Title: Is a Blunt Thoracic Trauma Integrated Care Pathway (BTTICP) for the management of Blunt Thoracic Injury (BTI) feasible and acceptable compared to standard UK practice?
Funder: Health Education England

Abstract: Background: Blunt Thoracic Injury (BTI) accounts for 15% of presentations in Major Trauma Centres (MTC) throughout the United Kingdom (UK). Associated with high levels of respiratory related complications such as pneumonia, respiratory failure and pulmonary embolism, BTI is painful and debilitating. These complications result in increased hospital length of stay, increased avoidable admissions to intensive care, increased ventilatory support requirements and increased mortality in high risk groups. Previous research has measured the effectiveness of individual components of care in reducing complications (e.g. effective analgesia through thoracic epidural). It is apparent from the evidence that the problem is more complex than this and prevention of respiratory complications lies in the correct timing and grouping of treatment options. Integrated Care Pathways are multi-disciplinary evidence-based documents that outline care that patients will potentially receive and the expected or clinically recommended timeframes. They have been implemented in practice with success and allow clinical freedom while reducing unnecessary variation from standardised care. Developing an evidence-based Blunt Thoracic Trauma Integrated Care Pathway (BTTICP) will increase access to treatment for BTI patients and provide more uniform decision making for clinicians to reduce inconsistent care and standardise care. This will reduce complications, shorten admission times and lead the way for other avenues of trauma care to follow. Methods: This study aims to inform the design of a multi-centred RCT by undertaking feasibility testing and evaluation of the proposed BTTICP. The study is based on a process of identifying the current evidence available, identifying gaps in the knowledge base and undertaking local work to add to this knowledge base. The study will develop an evidence based BTTICP using evidence and expert opinion. This BTTICP will be introduced into practice and finally a feasibility control study will be undertaken to investigate the practicality of this intervention in clinical practice. This whole process will be undertaken through a four stage approach. Design: Stage 1 (months 1-12) A review of previous relevant research and systematic review Stage 2 (months 12-24) Six-month follow-up study. Prospective mixed methods study of Health Related Quality of Life (HRQoL) in patients recovering from BTI. This will allow the identification of variables that correlate with HRQoL from both patients and their partner/family-member. Stage 3 (months 24-36) Utilising data from the Stage 2 and working collaboratively with patients and practitioners to: I.Develop a protocol and pathway for an intervention II.Observe Usual Care which will be the comparatorIII.Determine the most appropriate outcome measures Stage 4 (Months 36-48) Undertaking a feasibility study, including introduction into practice, training practitioners, testing the fidelity of protocols and establishing the suitability and acceptability of the BTTICP. Population: Patients with BTI and multiple rib fractures who are admitted to a MTC for more than 24 hours without significant or distracting injury in another organ system. Outcomes: Primary feasibility outcomes will: Assess the complexity of recruitment in trauma patients Protocol compliance and acceptability for clinicians and patients Sample size determination for subsequent Randomised Controlled Trial Other outcomes associated with early stages of the study include: Staff and patient attitudes, knowledge and training needs, measurement of infective and ventilatory complication rates, HRQoL, physical activity and long term self assessed pain perception. Benefits: This study has important clinical and cost implications for the management for patients with BTI requiring admission. It will also have operational, safety and educational benefits to the staff involved. Benefits include: Reduced infective and ventilatory complications Reduced length of hospital stay Reduced Intensive Care admissions associated with complications Improved patient comfort and satisfaction Improved staff knowledge of current evidence base Improved understanding of patient experience of inpatient trauma care.

Lay abstract: Blunt thoracic trauma involving multiple fractured ribs accounts for 15% of all United Kingdom (UK) trauma centre admissions (approximately 5,550 admissions per year). This common presentation is normally observed in patients involved in road traffic incidents, falls from heights, assault with a blunt object, crush injuries and pedestrians hit by vehicles. It is recognised that effective patient care for those with severe physical injuries must be provided by appropriately trained professionals, at the right place and at the right time. Initially, this means an advanced trauma teams of doctors, nurses and paramedics provide specialist care at the point of and location of the incident/injury. This specialised care must continue throughout each patient's journey from injury through to recovery. This care is co-ordinated, and often provided by, Major Trauma Centres (MTC) which are often large teaching hospitals that have experience of providing care to patients with complex medical problems. The UK has a network of MTCs who provide emergency trauma care to patients 365 days of the year. Despite the recent improvement in the management of the most severely injured patients at MTCs throughout the UK, there remains high levels of post injury complications and prolonged recovery for patients with multiple fractured ribs. Although individual treatment options that include pain relief, physiotherapy, breathing exercises and surgical operations to stabilise the broken ribs are used in normal practice, there is still no formal agreement on the best combination of treatment options for those with rib fractures. In this fellowship, I will develop an integrated care pathway (ICP) that standardises post injury care for patients after admission for broken ribs. An ICP is a document that can be used by all members of the healthcare team to provide appropriate care in a timely manner. This process has been used repeatedly in clinical practice for different medical problems with high levels of success and improved patient outcomes. There is evidence to suggest that ICPs also improves access to more complex aspects for treatment. It reduces variance using evidence-based care and supports patient empowerment whilst reducing clinical risk to the patient. This tool will be developed from a combination of the best available research methods to ensure that the most beneficial care is provided to every patient. From previous studies, it is likely that the ICP will organise the management of care, reduce complications and improve patient's long-term quality of life. Developing new care pathways involves multiple processes including identifying the best research already available, examining both clinician and patient opinion and developing a practical and appropriate tool which is appropriate in the clinical setting. After educating staff in clinical areas on the practicality of using the integrated care pathway and implementing the tool into practice, a scoping feasibility study can be undertaken. This will assess the acceptability and practicality this intervention will have for all clinicians and patients. In my on going development as a researcher, I will further investigate the effect of this integrated care pathway randomised controlled trial (RCT) in a post-doctoral role. This feasibility study will provide essential information needed to develop a strong and effective RCT in the future. Below is a brief guide to the study design and structure with brief descriptions of aims and objectives for each of the 4 stages of this project. Study Structure and Design: Stage 1 (months 1-12) A review of previous relevant research and systematic review Stage 2 (months 12-24) Blunt Thoracic Trauma Follow up Study: A six month follow up study with patients recovering from multiple rib fractures and their significant other/proxy/carer. This will involve undertaking pre-designed questionnaires that examine aspects of quality of life and an in-depth interview to discuss the challenges associated with recovery from multiple rib fractures. This will help identify aspects of in-hospital care that the ICP will focus on. Stage 3 (months 24-36) Developing the ICP: Using the data identified in the in-depth search of previous research and the outcomes of the questionaries and in-depth interviews, the ICP will be developed in collaboration with patients and experienced trauma healthcare practitioners. This stage will also allow us to investigate which variables and outcomes we will need to closely measure in the stage 4 feasibility study. Stage 4 (months 36-48) Feasibility study of ICP in practice: This will involve introducing the tool into the clinical practice environment at two London hospitals, teaching healthcare professionals to use the tool and finally testing the practicality of the ICP and establishing its suitability and acceptability to both patients and healthcare professionals alike.

Research activity codes: 6.7 PHYSICAL;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INJURIES AND ACCIDENTS