder girdle exercises reduce chronic pain in patients with blunt chest wall trauma, when compared with normal care.

METHODS

A single centre, parallel, feasibility randomised controlled trial was completed at a University Teaching Hospital in Wales between June and September 2019. Adult patients with blunt chest wall trauma, admitted to hospital for greater than 24 hours, with no concurrent, immediately life-threatening injuries, were included. The intervention was a simple physiotherapy programme comprising thoracic and shoulder girdle exercises. Feasibility outcome measures included: primary outcomes: (1) 80% or more of identified eligible patients were approached for potential recruitment to the trial (2) 30% or less of approached, eligible patients dissented to participate in the trial; secondary outcomes: (3) follow-up data for patient secondary outcomes can be collected for 80% or more of patients, (4) there should be no greater than 10% increase in serious adverse events in the intervention group compared with the control group.

RESULTS

A total of 19/19 (100%) patients were deemed eligible for the trial and were approached for participation, 5/19 (26%) eligible patients declined to participate in the trial, follow-up data were collected for n=10/14 (71%) patients and there were no serious adverse events reported in either group.

CONCLUSIONS

We have demonstrated that a fully powered randomised clinical trial of the EarLy Exercise in blunt Chest wall Trauma Trial is feasible.

TRIAL REGISTRATION NUMBER

ISRCTN16197429.

Prognostic prediction tools and clinician communication: a qualitative study of the effect of the STUMBL tool on clinical practice

BACKGROUND

In recent years, researchers and clinicians have been developing prognostic prediction tools (PPTs) as a way of identifying patients at risk of deterioration. The use of PPTs in the clinical environment not only impacts the risk of adverse outcomes for patients, but the use of these tools also effect clinical practice. Much attention has been paid to the clinical performance of PPTs. But more insight is needed on how the use of PPTs impacts clinical practice. The objective of this study was to map some of the ways in which PPTs effect clinical practice. The STUMBL (STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients) feasibility trial evaluated the use of a new prognostic prediction tool (PPT) to guide the management blunt chest wall trauma patients in the emergency departments (ED). The trial was undertaken between October 2016 and September 2018 and conducted at four sites in England and Wales. Nested within the feasibility trial was a qualitative study aimed at understanding how ED clinicians experienced and used the PPT. The qualitative methods included a focus group and telephone interviews with 9 ED clinicians. This study focused on participant perceptions of the feasibility and use of the STUMBL tool on clinical practice in the ED.

RESULTS

Clinical practice is reshaped as a result of the introduction of the STUMBL PPT into the clinical environment. The PPT enhanced reflexive awareness of prognostic practice; facilitated communication between patients and professionals; helps to guide patient outcomes; and provides a common ground for clinician discussion on prognostication.

CONCLUSIONS

The qualitative data collected offered useful insights into the ways in which the tool changes clinical practice. This was a small study of the effect of one kind of PPT on clinical practice. Nevertheless, this study maps areas in which clinical practice is affected by the introduction of a PPT into the clinical environment. More research is needed to better understand these effects, and to understand how these tools become embedded in clinical practice over the longer term.