The development of a patient pathway-based intervention for hospital discharge after blunt thoracic injuries

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: The management of patients presenting to trauma services and emergency departments with blunt thoracic injuries (BTI) remains challenging and significant short-term complications have been identified in the literature. Although there is growing evidence to demonstrate the long-term physical, psychological, and socio-economic burden associated with BTI, recovery for UK BTI patients is complex with a paucity of research in the literature. Further research is needed to understand how pathway-based interventions can be used to optimise BTI patients’ perceived indicators of quality of life.
Aim: The aim of this thesis was to examine recovery after BTI, and to develop a discharge pathway-based intervention focused on optimising patient self-care and recognising and improving risk-stratification in the post discharge recovery period.
Methods: The Medical Research Council (MRC) theoretical framework for development and evaluation of complex interventions and a recognised ‘Health-Related Quality of Life’ (HRQoL) conceptual model informed a multi-phase approach resulting in the development of a patient pathway-based intervention.
Phase one involved investigating how Patient Reported Outcomes (PROs) and HRQoL have been investigated in the BTI population previously using narrative review methods. Secondly, a mixed methods approach (prospective longitudinal survey methods and qualitative semi-structured interviews) was used to investigate long-term outcomes after BTI and develop predictive models for poor long-term outcomes.
Phase two of this thesis follows the intervention development process. In this phase, a systematic review of the existing literature investigated how pathway-based interventions had been developed and evaluated previously. In the second part of phase two, intervention components were explored with patients and healthcare professionals, and a Delphi Study conducted to achieve consensus on pathway components to be included in a standardised pathway-based intervention for hospital discharge after BTI.
Results: A review of 15 studies identified key characteristics of long-term recovery and HRQoL outcomes (physical, psychological, and socio-economic) highlighting the key timepoints in recovery and outcomes of interest. A mixed method observational study incorporating survey methods and including 337 participants from 12 hospitals in England and Wales described the recovery trajectory over the first six-months after hospital discharge. This study also developed prognostic models for poor physical function, chronic pain, and neuropathic pain at six-months after hospital discharge. A qualitative interview study with 11 participants explored the challenges experienced throughout recovery after BTI. Key challenges for thesis participants included pain and analgesic management, investigations and treatments, unidentified injuries, and the long-term impact on mental health. A subsequent systematic review of 16 studies highlighted the scope and breadth of pathway-based interventions in the literature. This systematic review did not identify any pathway-based intervention specifically relating to the process of hospital discharge for patients with BTI.   The intervention development stage included was based around a three-stage approach. Firstly, a cross-sectional study conducted at the 3rd Global conference for emergency nursing and Trauma Care in Holland in 2018 identified the key broad care component categories in BTI management. Secondly, important components of discharge care were explored with patients through a qualitative interview study with 14 participants. This study highlighted challenges within the hospital discharge process and identified quality and safety issues that could be improved through a more standardised, pathway driven approach to discharge. The intervention development phase culminated in a three round Delphi study with an interdisciplinary expert panel with 88 participants. Care components were categorised into key component areas of BTI care, 70 statements of care were introduced to the panel and subsequently, 40 statements achieved consensus across the panel. These findings have been integrated into a pathway development framework and an intervention development toolkit has been drafted.  Discussion: This thesis has described the development of a complex pathway-based intervention for hospital discharge after BTI. This process has provided a deeper understanding of the recovery journey after BTI particularly focusing on the determinants of patient perceived HRQoL. The complexity of the outcomes for patients recovering from BTI is represented in the challenge of developing prognostic models with easy clinical utility. The final prognostic models presented in this thesis required data collection at multiple timepoints using data which is not routinely available in clinical practice. Despite this, the final prognostic models provide greater insight into the risk factors for poor physical function, chronic pain, and neuropathic pain at six months after hospital discharge. The prognostic models for long-term outcomes will need refinement before undergoing a process of external validation prior to development into risk stratification scores. A first draft of the pathway toolkit is presented within this thesis, but this will need refinement prior to being assessed for feasibility and acceptability before moving on to a full experimental evaluation. 
Conclusions: This thesis presents the investigation of the long-term outcomes of BTI patients over the first six months after discharge from hospital and proposes a pathway-based intervention development toolkit for local trauma hospital to use when constructing a standardised approach to hospital discharge after BTI. Whilst this injury presentation is associated with substantial recovery burden over the first six months after hospital discharge, there are opportunities to optimise self-care through a process of pathway-based discharge. 
Date of Award1 Oct 2021
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorGerry Lee (Supervisor), Christine Norton (Supervisor), Andreas Xyrichis (Supervisor) & Philip Hopkins (Supervisor)

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