Patient and clinician perceptions of blunt chest trauma management and recovery: a qualitative study.

PURPOSE: To explore patient and clinician perceptions of blunt chest trauma management and recovery, when discharged directly home from the Emergency Department (ED). METHODS: This was a qualitative study, completed in a trauma unit in Wales. Blunt chest trauma was defined as an isolated blunt injury to the chest wall, resulting in bruising or rib fractures. Data collection involved semi-structured telephone interviews and focus groups with patients and clinicians respectively. Data analysis was completed using reflexive thematic coding. RESULTS: Twelve patient interviews and three focus groups (23 clinicians) were conducted. In the interviews, seven males and five females participated, with a mean age of 54 years (range 28-74). Clinicians included nurses, doctors, and therapists. Two main themes emerged; 1) the ED experience and 2) recovery once home; each with a number of sub-themes. Results highlighted the significant impact of pain on recovery, and that there is a disjuncture between organisational perspectives of clinicians, and the individual personal perspective of patients. DISCUSSION: Recovery from blunt chest trauma for patients discharged directly home from the ED is a challenging and complex process. Protocol-driven care does not always lead to good patient experience, as it focuses primarily on hospital services and resources.

Recovery from blunt chest trauma is a complex process, leading to poor outcomes including pain and disability.Protocol-driven care of blunt chest trauma does not always lead to a good patient experience.Patients with blunt chest trauma benefit from reassurance that their severity of pain is normal, prior to discharge home from the Emergency Department (ED).Education regarding pacing activity, rest, and reliance on others for a period of time following injury can lead to an improved recovery experience.

Pre-treatment optimisation with pulmonary rehabilitation of elderly lung cancer patients with frailty for surgery.

OBJECTIVE: Frailty develops as a result of age-related decline in many physiological systems and is associated with increased vulnerability to adverse outcomes following thoracic surgery. We prospectively tested our hypothesis that pre-operative pulmonary rehabilitation (Prehab) improves frailty, as suggested by a frailty index > 3 (FI > 3) and fitness, and thereby reduces the risk of post-surgical complications and death in vulnerable elderly lung cancer patients. METHODS: 221 surgical patients, 80 with FI > 3 vs. 141 patients with FI < 3, following Prehab proceeded to surgery. Their Frailty index (FI), dyspnoea scores, performance status (PS), level of activity (LOA) and six-minute walk test (6MWT) prior to and following Prehab were determined. The post-operative length of hospital stay (LOHS), complications, mortality and mid-term survival at 1100 days were compared. Similarly, outcomes for elderly patient ≥ 70 years with FI > 3 (≥ 70,FI > 3) were compared with younger patients < 70 years with FI ≤ 3 (< 70,FI ≤ 3). RESULTS: Patients with FI > 3 were significantly older, had lower 6MWT and higher thoracoscores hence, 82.5% of patients with FI > 3 vs. 33.3% (p = 0.02) with FI ≤ 3 were considered high risk for surgery and postoperative adverse events. With Prehab there was significant improvement in the FI, dyspnoea scores, PS, LOA and 6MWT. Following surgery, there were no differences in major complication rates (8.8% vs. 9.2% p = ns); LOHS median (IQR) [7 (6.8) vs. 8 (5.5) days]; mortality at 30-days (3.7% vs. 0.7%, p = ns); 90-days (6.3% vs. 2.8%, p = ns) and 1-year survival (81.1% vs. 83.7% p = ns). Survival at 1100 days was (63.2% vs. 71.1%, p = 0.19). Likewise, 87.7% elderly ≥ 70,FI > 3 patients were considered high-risk for surgery and postoperative adverse events vs. 35.1% younger patients < 70,FI ≤ 3 (p = 0.0001). Following Prehab and surgery, there were no significant differences in complications, LOHS, mortality at 365 days between the two groups. Survival at 1100 days for ≥ 70,FI > 3 was 55.2% vs. 79.96% for < 70,FI ≤ 3; (p = 0,01). CONCLUSION: Our study suggests that Prehab optimises vulnerable high-risk elderly lung cancer patients with frailty allowing them to undergo surgery with outcomes of post-surgical complications, LOHS and mortality at 365 days no different to patients with no frailty. However, mid-term survival was lower for elderly patients with frailty.

Health care utilization outcomes in patients with blunt chest wall trauma following discharge from the emergency department: A retrospective, observational data-linkage study.

BACKGROUND: Although much is published reporting clinical outcomes in the patients with blunt chest wall trauma who are admitted to hospital from the ED, less is known about the patients' recovery when they are discharged directly without admission. The aim of this study was to investigate the health care utilization outcomes in adult patients with blunt chest wall trauma, discharged directly from ED in a trauma unit in the United Kingdom. METHODS: This was a longitudinal, retrospective, single-center, observational study incorporating analysis of linked datasets, using the Secure Anonymised Information Linkage databank for admissions to a trauma unit in the Wales, between January 1, 2016, and December 31, 2020. All patients 16 years or older with a primary diagnosis of blunt chest wall trauma discharged directly home were included. Data were analyzed using a negative binomial regression model. RESULTS: There were 3,205 presentations to the ED included. Mean age was 53 years, 57% were male, with the predominant injury mechanism being a low velocity fall (50%). 93% of the cohort sustained between 0 and 3 rib fractures. Four percent of the cohort were reported to have chronic obstructive pulmonary disease, and 4% using preinjury anticoagulants. On regression analysis, inpatient admissions, outpatient appointments and primary care contacts all significantly increased in the 12-week period postinjury, compared with the 12-week period preinjury (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.33-1.99; p < 0.001; OR, 1.28; 95% CI, 1.14-1.43; p < 0.001; OR, 1.02; 95% CI, 1.01-1.02; p < 0.001, respectively). Risk of health care resource utilization increased significantly with each additional year of age, chronic obstructive pulmonary disease and preinjury anticoagulant use (all p < 0.05). Social deprivation and number of rib fracture did not impact outcomes. CONCLUSION: The results of this study demonstrate the need for appropriate signposting and follow-up for patients with blunt chest wall trauma presenting to the ED, not requiring admission to the hospital. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

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.

Pre-treatment optimization with pulmonary rehabilitation in lung cancer: Making the inoperable patients operable.

BACKGROUND: Anatomical lung resection offers the best prospect of long-term survival in patients with non-small cell lung cancer (NSCLC). However, some patients with significant dyspnoea, impaired performance status (PS), borderline or poor pulmonary function are considered inoperable and instead referred for radiotherapy, chemotherapy or palliative care. The aims of the study were to determine whether pre-operative pulmonary physiotherapy (Prehab), by improving clinical parameters, (i) makes patients suitable for surgery who were considered inoperable on subjective criteria of dyspnoea >3 and PS >2, and objective criteria of diffusing capacity for carbon monoxide (DLCO) <50%; and (ii) thereby allows them to safely receive curative surgery with reduced morbidity and mortality. METHODS: From January 2017 to December 2018 a total of 306 patients were prospectively and sequentially assessed for Prehab and 216 patients with lung cancer studied. Their mean age (95% CI) was 71.7 ± 1.1 years, 50.5% (n = 109) were men and they received Prehab over 39.0 ± 7.0 days averaging 3.1 ± 0.6 sessions. Their dyspnoea scores, PS, level of activity, six minute walk test (6MWT) and frailty index prior to and following Prehab were determined. Following surgery the post-operative length of hospital stay (LOHS), complications and mortality at 30 days, 90 days and 1 year determined. Similar outcomes were determined for (i) high-risk patients with dyspnoea scores >3 and PS >2, and compared with low-risk patients having dyspnoea scores <2 and PS <2 (subjective criteria); and (ii) high-risk patients with DLCO <50% and compared with low-risk patients with DLCO >80% (objective criteria). FINDINGS: In the total cohort following Prehab, there was significant improvement in the dyspnoea scores <2 / ≥2 (40%/60% prior to Prehab vs. 65%/35% following Prehab, p = 0.00002), PS <2 / ≥2 (45%/55% prior to vs. 62%/38% following Prehab, p = 0.003), frailty index ≤3 / >3 (49%/51% vs 70%/30%, p = 0.0006), and 6MWT (306.6 ± 6.8 m vs 354.8 ± 52.7 m, p = 0.04). Post-operative major complication rates were 8.7%; median LOHS was 7 (IQR 6) days; hospital mortality at 30 days 1.3%, 90 days 4.7% and 1 year 16%. Using subjective criteria of dyspnoea scores >3 and PS >2, 100% of high-risk patients were considered inoperable. Following optimization with Prehab 84.2% of the high-risk patients were ready to proceed with radical treatment and 52.6% with surgery, and subsequently 42.8% of patients underwent surgery. Likewise, 78.8% of patients with DLCO <50% were considered inoperable. Following Prehab 86.5% of high-risk patients were ready to proceed with radical treatment and 59.1% with surgery, and 54.6% of high-risk patients underwent surgery. In each category there were no significant differences in complications, LOHS or mortality rates between the high-risk and low-risk patients. INTERPRETATION: Our prospective study showed that with Prehab there was clinical and statistically significant improvement in the dyspnoea scores, PS, level of activity and frailty, particularly in the high-risk group of patients. Importantly, Prehab made previously inoperable patients operable, allowing them to safely undergo curative lung resection. This strategy helps improve resection rates and may contribute to the long term survival of lung cancer patients. FUNDING: This is a Welsh Health Specialised Services Committee (WHSSC) commissioned service.

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.