Title: Multicentre Research Programme to Enhance Return to Work after Trauma (ROWTATE)
Funder: Department of Health and Social Care

Abstract: Background Trauma of at least moderate severity (Injury Severity Score (ISS) >8) is a major cause of death, disability and NHS resource use. Many survivors experience physical and psychological problems, reduced quality of life (QoL) and difficulty returning to work, with psychological and occupational needs frequently unmet. The detrimental effects of being out of work on patient health, NHS costs and society are well documented. Our recent study found one third of patients with ISS>8 have not returned to work one year later with many suffering significant physical and psychological problems. Systematic reviews demonstrate vocational rehabilitation (VR) improves return-to-work in some conditions. Evidence is lacking for VR amongst trauma survivors who often suffer multiple injuries, affecting several body regions, with psychological and/or cognitive problems impacting on work ability. We have developed VR interventions for traumatic brain injury and stroke. Our proposal adapts these for a much wider range of injuries, potentially enabling wide-scale NHS roll-out. Aim To develop, evaluate and assess implementation of an intervention to enhance return-to-work and improve quality of life (QoL) and wellbeing in people with at least moderate trauma. The programme comprises four work-packages (WPs). Methods WP1 develops theory and intervention through an iterative process including trauma survivor focus groups, key informant interviews and co-production. Outputs include intervention programme theory, logic model, intervention manual, fidelity checklist, data collection tools and training package. (Months 1-12) WP2 is a feasibility study piloting data collection processes and tools and assessing follow-up rates; case-studies evaluating intervention usage and acceptability, outcome measure acceptability and therapist training; assessment of intervention fidelity and contamination and focus groups exploring barriers and facilitators to recruitment and retention. (Months 13-22) WP3 is the definitive trial evaluating clinical and cost effectiveness of the intervention using a pragmatic individually randomised controlled trial, in five major trauma centres, randomising 722 working-age adults with ISS>8. The intervention is a case-coordinated package of individually tailored VR provided by occupational therapists and clinical psychologists plus usual care. The control arm receives treatment as usual. The primary outcome measure is return-to-work (including voluntary work and full-time education) 12 months post-randomisation. Secondary outcomes include QoL, psychological measures, broader employment outcomes, recovery expectations and self-efficacy. A nested economic evaluation assesses cost-effectiveness. (Months 23-67) WP4 is a process and implementation study. Process evaluation nested within WPs 2 and 3 assesses intervention fidelity, factors affecting intervention quality and enablers and barriers to intervention deployment. Qualitative data collected across all WPs will be analysed for implementation-relevant content. This includes ethnographic research and document analysis (WP1), case-studies (WP2), interviews with trauma survivors, service providers, employers and commissioners (WP3). Data synthesis will produce implementation toolkits and workshops to facilitate commissioner and practitioner implementation. (Months 1-70) Impact and Dissemination We anticipate our intervention will result in an additional 4000-7500 trauma survivors achieving a sustainable return-to-work each year across England. Dissemination includes policy makers, commissioners, practitioners, employer and patient organisations via implementation toolkits and workshops, brief evidence summaries, open-access academic and practitioner journal articles, conferences (academic, practitioner, policy maker) and social media.

Lay abstract: Aim To develop a programme to help moderately and severely injured patients return to work and assess how well it works. Background Moderate or severe traumatic injuries can be life changing or life threatening; often caused by road accidents, falls, sporting injuries or assaults. Such injuries are common, but more patients now survive due to improved care and recently developed Major Trauma Centres. However, many suffer physical and psychological problems, reducing quality of life and the chance of returning to work. We recently found one third of these patients have not returned to work after one year and many suffered physical, psychological and financial problems. Despite Major Trauma Centres, rehabilitation and help for injured people to return to work is patchy and poorly developed. We know being in work is good for physical and psychological health. Individualised support (vocational rehabilitation) can help patients with some conditions (e.g. back pain, spinal cord or brain injuries, mental health problems) to stay in or return to work. We have already developed a vocational rehabilitation programme for people with brain injuries. As trauma includes many different types of injuries which result in different work-related problems, we now need to adapt the programme to cover these and test how well it works. Design and methods Initially we will talk to patients, NHS service providers and commissioners to ensure our vocational rehabilitation programme (called ROWTATE) meets patients needs and is realistic to provide in the NHS. ROWTATE will then be provided to a small number of patients in 2 Major Trauma Centres to see if it is acceptable to patients and identify any problems with it's delivery. This will help improve ROWTATE so we can test it in a large scale trial in about 700 patients. We will measure how many injured people receiving ROWTATE return to work 12 months later and compare this to people who have not received the programme. We will measure physical, psychological and financial problems and assess if ROWTATE saves the NHS, patients and wider society more than it costs to provide. We will also explore factors which help or hinder rolling out ROWTATE across the NHS. Patient and public involvement We will work closely with a group of trauma survivors, led by Trevor Jones and involve them throughout the project including overall management and in individual studies. They will advise us, undertake some aspects of the research, as well as contributing to analysing data, interpreting findings, writing reports for publication and advising on communicating our results to the public. Dissemination We will develop a plan to publicise our findings to policy makers, NHS providers and commissioners, employers, charities, patient organisations and the public using different methods and types of media.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: INJURIES AND ACCIDENTS