Conceptualizing the key components of rehabilitation following major musculoskeletal trauma: A mixed methods service evaluation

A group concept mapping and ethnographic study of intensive care rehabilitation culture

BACKGROUND

Early physical activity and physical rehabilitation are advocated in the critical care unit for patients recovering from critical illness. Despite this, there are still many factors associated with implementation of early physical rehabilitation into routine critical care and practice. One such factor that has been consistently identified is unit culture, yet there is little understanding of how or why the culture of a critical care unit impacts on implementation of early rehabilitation.

AIM

To develop a detailed understanding of the cultural barriers and enablers to the promotion and implementation of physical activity and early mobilization in National Health Service (NHS) critical care units in the United Kingdom (UK).

STUDY DESIGN

A mixed-methods, two-phase study incorporating online group concept mapping (GCM) and ethnography. GCM will be conducted to provide a multistakeholder co-authored conceptual framework of rehabilitation culture. Ethnographic observations and interviews will be conducted of culture and behaviours in relation to the implementation and promotion of early physical activity and rehabilitation in two NHS critical care units in the North East of England.

RESULTS

The results of the Group Concept Mapping and ethnographic observations and interviews will be triangulated to develop a contextual framework of rehabilitation culture in critical care.

RELEVANCE TO CLINICAL PRACTICE

This study will provide a detailed understanding of barriers and facilitators in relation to providing a positive rehabilitation culture in the critical care unit.

Development and validation of the MAnchester Needs Tool for Injured Children (MANTIC)

OBJECTIVE

To develop a measure of the needs injured children and their families' needs throughout recovery; The MAnchester Needs Tool for Injured Children (MANTIC).

DESIGN

Tool development, psychometric testing.

SETTING

Five children's major trauma centres in England.

PARTICIPANTS

Children aged 2 to 16 years with any type of moderate/severe injury(ies) treated in a major trauma centre within 12 months of injury, plus their parents.

METHODS

Stage 1a (Item generation): Interviews with injured children and their parents to generate draft items. Stage 1b (Co-production): Feedback about item clarity, relevance and appropriate response options was provided by parents and the patient and public involvement group. Stage 2 (Psychometric development): Completion of the prototype MANTIC by injured children and their parents with restructuring (as necessary) to establish construct validity. Concurrent validity was assessed by correlation with quality of life (EQ-5D-Y). MANTICs were repeated 2 weeks later to assess test-retest reliability.

RESULTS

Stages 1a,b: Interviews (13 injured children, 19 parents) generated 64 items with semantic differential four-point response scale (strongly disagree, disagree, agree, strongly agree). Stage 2: One hundred and forty-four participants completed MANTIC questionnaires (mean age 9.8 years, SD 3.8; 68.1% male). Item responses were strong requiring only minor changes to establish construct validity. Concurrent validity with quality of life was moderate (r = 0.55, P < 0.01) as was test-retest reliability (ICC = 0.46 and 0.59, P < 0.001). Uni-dimensionality was strong (Cronbach's α > 0.7).

CONCLUSION

The MANTIC is a feasible, acceptable, valid self-report measure of the needs of injured children and their families, freely available for clinical or research purposes.

Cost-effectiveness of a purpose-built ward environment and new allied health model of care for major trauma

BACKGROUND

Targeted rehabilitation within the acute inpatient setting could have a substantial impact on improving outcomes for major trauma patients. The aim of this study was to investigate the cost-effectiveness of the introduction of a purpose-built ward environment, and a new allied health model of care (AHMOC) delivered in the acute inpatient setting, in a major trauma population.

METHODS

The statewide trauma registry, the trauma center's data warehouse, and electronic medical record data were used for this observational study. There were three phases: baseline, new ward, and new AHMOC. Cost-effectiveness was measured as cost per quality-adjusted life year using preinjury, hospital discharge, 1-month and 6-month 5-level, EQ-5D utility scores. Total costs included initial acute and inpatient rehabilitation care, as well as outpatient, readmission and ED presentations to 6-months.

RESULTS

Four hundred eleven patients were included. Case-mix was stable between phases. The median (IQR) number of allied health services received by patients was 8 (5-17) at baseline, 10 (5-19) in the new ward phase, and 17 (9-23) in the AHMOC phase. The proportion discharged to rehabilitation was 37% at baseline, 45% with the new ward and 28% with the new AHMOC. Mean (SD) total Australian dollar costs were $69,335 ($141,175) at baseline, $55,943 ($82,706) with the new ward and $37,833 ($49,004) with the AHMOC. The probability of the AHMOC being cost-effective at a willingness-to-pay threshold of $50,000 per quality-adjusted life year was 99.4% compared with baseline and 98% compared with the new ward.

CONCLUSION

The new allied health model of care was found to be a cost-effective intervention. Uptake of this model of allied health care at other trauma centers has the potential to reduce the cost and burden of major trauma.

LEVEL OF EVIDENCE

Economic and Value-based Evaluations; Level III.

Rehabilitation outcomes based on service provision and geographical location for patients with multiple trauma: A mixed-method systematic review

INTRODUCTION

Previous research has highlighted the benefit of regionalised trauma networks in relation to decreased mortality. However, patients who now survive increasingly complex injuries continue to navigate the challenges of recovery, often with a poor view of their experiences of the rehabilitation journey. Geographical location, unclear rehabilitation outcomes and limited access to the provision of care are increasingly noted by patients as negatively influencing their view of recovery.

STUDY DESIGN

This mixed-methods systematic review included research that addresses the impact of service provision and geographical location of rehabilitation services for multiple trauma patients. The primary aim of the study was to analyse functional independence measure (FIM) outcomes. The secondary aim of the research was to examine the rehabilitation needs and experiences of multiple trauma patients by identifying themes around the barriers and challenges to rehabilitation provision. Finally, the study aimed to contribute to the gap in literature around the rehabilitation patient experience.

METHODS

An electronic search of seven databases was undertaken against pre-determined inclusion/exclusion criteria. The Mixed Methods Appraisal Tool was utilised for quality appraisal. Following data extraction, both quantitative and qualitative analysis methods were utilised. In total, 17,700 studies were identified and screened against the inclusion/exclusion criteria. Eleven studies met the inclusion criteria (five quantitative, four qualitative, two mixed method).

RESULTS

FIM scores showed no significant difference in all studies after long-term follow-up. However, statistically significantly less FIM improvement was noted in those with unmet needs. Patients with physiotherapist assessed unmet rehabilitation needs were statistically less likely to improve than patients whose needs were reportedly met. In contrast, there was a differing opinion regarding the success of structured therapy input, communication and coordination, long-term support and planning for home. Common qualitative themes revealed lack of rehabilitation post-discharge, often with long waiting times.

CONCLUSION

Stronger communication pathways and coordination within a trauma network, particularly when repatriating outside of a network catchment area is recommended. This review has exposed the many rehabilitation variations and complexities a patient may experience following trauma. Furthermore, this highlights the importance of arming clinicians with the tools and expertise to improve patient outcomes.

Identifying and prioritising the key components of a Quality Improvement Network for allied health professionals and psychological therapists: a group concept mapping project

INTRODUCTION

Despite growing enthusiasm for quality improvement (QI), the complexities of modern healthcare continue to create gaps in our ability to consistently deliver the most effective and efficient care for patients, and improvement activities often fail to achieve widespread uptake even when there is robust evidence of their benefits.

METHODS

We undertook a novel, mixed methods evaluation and planning project using group concept mapping (GCM) methodology to identify and prioritise the ways in which our recently established Quality Improvement Network (QIN) could support allied health professionals, psychological therapists and administrative staff in their daily work to improve patient outcomes and experience. Mid-level leaders across our therapy services department contributed towards a statement generation activity and individually sorted these statements into themes. Each statement was rated for perceived importance and current success. Multidimensional scaling and hierarchical cluster analysis were applied to the sorted data to produce themed clusters of ideas within concept maps. Priority values were applied to these maps to identify key areas for future QIN activity.

RESULTS

Overall, 34 participants took part in ideas generation, 20 in sorting and 30 in the rating activity. A five-item cluster map was agreed on, containing the following named clusters: data support; practical skills and training; time and resources; embedding a QI culture; and sharing ideas and working together. Statements contained within each of the five clusters highlight the importance of supporting a range of activities spanning the technical and human aspects of QI at an individual, group/team, organisation and wider systems level.

CONCLUSION

GCM provided a structured and systematic approach for identifying the perceived support needs of allied health professionals, psychological therapists and administrative support staff in relation to QI. The findings from this project provide a useful benchmark from which to track targeted QI support in an applied healthcare setting.

Identifying Occupational Therapy Research Priorities in Trinidad and Tobago: A Group Concept Mapping Study

In Trinidad and Tobago, occupational therapy is an emerging profession with limitations in the number of practitioners and the scope of practice. With the development of a new Master of Science Occupational Therapy programme in the country, the profession is continuously growing. There has been an increased demand for culturally relevant research to build the occupational therapy evidence base locally. However, the narrow range of occupational therapy literature in the country makes it difficult to highlight research gaps and decipher what research areas should be prioritised to best impact occupational therapy practice at present. This group concept mapping study is aimed at identifying priority areas for occupational therapy research in Trinidad and Tobago from the perspectives of occupational therapy students and practitioners. Participants brainstormed and contributed specific research ideas they would like to see developed in the country. Individually, participants sorted these ideas into themes and rated each idea based on perceived importance and feasibility. Using the GroupWisdom™ software, multidimensional scaling and hierarchical cluster analyses were applied to the sort data to create idea clusters within a concept map. Rating values were analysed to determine priority research themes within the concept map. The resulting concept map illustrated seven research priorities: Contextualising Practitioner Development, The Realities of Emerging OT Practice, Localising Mental Health OT, Occupation and Participation of Children and Youth, School-based OT in the Local Context, OT with Special Populations, and OT Contributions to the Public Health Sector. These findings represent the research needs of the occupational therapy profession in Trinidad and Tobago and will help to focus future researchers' efforts to expand the local evidence base.

Evaluating health service outcomes of public involvement in health service design in high-income countries: a systematic review

BACKGROUND

Internationally, it is expected that health services will involve the public in health service design. Evaluation of public involvement has typically focused on the process and experiences for participants. Less is known about outcomes for health services. The aim of this systematic review was to a) identify and synthesise what is known about health service outcomes of public involvement and b) document how outcomes were evaluated.

METHODS

Searches were undertaken in MEDLINE, EMBASE, The Cochrane Library, PsycINFO, Web of Science, and CINAHL for studies that reported health service outcomes from public involvement in health service design. The review was limited to high-income countries and studies in English. Study quality was assessed using the Mixed Methods Appraisal Tool and critical appraisal guidelines for assessing the quality and impact of user involvement in health research. Content analysis was used to determine the outcomes of public involvement in health service design and how outcomes were evaluated.

RESULTS

A total of 93 articles were included. The majority were published in the last 5 years, were qualitative, and were located in the United Kingdom. A range of health service outcomes (discrete products, improvements to health services and system/policy level changes) were reported at various levels (service level, across services, and across organisations). However, evaluations of outcomes were reported in less than half of studies. In studies where outcomes were evaluated, a range of methods were used; most frequent were mixed methods. The quality of study design and reporting was inconsistent.

CONCLUSION

When reporting public involvement in health service design authors outline a range of outcomes for health services, but it is challenging to determine the extent of outcomes due to inadequate descriptions of study design and poor reporting. There is an urgent need for evaluations, including longitudinal study designs and cost-benefit analyses, to fully understand outcomes from public involvement in health service design.