Implementation and development of a chest wall trauma pathway to improve patient safety

Background

A Quality Improvement Project (QIP) at University Hospitals Dorset involving multiple specialties (Older People's Services, General Surgery, Pain Team, Anaesthetics, Emergency Department, Radiology, Pharmacy) focused on improving care for adult patients with Chest Wall Trauma. Incidence and severity increase significantly with age (recent audits found a 12% mortality), with complications that can be life-threatening. Key to good management are early injury recognition, effective pain control, frailty assessment, and timely escalation planning.

Introduction

A series of deaths following falls in older patients revealed delayed or missed diagnoses of traumatic haemothorax. In 56% of cases, significant chest trauma went unrecognised. A Chest Wall Trauma (CWT) pathway was introduced. A notable issue was reluctance among resident doctors to prescribe NSAIDs in older patients, with only 24.5% receiving appropriate NSAID therapy. Our aims: earlier recognition, frailty identification, optimal analgesia, and reduced morbidity/mortality.

Methods

The CWT pathway was developed through 3 PDSA cycles, using QI methodology. Retrospective data was collected via coded and bulk admission data. Initial cycles revealed under-recognition of injury, suboptimal analgesia, weak shared care between surgery and OPS, and limited escalation planning. These insights informed pathway iterations, now in its 4th version.

Results

Prompt injury recognition improved, with 94–96% of patients receiving early trauma CT scans. Paracetamol and opiates were prescribed in 100% of cases. NSAIDs remained underutilised in older adults (24.5% prescribed). Collaborative care improved markedly, with >94% of patients admitted under the most appropriate specialty (up from 58%). Escalation planning has been found to be reactive, with only 45% of patients having a documented escalation status during admission.

Conclusions

Timely injury recognition and appropriate ward admission have improved significantly. The 4th pathway iteration includes clearer NSAID guidance for older patients, structured escalation prompts, and digital integration within the Electronic Patient Record (EPR) improving availability of the pathway.

Research Ethics approval not obtained as Clinical Audit Facilitator did not feel it was necessary.