Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients involving dedicated early rehabilitation intervention programs: design of a prospective, multi-centre, non-randomised clinical trial

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

Patient experiences of rehabilitation following traumatic complex musculoskeletal injury – A mixed methods pilot study

Introduction

The aim of this pilot study was to measure patient reported outcomes and evaluate their rehabilitation experience following traumatic complex musculoskeletal (CMSK) injury.

Methods

A mixed methods prospective observational study was undertaken between December 2015 and March 2018 to explore patient reported outcomes following CMSK injury sustained as a result of major trauma and perception of their rehabilitation and its impact on their recovery. The participants were asked to complete a series of outcome measures at 18-months post-injury. The data was anonymised and analysed by the lead researcher.

Results

Thirty patients were recruited into the study (19 males, 11 females) between 23 and 76 years of age (median 52 years). Their injury profile was split between open fractures 30%, pelvic fractures 23%, multiple fractures 27% and polytrauma 20%. The majority (60%) reported moderate disability at 18-months post injury with 50% returning to full time employment. Patients with multiple or open fractures reported the worst outcomes. There was no relationship between frequency, quantity or duration of physiotherapy and outcome. However, 77% reported supplementing their NHS rehabilitation with other interventions such as gym membership, hydrotherapy and psychological therapies. The thematic analysis showed that patients considered intensity, quality and coordinated timely access to rehabilitation as the most important factors.

Conclusion

From a patient perspective, the current NHS rehabilitation provision does not appear to meet their complex needs. In addition to physical and vocational rehabilitation, patients wanted effective pain management and psychological support. Strengthening current therapy services and involving other sectors (e.g. Citizen’s Advice) could help achieve this. Early access to an intensive multidisciplinary rehabilitation programme was perceived to have positive benefits and improve outcomes.

[Care Management for Polytrauma Patients in a Level-1 Trauma Centre]

Care Management for Polytrauma Patients in a Level-1 Trauma Centre Abstract. In our level-1 trauma institution, polytrauma patients with an Injury Severity Score of 16 or higher are facing waiting times for transfer to a rehabilitation facility, causing a negative financial outcome for our institution. The purpose of this study is to stimulate rapid transfer to a rehabilitation facility. In a single-centre case study, care management for (poly)trauma patients was started to ensure time-directed treatment for trauma patients related to Diagnosis-Related Groups (DRG). In the period of 2013-2018 there was an increase in trauma admissions up to 14 % (n = 16 157) with a mean length of hospital stay of 6.4 days, together with a reduction in the number of trauma bed capacity from 50 to 42. In relation to the DRGs, regular trauma patients who were not in need of a stationary rehabilitation facility stayed in line with the expected time of hospital stay. But (poly)trauma patients (n = 1831) with the need of a stationary stay in a rehabilitation centre were faced with waiting times before they could be transferred. The average excess waiting time in relation to DRG for polytrauma patients was 5.1 days. Trauma patients for a rehabilitation centre have a higher Case Mix Index (CMI) compared to those who do not require inpatient rehabilitation (4.22 versus 1.04, p <0.0001). With about 280 trauma patients annually waiting an extra 5.1 days for transfer to a rehabilitation facility, the financial burden for our department amounts to Swiss francs 885,360 without reimbursement. Since no extra bed capacities in rehabilitation facilities are available in our area, it may be advised to set up an early in-hospital trauma rehabilitation program in a level-1 trauma centre in order to reduce financial loss.

Toward overcoming physical disability in spinal cord injury: a qualitative inquiry of the experiences of injured individuals and their families

Background

Spinal cord injury (SCI) is a life-changing experience for the individuals with SCI and their families. This study aimed to investigate physical strategies used for overcoming physical disability in individuals with SCI.

Methods

In this qualitative study, 17 SCI persons and 13 family caregivers were selected by a purposeful sampling. Settings of the study were Brain and SCI research (BASIR) center of Tehran University of Medical Sciences and Southern Social Welfare Center of Tehran and SCI Association of Tehran, Iran. Data were collected by face-to-face semi-structured interviews, which were continued until data saturation. The gathered data were concurrently analyzed by the content analysis method.

Results

The data analysis revealed one main theme (towards overcoming physical disability) and three sub-themes: 1) physical rehabilitation by various methods; 2) tendency towards the use of alternative medical methods; and 3) making effort for self-reliance.

Conclusion

The participants used physiotherapy and occupational therapy as an effective and essential approach offered by the healthcare team. Some individuals with SCI with help of their family had invented simple rehabilitation equipment for help to their physical rehabilitation. However, most participants had referred to different complimentary medicine specialists based on advice friends and relatives and they often had spent a lot of time and money ineffectively. Therefore, they need training and support of the healthcare team as well as social support to achieve physical independence and physical recovery. Further research is suggested to investigate the barriers to achieving physical empowerment in people with SCI in Iran.

Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients: A non-randomized clinical trial in the Netherlands

Background

Multidisciplinary rehabilitation has been recommended for multi-trauma patients, but there is only low-quality evidence to support its use with these patients. This study examined whether a Supported Fast track multi-Trauma Rehabilitation Service (Fast Track) was cost-effective compared to conventional trauma rehabilitation service (Care As Usual) in patients with multi-trauma from a societal perspective with a one-year follow-up.

Methods

An economic evaluation alongside a prospective, multi-center, non-randomized, controlled clinical study, was conducted in the Netherlands. The primary outcome measure was the Functional Independence Measure (FIM). Generic Quality of Life and Quality Adjusted Life Years (QALYs) of the patients were derived using the Short-form 36 Health Status Questionnaire.

Incremental Cost-Effectiveness Ratios (ICERs) were stated in terms of costs per unit of FIM improvement and costs per QALY. To investigate the uncertainty around the ICERs, non-parametric bootstrapping was used.

Results

In total, 132 patients participated, 65 Fast Track patients and 67 Care As Usual patients. Mean total costs per person were €18,918 higher in the Fast Track group than in the Care As Usual group. Average incremental effects on the FIM were 3.7 points (in favor of the Fast Track group) and the incremental (extra) bootstrapped costs were €19,033, resulting in an ICER for cost per FIM improvement of €5,177. Care As Usual dominated Fast Track in cost per QALY as it gave both higher QALYs and lower costs. All sensitivity analyses attested to the robustness of our results.

Conclusions

This study demonstrated that a multidisciplinary rehabilitation program for multi-trauma patients according to the supported fast track principle is promising but cost-effectiveness evidence remains inconclusive. In terms of functional outcome, Fast Track was more expensive but yielded also more effects compared to the Care As Usual group. Looking at the costs per QALYs, unfavorable ICERs were found. Given the lack of a willingness-to-pay threshold for functional recovery and the relatively short time horizon, it is not possible to draw firm conclusions about the first.

Trial registration

(Current Controlled Trials register: ISRCTN68246661).

All-terrain vehicle-related injuries and deaths in Newfoundland and Labrador between 2003 and 2013: a retrospective trauma registry review

BACKGROUND

Injury and death involving all-terrain vehicles (ATV) has been reported in a number of Canadian provinces. The objective of this study is to describe the frequency, nature, severity, population affected, immediate health costs, efficacy of related legislation, and helmet use in ATV related injuries and deaths in Newfoundland and Labrador (NL).

METHODS

A retrospective review of injured or deceased ATV riders of all ages entered in the Newfoundland and Labrador Trauma Registry from 2003 to 2013 was conducted. Variables studied included demographics, injury type and severity, use of helmets, admission/discharge dates, and referring/receiving institution. Data was also obtained from the Newfoundland and Labrador Center for Health Information (NLCHI) and included all in-hospital deaths and hospitalizations due to ATVs between 1995 and 2013.

RESULTS

There were a total of 298 patients registered in the trauma registry, resulting in 2759 admission days, nine deaths, and a total estimated immediate healthcare system cost in excess of $1.6 million. More males (N=253, 84.9%) than females (N=45, 15.1%) were injured in ATV related incidents, t(20)=7.12, p<.0001. Head and thorax injuries were the most serious. 38.6% of patients were confirmed to be wearing helmets. Mean injury severity scores are as follows: head injury (M=11, SD=9.51), thorax (M=10, SD=8.3), abdominal/pelvis (M=9, SD=7.62), upper extremity (M=9, SD=8.53), other injuries (M=9, SD=10.56) lower extremity (M=8, SD=8.34), and spine (M=8, SD=6.52).

CONCLUSIONS

This study describes ATV related injuries and deaths in NL. Information from this study may guide physician practice, public education, and future legislation.

Effects of an Integrated 'Fast Track' Rehabilitation Service for Multi-Trauma Patients: A Non-Randomized Clinical Trial in the Netherlands

Objectives

The effects on health related outcomes of a newly-developed rehabilitation program, called ‘supported Fast Track multi-trauma rehabilitation service’ (Fast Track), were evaluated in comparison with conventional trauma rehabilitation service (Care as Usual).

Methods

Prospective, multi-center, non-randomized controlled study. Between 2009 and 2012, 132 adult multi-trauma patients were included: 65 Fast Track and 67 Care as Usual patients with an Injury Severity Score ≥16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. The Fast Track program involved: integrated coordination between trauma surgeon and rehabilitation physician, shorter stay in hospital with faster transfer to a specialized trauma rehabilitation unit, earlier start of multidisciplinary treatment and ‘non-weight bearing’ mobilization. Primary outcomes were functional status (FIM) and quality of life (SF-36) measured through questionnaires at baseline, 3, 6, 9 and 12 months post-trauma. Outcomes were analyzed using a linear mixed-effects regression model.

Results

The FIM scores significantly increased between 0 and 3 months (p<0.001) for both groups showing that they had improved overall, and continued to improve between 3 and 6 months for Fast Track (p = 0.04) and between 3 and 9 months for Care as Usual (p = 0.03). SF-36 scores significantly improved in both groups between 3 and 6 months (Fast Track, p<0.001; Care as Usual, p = 0.01). At 12 months, SF-36 scores were still below (self-reported) baseline measurements of patient health prior to the accident. However, the FIM and SF-36 scores differed little between the groups at any of the measured time points.

Conclusion

Both Fast Track and Care as Usual rehabilitation programs were effective in that multi-trauma patients improved their functional status and quality of life. A faster (maximum) recovery in functional status was observed for Fast Track at 6 months compared to 9 months for Care as Usual. At twelve months follow-up no differential effects between treatment conditions were found.

Trial Registration

ISRCTN68246661

The injury trajectory for young people 16-24 years in the six months following injury: A mixed methods study

BACKGROUND

Adolescents and young people are the population at greatest risk of injury and therefore injury-related mortality and morbidity. Inquiry into the injury trajectory of young people is needed to identify this group's specific needs for healthcare. This paper reports the integration of quantitative and qualitative findings from a sequential explanatory mixed methods study examining young people aged 16-24 years' experience and trajectory of traumatic physical injury in the initial six months. The aim of integration was to address the question: In what ways are injured young peoples' experiences and self-management during the initial six months of the injury trajectory impacted by their injury, family support, and provision of healthcare?

METHODS

Key findings from epidemiological datasets on young person injuries from hospital and coronial databases (Phase 1) were combined with key findings from qualitative interviews with 12 injured young people and 10 family members (Phase 2).

RESULTS

The integration of findings from Phase 1 and Phase 2 resulted in three new findings; [1] (Alfred Health, 2014). A young person's perception of the severity of their injury, as well as the amount of time spent in hospital, impacts substantially on the way in which they experience injury, and this is managed differently between genders; [2] (Newnam et al., 2014). Admission to an Intensive care unit, including the intensity and duration of care, is the primary influence on how a family will provide support to the young person in the inpatient period; and [3] (Lyons et al., 2010). Young people's perception and understanding of their recovery from injury is in contrast with how healthcare systems are structured to provide rehabilitation and recovery care.

CONCLUSION

The injury trajectory and recovery process of young people in the six months following injury have been have conceptualised. These trajectories of recovery can inform the development of anticipatory guidance frameworks for clinicians and guide the provision of and planning for clinical services for injured young people.

Orthopaedic nursing challenges in poly-traumatised patient management: A critical analysis of an Orthopaedic and Trauma Unit

INTRODUCTION AND BACKGROUND

Trauma is the most frequent cause of death in people under 40 years old. It is an important problem not only because of the high mortality but also because of the consequential disability that can lead to serious economic consequences.

STUDY AIMS

This descriptive, comparative study investigates the definitive management of poly-traumatised patients in an Italian Orthopaedic Ward in order to highlight its strengths and weaknesses in comparison with the most recent literature. This has led to the development of a pre-established algorithm for evaluation, preventive care and management of the poly-trauma patient and a flow-chart for improved patient care.

RESEARCH METHODS

A five-step observational and exploratory approach was employed in this study which critically analysed the nursing management of 60 multiple trauma patients admitted to our Orthopaedic Unit from April 2013 to October 2014.

RESULTS

The findings highlight the need for adherence to plans of care, which can be approached by a shared management of poly-trauma patients that involves the medical team, the patient and his family/caregiver.

DISCUSSION

The protocols and guidelines in use in our Orthopaedic and Trauma Unit are in line with European standards, although there is still margin for improvement. The study has led to the development of an algorithm that allows health professionals to have reference values for the care of polytrauma patients.

CONCLUSIONS AND RECOMMENDATIONS

This study demonstrates the use of theoretical and practical tools for the evaluation and management of poly-traumatised patients during their hospital stay. We recommend the use of both proposed tools: the general algorithm and the flow-chart for the management of the poly-trauma patient, as they allow identification of barriers and facilitators related to the implementation of international guidelines, currently well-defined for Emergency Departments but not yet for Orthopaedic Units.

Short- and long-term subjective medical treatment outcome of trauma surgery patients: the importance of physician empathy

PURPOSE

To investigate accident casualties' long-term subjective evaluation of treatment outcome 6 weeks and 12 months after discharge and its relation to the experienced surgeon's empathy during hospital treatment after trauma in consideration of patient-, injury-, and health-related factors. The long-term results are compared to the 6-week follow-up outcomes.

PATIENTS AND METHODS

Two hundred and seventeen surgery patients were surveyed at 6 weeks, and 206 patients at 12 months after discharge from the trauma surgical general ward. The subjective evaluation of medical treatment outcome was measured 6 weeks and 12 months after discharge with the respective scale from the Cologne Patient Questionnaire. Physician Empathy was assessed with the Consultation and Relational Empathy Measure. The correlation between physician empathy and control variables with the subjective evaluation of medical treatment outcome 12 months after discharge was identified by means of logistic regression analysis under control of sociodemographic and injury-related factors.

RESULTS

One hundred and thirty-six patients were included within the logistic regression analysis at the 12-month follow-up. Compared to the 6-week follow-up, the level of subjective evaluation of medical treatment outcome was slightly lower and the association with physician empathy was weaker. Compared to patients who rated the empathy of their surgeon lower than 31 points, patients with ratings of 41 points or higher had a 4.2-fold higher probability to be in the group with a better medical treatment outcome (3.5 and above) on the Cologne Patient Questionnaire scale 12 months after discharge from hospital (P=0.009, R (2)=33.5, 95% confidence interval: 1.440-12.629).

CONCLUSION

Physician empathy is the strongest predictor for a higher level of trauma patients' subjective evaluation of treatment outcome 6 weeks and 12 months after discharge from the hospital. Interpersonal factors between surgeons and their patients are possible key levers for improving patient outcomes in an advanced health system. Communication trainings for surgeons might prepare them to react appropriately to their patients' needs and lead to satisfactory outcomes for both parties.

Psychosocial recovery for children disabled in an earthquake: school social work in Dujiangyan, China

In the Sichuan earthquake on May 12, 2008, schools were hardest hit. The School Social Work service at the You Ai School of Dujiangyan became a major factor in assisting 140 children, disabled in the disaster, in their psychosocial recovery. This article aims to identify indicators of recovery for children from early primary to junior high. Content analysis is used instead of a lengthy psychological scale, as the latter might not be applicable for young children. Results show that disabled children are capable of recovery 3 years after the disaster. Effects of social work intervention and inclusive education have yet to be studied.

Measuring acute rehabilitation needs in trauma: preliminary evaluation of the Rehabilitation Complexity Scale

BACKGROUND

Injury severity, disability and care dependency are frequently used as surrogate measures for rehabilitation requirements following trauma. The true rehabilitation needs of patients may be different but there are no validated tools for the measurement of rehabilitation complexity in acute trauma care. The aim of the study was to evaluate the potential utility of the Rehabilitation Complexity Scale (RCS) version 2 in measuring acute rehabilitation needs in trauma patients.

METHODS

A prospective observation study of 103 patients with traumatic injuries in a Major Trauma Centre. Rehabilitation complexity was measured using the RCS and disability was measured using the Barthel Index. Demographic information and injury characteristics were obtained from the trauma database.

RESULTS

The RCS was closely correlated with injury severity (r=0.69, p<0.001) and the Barthel Index (r=0.91, p<0.001). However the Barthel was poor at discriminating between patients rehabilitation needs, especially for patients with higher injury severities. Of 58 patients classified as 'very dependent' by the Barthel, 21 (36%) had low or moderate rehabilitation complexity. The RCS correlated with acute hospital length of stay (r=0.64, p=<0.001) and patients with a low RCS were more likely to be discharged home. The Barthel which had a flooring effect (56% of patients classified as very dependent were discharged home) and lacked discrimination despite close statistical correlation.

CONCLUSION

The RCS outperformed the ISS and the Barthel in its ability to identify rehabilitation requirements in relation to injury severity, rehabilitation complexity, length of stay and discharge destination. The RCS is potentially a feasible and useful tool for the assessment of rehabilitation complexity in acute trauma care by providing specific measurement of patients' rehabilitation requirements. A larger longitudinal study is needed to evaluate the RCS in the assessment of patient need, service provision and trauma system performance.

Fast-track surgery: procedure-specific aspects and future direction

INTRODUCTION

Fast-track (FT) surgery can be defined as a coordinated perioperative approach aimed at reducing surgical stress and facilitating postoperative recovery. The objective of this review was to examine the literature on the procedure-specific application of FT surgery.

DISCUSSION

The concept of FT rehabilitation has been applied mainly in colorectal surgery, but positive data have appeared also in other areas such as orthopedic, hepatopancreaticobiliary, urological, upper gastrointestinal, gynecological, thoracic, vascular, endocrine, breast, and pediatric surgeries. There is very little experience with comprehensive FT programs in cardiac surgery or trauma. Quantitative analysis from randomized trials and cohort studies suggest that FT is effective in reducing hospital stay without increased adverse events. Other benefits of the FT approach include a reduction in complications, ileus, fatigue, pain, and hospital expenses. However, despite clear benefits of FT care, implementation in daily practice has been slow. Further efforts must be undertaken to secure implementation in routine clinical practice. Standardized FT protocols should be provided on a procedure-specific basis.

Rehabilitation needs of persons discharged from an African trauma center

BACKGROUND

The study prospectively assessed the functional impairments and rehabilitation needs of Africans admitted to a regional trauma center. It also acts as a pilot study to demonstrate the practical use of the Language Independent Functional Evaluation (L.I.F.E.) software in an acute hospital setting.

METHODS

A 5 page questionnaire was used to gather demographic data (age, sex, medical diagnosis, education, housing type, place of residency, occupation), cause of disability/injury, severity of disability or functional impairment, and rehabilitation treatment received (types of rehab, frequency of treatment, duration of therapy, follow up therapy, equipment). Functional status on discharge was evaluated with the L.I.F.E. scale.

RESULTS

84 consecutive consenting subjects were recorded. The predominant disability/injury of respondents involved the lower extremities (70%), followed by upper extremities (23%). The mechanisms of injury were largely related to auto accidents (69%). Falls made up 17% of these injuries and 14% were related to violence. Eleven subjects had disability measured using L.I.F.E and all were classified as having major disabilities. Only 14 patients (17%) received any rehabilitation therapy which consisted of only physical therapy provided at a frequency of once a day for less than one week duration.

CONCLUSION

This study found that most persons admitted to a sophisticated trauma unit in Ghana are discharged without adequate rehabilitation services, and that the level of disability experienced by these people can be measured, even while they are still sick and in the hospital, using L.I.F.E. The implications are clear: African trauma systems must measure the long term outcomes from their treatments and provide the inpatient medical rehabilitation services that are a standard of care for trauma victims elsewhere in the world.

International benchmarking of tertiary trauma centers: productivity and throughput approach

Background

Care process in tertiary trauma centers consists of a chain of care phases in different departments from the emergency department (ED) to post-operative rehabilitation. The historical evolution of healthcare systems and organizations has led to variations in trauma patient processes in different countries. The present study is aimed at revealing differences in the throughput and productivity of trauma patient processes between German (UKB) and Finnish (HUS) tertiary trauma centers. Problems related to the comparison of different healthcare systems were also identified. The share of patients discharged was used as a control measure.

Results

The biggest differences between the hospitals were found in the use of resources in the ED and in post-operative care. Despite problems in defining comparable patients and resources, ED productivity was significantly higher in UKB. Post-operative care was, on average, 41% shorter in HUS. However, the share of patients discharged was significantly higher in UKB (96.5% vs. 68.9%). Differences were also found in the pre-operative length of stay of patients with proximal femoral fractures (UKB: 0.97 days, HUS: 1.57 days). The productivity of the operating unit was quite similar in the hospitals. In terms of ED mortality, no statistically significant differences were found.

Conclusions

The results of the present study showed significant differences in the use of resources and throughput times in trauma patient processes between Finnish and German hospitals. However, due to system-level differences between German and Finnish healthcare, the results cannot be directly transformed into development proposals for the organizations. On the other hand, in spite of certain differences regarding the healthcare systems, the demographic data of the trauma patients and medical procedures are comparable. Based on the present study, the ED process of severe trauma, pre-operative care, and operating unit processes were the most comparable parts of trauma care between the hospitals. The study also showed that the international benchmarking approach could be used to reveal bottlenecks in system-level policies and practices.

[Fast track in casualty surgery]

The concept of "fast track" has not yet been established in orthopaedic trauma surgery. Principles such as those used in the "fast track" procedure for abdominal surgery have been employed in orthopaedic surgery for a long time. The best results can be achieved by early operative treatment, stable osteosynthesis and, if the soft tissues allow, an early initiation of mobilization under optimal pain management. Based on new techniques in osteosynthesis, in particular locked-screw techniques, "fast track" is also applicable for fragility fractures (osteoporosis), complex shattered bone and bone defect situations.