Award Title: Co-PaCT study: Development of Co-produced guidance for the care of Patients with blunt Chest wall Trauma: a mixed methods study
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Identifying patients with isolated blunt chest wall trauma (BCWT) who are at high risk of developing delayed complications is a well-recognised complex problem.[1] Morriston Hospital Emergency Department (ED) managed over 1100 patients with BCWT in 2018. Over 1000 of these patients were discharged directly from the ED, which reflects the high volume of patients who are expected to self- manage their injury at home. Of those discharged directly home, 848 patients were instructed to see their General Practitioner (GP) if they experienced problems. In our recent STUMBL Trial, 6% of all trial patients had an unplanned re-attendance at the ED with on-going problems, having been previously discharged home without hospital admission.[1] Decisions regarding care and service innovation primarily focus on efficiency (to reduce number of hospital admissions), rather than patient needs. In this study we propose to gain understanding of the patient experience of being managed at home, and to work with stakeholders to co-produce guidance aimed at improving care of the patient with BCWT.

Aim: To co-produce guidance for optimal care for patients with BCWT not requiring admission to hospital; based on current best practice, epidemiological data and stakeholder experience and opinions.
Research questions:
1)	What is current practice regarding guidance for the management of patients with BCWT who are not admitted to hospital?
2)	What is the epidemiology of patients with BCWT who are not admitted to hospital?
# Patient characteristics: age, severity of injury, pre-morbid history, risk factors for pulmonary complications.
# Management strategies: advice sheets and analgesia provided, provision of follow up.
# Outcomes – further ED or Minor Injuries Unit (MIU) contacts, primary care usage, hospital admissions, primary admission diagnosis (on re-attendance), length of stay and mortality
3)	What are the patient perspectives of non-admission to hospital?
# Patient perspectives on service provided and recovery from BCWT versus initial expectation # Current service models used in clinical decision-making, including follow-up provision
# Recommendations for inclusion in the co-produced guidance to improve care for patients with BCWT who are not admitted to hospital

Design: A mixed methods study using national anonymized linked routine data and qualitative methods in Swansea Bay University Health Board (SBUHB) (Morriston Hospital ED and Singleton and Neath Port Talbot Hospital MIUs).

Plan of investigation:
1.	Investigate current UK practice through a survey study, regarding management of BCWT guidance in the community setting
2.	Identify patients with BCWT through the Information Department based at Morriston Hospital (who are discharged home from the ED or MIU without hospital admission) and anonymously link to their NHS health data
3.	Conduct qualitative focus groups with patients and clinicians in the ED
4.	Facilitate co-production workshops with stakeholders
5.	Dissemination of co-produced guidance and maximisation of study impact.

Lay Abstract: Many patients go to A&E for help when they have hurt their ribs. A large proportion of these patients are elderly, frail people who have fallen. Four times more people fall and hurt their ribs, than those who break their hip, but much less is known about the people who hurt their ribs and how best to manage them. If they are sent directly home from A&E, the patient is expected to manage their injury on their own, and this can often mean that the patient needs to go back to A&E or to the GP. If they
do get a chest infection or pneumonia, this can lead to a long hospital stay, or can even be fatal. There are currently no standard guidelines that can be used to help care for the patients who are discharged home from A&E.

We aim to develop guidelines that can be used to improve the care of patients with rib injuries, who are not admitted to hospital. We will do this by working with these patients and with the clinicians who manage the patients in A&E.

What we want to understand:
1) How clinicians in the UK currently manage the patients who are directly discharged from A&E;
2) The similarities and differences between the people who have injured their ribs and been managed at home in the past. We want to know:
a) their age, how severe their injury was, did they have a lung disease before they hurt their ribs, what medication they normally take.
b) what painkillers they were given by A&E and whether the painkillers helped, what advice (If any written or verbal) they were given in A&E.
c) whether they developed a chest infection or their pain was unmanageable, whether they went to their GP or back to A&E, what tablets they were given when they went back, whether they needed to be admitted to hospital and if so, how long they stayed in hospital.

Research Activity Codes: 7.3 MANAGEMENT AND DECISION MAKING
Health Categories: INJURIES AND ACCIDENTS