Implementation evaluation and refinement of an intervention to improve blunt chest injury management—A mixed‐methods study

Abstract

Aims and objectives:To investigate uptake of a Chest Injury Protocol (ChIP), examine factors influencing its implementation and identify interventions for promoting its use.Background: Failure to treat blunt chest injuries in a timely manner with sufficient analgesia, physiotherapy and respiratory support, can lead to complications such as pneumonia and respiratory failure and/or death.Design: This is a mixed-methods implementation evaluation study.Methods: Two methods were used: (i) identification and review of the characteristics of all patients eligible for the ChIP protocol, and (ii) survey of hospital staff opinions mapped to the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementation. The characteristics and treatment received between the groups were compared using the chi-square test or Fischer's exact test for proportions, and the Mann-Whitney U-test for continuous data. Quantitative survey data were analysed using descriptive statistics. Qualitative data were coded in NVivo 10 using a coding guide based on the TDF and Behaviour Change Wheel (BCW). Identification of interventions to change target behaviours was sourced from the Behaviour Change Technique Taxonomy Version 1 in consultation with stakeholders.Results: Only 68.4% of eligible patients received ChIP. Fifteen facilitators and 10 barriers were identified to influence the implementation of ChIP in the clinical setting. These themes were mapped to 10 of the 14 TDF domains and corresponded with all nine intervention functions in the BCW. Seven of these intervention functions were selected to address the target behaviours and a multi-faceted relaunch of the revised protocol developed. Following re-launch, uptake increased to 91%.Conclusions: This study demonstrated how the BCW may be used to revise and improve a clinical protocol in the ED context.Relevance to clinical practice: Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions. Enhancing the self-efficacy of emergency nurses when performing assessments has the potential to improve patient outcomes and should be included in implementation strategy.behaviour change, behaviour change wheel, chest injury, implementation evaluation, nursing, theoretical domains frameworkThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. (Leone et al., 2008). Patients with at least three rib fractures have a significantly increased risk of in-hospital mortality (Holcomb, McMullin, Kozar, Lygas, & Moore, 2003;Testerman, 2006), an effect even more pronounced in older patients (Kent, Woods, & Bostrom, 2008) in whom each additional rib fracture increases the risk of mortality by 19% and of pneumonia by 27% (Bulger, Arneson, Mock, & Jurkovich, 2000). Much of literature around blunt chest injury advises implementation ...

How does the implementation of a patient pathway-based intervention in the acute care of blunt thoracic injury impact on patient outcomes? A systematic review of the literature

“…of #) 6 (±3) vs. 6 (±2); p = 0.56 Protocol group vs. Control group 17 (±7) vs. 17 (±7); p = 0.97 Thoracic Trauma Severity Score: 8 (±3) vs. 8 (±3); p = 0.97 Curtis et al. (2017) [31] No Pathway Group (median): 81.0 (IQR 66–88) Pathway Group (median): 79.5 (IQR 69–87) No Pathway Group: 41.8% ( n = 56) Pathway Group: 46.2 ( n = 134) Not reported No Pathway Group (median): (IQR 0–3) Pathway Group (Median): 0 (IQR 0–2) No Pathway Group (median): 4.0 (IQR 2–9) Pathway Group (median): 5.0 (IQR 2–9) Dennis et al. (2017) [24] Pre-protocol vs. Protocol group (Median in years) 46.32 (IQR 30.7–61.94) vs. 48.33 (IQR 34.51–64.16); p = 0.722 Pre-protocol vs. Protocol group 77.9% ( n = 254) vs. 77.8% ( n = 246); p = 0.984 Pre-protocol vs. Protocol group Blunt Thoracic Injury: 80.1% ( n = 261) vs. 77.5% ( n = 245); p = 0.484 Not Reported.…”

“… Curtis et al. (2017) [31] Single Australia Retrospective Observational Study & staff survey Emergency Department/Trauma Ward Evaluation of Chest Injury Protocol (ChIP) (Curtis et al. 2016)[31] n = 424 patient participants n = 99 staff participants No.…”

“…Curtis et al. identify the importance of effectively embedding pathways in clinical practice using recognised implementation science methods [ 31 ]. Several factors have been reported as facilitators to effectively embed a pathway in clinical practice.…”

“…One mixed-methods study evaluated the intervention implementation process and used the outcomes to refine the clinical pathway [ 31 ]. Curtis et al.…”

“…These themes included knowledge of the pathway, positive feedback, beliefs about the benefits of the pathway and environmental context. After refinement and a relaunch programme, uptake of the intervention increased from 68.4% to 91.0% of eligible patients [ 31 ]. This demonstrates how implementation science underpinning the introduction of a patient pathway-based intervention can positively impact on uptake in clinical practice.…”