|Year : 2018 | Volume
| Issue : 1 | Page : 5-10
A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures
Helen Ingoe1, Catriona Mcdaid2, William Eardley1, Amar Rangan1, Catherine Hewitt2
1 Department of Health Sciences, York Trials Unit, University of York, York; Department of Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, England
2 Department of Health Sciences, York Trials Unit, University of York, York, England
|Date of Web Publication||20-Dec-2018|
Department of Health Sciences, York Trials Unit, University of York, York; Department of Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough
Source of Support: None, Conflict of Interest: None
Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs).
Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial.
Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted.
Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%).
Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance.
Keywords: Blunt chest trauma, flail chest, major trauma center, rib fracture, survey, trauma unit
|How to cite this article:|
Ingoe H, Mcdaid C, Eardley W, Rangan A, Hewitt C. A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures. J Cardiothorac Trauma 2018;3:5-10
|How to cite this URL:|
Ingoe H, Mcdaid C, Eardley W, Rangan A, Hewitt C. A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures. J Cardiothorac Trauma [serial online] 2018 [cited 2020 Aug 12];3:5-10. Available from: http://www.jctt.org/text.asp?2018/3/1/5/248099
| Introduction|| |
Despite an increasing number of published observational studies addressing chest wall trauma, it still remains unclear that which patients should be considered for rib fracture fixation. Robust evidence for the effectiveness of surgical intervention in this population is lacking, and there are calls for large, well-designed randomized controlled trials (RCTs) to address this research gap. To develop a trial addressing clinical and cost-effectiveness that is adequately powered and relevant to the current clinical practice, certain aspects need clarification. Undertaking a large clinical trial involving multiple sites and specialties in the trauma setting poses challenges on how to standardize the identification, recruitment, and delivery of interventions to patients. Most patients who require admission to hospital do not require surgical rib fixation; however, the current evidence does not clearly define which patients are likely to benefit from rib fixation. It is hypothesized that flail chest injuries,, respiratory compromise, chest deformity, and ongoing pain despite multimodal analgesia are the indications for fixation. The aims of this survey are to describe hospital demographics, existing pathways, and current clinical care of patients with rib fractures and to establish whether clinicians would be willing to randomize patients into a surgical trial of rib fracture fixation in the future.
| Subjects and Methods|| |
The first part of the survey gathered hospital demographic data and available services within that hospital. The second part of the survey looked at the current clinical care of patients with rib fractures, including the setting and specialty that assumed care in different scenarios. The third part of the questionnaire related to willingness to take part in further research includes randomizing patients with rib fractures in a clinical trial assessing the effectiveness of rib fixation (Full questionnaire is available as supplementary material in File 1). The survey was reviewed and ethical approval granted from the Department of Health Sciences, Research Governance Committee, University of York. The sampling frame was trauma leads from each trust who would have overall knowledge of hospital protocols and service management. The trauma network is a collaboration between hospitals and services that provide trauma care and is headed by a trauma network lead. Trauma network services in England and Wales include 27 major trauma centers (MTCs), 170 trauma units (TUs), as well as prehospital care and rehabilitation services. E-mails were sent to all trauma network managers who were asked to identify their respective MTC and TU leads or any other persons they thought would be most appropriate to complete the survey. The e-mail addresses of the identified MTC and TU leads were entered into the survey software. To maximize reach and response rates anonymous links were also sent to trauma network managers at the opening of the survey window if network managers were unwilling to share personal e-mail addresses but were willing to deliver the survey through their internal e-mail systems to TU and MTC leads. No financial incentives were offered to participants.
The survey was designed in Qualtrics (Qualtrics, Provo, UT) and responses were analyzed using SPSS (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY, USA: IBM Corp). Data were described descriptively using counts and percentages. Hospital demographics and specialties undertaking rib fracture care in several scenarios were compared statistically between MTCs and TUs using Chi-square tests or Fisher's exact tests as appropriate.
| Results|| |
The survey was open from May 26, 2017, to July 19, 2017. Reminders were sent at 2 and 4 weeks after the survey opening, generating a greater yield of participants after each reminder. Of 62 e-mail invited, a complete set of data were available only for 39 responders; three were partially complete. All entries were completed by unique individuals at unique IP addresses and the respondents represented at least 32 unique trusts.
All but four of the 20 trauma networks were represented by the survey. Those not responding included Southwest London and Surrey, Greater Manchester, Sussex, and Northwest London.
Major trauma center and trauma unit demographics
There were eight responses from MTCs and 34 from TUs. All surveyed TUs are part of a trauma network. Seven (21%) TUs are <10 miles from the nearest MTC, 13 (38%) are between 10 and 29 miles, 9 (27%) are between 30 and 49 miles, 3 (9%) are between 49 and 74 miles, and 2 (6%) are more than 75 miles. MTCs are mostly serving a population of over 750,000 (n = 5, 62%) and are based in cities (n = 5, 62%). Five (15%) TUs were also serving a population of over 750,000 but are mostly town (n = 16, 47%) or rural (n = 11, 32%) [Table 1]. All trusts providing rib fracture surgery also had thoracic surgery provision within the same hospital. As would be expected, MTCs had a significantly higher proportion of thoracic surgery (5, 63% vs. 4, 12%, P = 0.006) and rib fixation surgeons within their hospitals (7, 88% vs. 2, 6%, P < 0.0001) compared to TUs.
There were no significant differences between MTCs and TUs in having an emergency department protocol (7, 88% vs. 27, 79%, P = 1), guidance to identifying possible surgical candidates (5, 63% vs. 16, 66%, P = 1), or having a dedicated referral pathway (5, 63% vs. 14, 41%, P = 0.544). There were no significant differences between MTC and TU in physiotherapy provision (3, 38% vs. 14, 41%, P = 1); however, rehabilitation medicine was provided significantly more in MTCs than in TUs (5, 63% vs. 2, 6%, P = 0.001).
Specialties undertaking inpatient care
Multiple specialties undertake the care of rib fracture patients; however, this differs between trusts and the levels of support required by patients [Table 2]. General surgery is most likely to undertake rib fracture care when patients require no extra respiratory support in a TU (n = 26, 77%) compared to an MTC (n = 2, 77%); however, thoracic surgeons are most commonly reported to undertake this type of care in MTCs (n = 3, 38%) compared to a TU (n = 1, 3%).
|Table 2: Specialty who would undertake the in-patient care in the following scenarios stratified for major trauma center and trauma unit|
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In a TU, patients with chest drains are managed by general surgery (n = 28, 82%) with only three respondents confirming that emergency medicine, intensive care, or thoracic surgery would undertake this care routinely. This differed in MTCs where thoracic surgery (n = 3, 38%) shared the care more often with general surgery (n = 4, 50%).
When noninvasive ventilator (NIV) support is required, the care continues predominantly under general surgery in a TU (MTC: n = 3, 38% vs. TC: n = 14, 41%) with intensive care assuming the next biggest proportion of care (MTC: n = 2, 25% vs. TC: n = 11, 32%). Respiratory medicine undertook the care of those with NIV in some TUs (n = 4, 12%) but none in MTCs.
An intubated patient will only be looked after by general surgery (n = 12, 35%) and intensive care (n = 19, 56%) in a TU and 9% (n = 3) would transfer care to thoracic surgery at an MTC. In an MTC, intubated patients are cared for by general surgery (n = 3, 38%), intensive care (n = 3, 38%), and thoracic surgery (n = 2, 25%).
In the case of patients who are over 75 years of age, generally, care would not change from those <75 years of age. Some respondents declared that most cases are dealt on a case-by-case basis with consultant discussion between teams depending on patients' frailty and clinical needs. Elderly care would manage their care in an MTC (n = 2, 25%) and a TU (n = 6, 18%) based on their age if they required no other respiratory support.
Overall, centers reported that they would be willing (n = 13, 31%) or potentially be willing (n = 21, 50%) to take part or identify patients for an RCT of rib fracture fixation for flail chest and nonflail chest (n = 14, 33% and n = 21, 50%), respectively.
| Discussion|| |
This survey represented responses from 16 (80%) of trauma networks; the sample ratios, MTC to TU responses are representative of the population of MTCs and TUs (27:170) in England and Wales. More than half of TUs were within 30 miles of an MTC (n = 20, 59%). If undertaking a study which required transfer of patients, this is achievable in most centers based on distance; however, patient transfers may be challenging as TUs serve mostly rural areas n = 11 (32%). In a UK study, patients were found to be willing and found it acceptable to travel up to 1 h and 45 min for better outcomes in routine secondary care. It is possible that a small subset of patients would not be willing to participate in a trial due to the proximity of the trial center to family as well as not being able to attend trial follow-up. Further patient and public participation work are required to establish whether patients would be willing to travel for surgical intervention for rib fracture fixation in a trial setting.
The British Orthopaedic Association has prepared an audit standard for trauma in conjunction with Cardiothoracic Surgery Society of Great Britain and Ireland for the management of blunt chest wall trauma, published in April 2016. Specifically, the audit standard details that protocols should be in place for the resuscitation of patients with severe chest wall trauma and ongoing multidisciplinary management to include consultant led surgical, anesthetic, pain management, physiotherapy, and rehabilitation teams. The recent introduction of the audit standards may have increased the number of hospitals with dedicated rehabilitation services and relevant treatment and referral protocols; however, these numbers are still low and protocols mostly developed locally (n = 21, 62%) and not as a trauma network (n = 13, 38%). As part of a trial, there may be a need to develop protocols that address variations in local-care pathways within trial sites and to explore ways of ensuring comparable care across UK centers in terms of specialist physiotherapy and rehabilitation services. If TUs are unable to provide comparative physiotherapy and rehabilitation to those not undergoing rib fracture fixation in a trial setting, transfer of all trial participants may be required to the MTCs providing rib fracture fixation. This could create significant burden on the MTC service and may be a barrier to site set up and patient recruitment.
Current clinical input
This survey has highlighted the wide variety of specialties undertaking the care of patients with rib fractures. It is clear in TUs that general surgery is the most common specialty managing this population even when patients require ventilator support. Rib fracture care is multidisciplinary and lead specialty clinicians are key to instigating overall management, referring for higher levels of care, and seeking opinions for surgical fixation. In this survey, trauma and orthopedics (T&O) did not lead the care of a patient with isolated chest trauma in an MTC. In general, the decision to fix rib fractures is multidisciplinary at an MTC between T&O surgery, thoracic surgery, and intensive care and surgery undertaken jointly between T&O and thoracic surgery. It seems counterintuitive that general surgery as a specialty leads the majority of rib fracture patient care when they are unlikely to take part in the decision for rib fracture fixation or undertake the surgery. As general, surgery, and intensive care specialties, lead most of the rib fracture care in TUs any trial or national guidance should seek to engage with general surgical and intensive care societies at the outset.
Developing a trial protocol from a national perspective would be the ideal solution for a complex interventional trial on rib fracture fixation. However, it would be naïve to suggest that this could be rolled out universally throughout the trauma services as it does not take into account the nuances that encompass each rib fracture service. One solution to the complex area of recruitment to trial from multiple specialties in the emergency setting could be the use of the national trainee research collaborative. Advantages would include the ability to identify potential trial participants in the out-of-hours setting and to engage with multiple specialties that form part of the trainee research collaborative such as anesthetics, general surgery, and T&O.
Willingness to engage in future research
Several small non-UK RCTs have shown some improvement in patient outcomes (intensive care length of stay) following surgery; however, these trials are underpowered and use techniques not often used in the UK.,, Collaborative working between sites becomes crucial as a single-center study is unlikely to recruit enough patients to adequately power a study. A single site would be inherently biased and outcomes unlikely to be reproducible or generalizable. One RCT that aimed to recruit 100 patients was terminated as a result of recruiting <25% of their target. Another ongoing RCT aims to recruit 206 patients. A Cochrane review states that even if these two studies recruit to target, it is unlikely to definitively answer the research question of effectiveness due to their small sample sizes. It is encouraging that some UK centers are willing to recruit to a clinical trial on rib fracture fixation. Further research in the form of a feasibility study is required to understand why the majority of clinicians were only potentially willing to participate in a trial and to understand more fully how any barriers to patient recruitment due to variation in patient pathways could be overcome.
Although there was an adequate response rate from invited participants, the original sampling frame could have identified further participants. Thirty percent (n = 8) of MTCs and 19% (n = 32) of TUs were represented in the study. This reduces the impact of the conclusions drawn; however, as the survey covers 80% of the trauma networks, it is representative of the population and captures the regional variation. Identifying participants was difficult and relied on trauma network managers sharing e-mail addresses of their MTC and TU leads. Where this was not the case, we were then reliant on network managers willing to send an e-mail to their MTC and TU leads with an anonymous link.
| Conclusions|| |
Care of rib fracture patients in England and Wales is delivered in a variety of MTCs and TUs with different care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges have been highlighted in preparation for a clinical trial in this population and a feasibility trial should be the next step to establish whether a full-scale trial addressing the question of the effectiveness of rib fracture fixation is feasible.
Financial support and sponsorship
Educational grant was provided by Orthopaedic Research UK.
Conflicts of interest
CMcD and CH have received funding from the British Orthopaedic Association outside the scope of this project. CMcD is a member of the NIHR HTA and EME Editorial Board. AR has received educational grants from DePuy Ltd; ORUK grant for this project; NIHR grants outside the scope of this project. Surgeon member of NJR Steering Committee. None of above influence the work completed in this study.
| References|| |
Cataneo AJM, Cataneo DC, de Oliveira FHS, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database of Systematic Reviews 2015;7. Art. No.: CD009919. DOI: 10.1002/14651858.CD009919.pub2.
Levati S, Campbell P, Frost R, Dougall N, Wells M, Donaldson C, et al.
Optimisation of complex health interventions prior to a randomised controlled trial: A scoping review of strategies used. Pilot Feasibility Stud 2016;2:17.
Forward DP, Ollivere BJ, Ng JW, Coughlin TA, Rollins KE. Current concepts in rib fracture fixation. Bone Joint 360 2016;5:2-7.
Brasel KJ, Moore EE, Albrecht RA, deMoya M, Schreiber M, Karmy-Jones R, et al.
Western trauma association critical decisions in trauma: Management of rib fractures. J Trauma Acute Care Surg 2017;82:200-3.
Chan E, Stefancin E, Cunha J. Rib fixation following trauma: A cardiothoracic surgeon's perspective. J Trauma Treat 2016;5:339.
de Moya M, Nirula R, Biffl W. Rib fixation: Who, what, when? Trauma Surg Acute Care Open 2017;2:e000059.
Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, et al.
Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care 2014;29:139-43.
de Moya M, Bramos T, Agarwal S, Fikry K, Janjua S, King DR, et al.
Pain as an indication for rib fixation: A bi-institutional pilot study. J Trauma 2011;71:1750-4.
NHS Clinical Advisory Group. Regional Networks for Major Trauma NHS Clinical Advisory Groups Report; 2010.
Dixon A, Robertson R, Appleby J, Burge P, Devlin N, Magee H. Patient Choice – How Patients Choose and How Providers Respond. London: The King's Fund; 2010.
British Orthopaedic Association and the Cardiothoracic Surgery Society of Great Britain and Ireland. BOAST 15 The Management of Chest Wall Trauma; 2016.
Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al.
Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727-32.
Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al.
Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216:924-32.
Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4:583-7.
Malhotra AK. Flail Chest: Early Operative Fixation Versus Non-operative Management – A Prospective Randomized Study. ClinicalTrialsgov. NCT01147471; 2010.
St. Michael's Hospital. Treatment of Acute, Unstable Chest Wall Injuries. ClinicalTrialsgov. NCT01367951; 2011.
[Table 1], [Table 2]