Implementing an integrated approach to self-management support in an acute major trauma therapy team: an improvement project

Abstract

More patients now survive multiple trauma injuries, but the level of long-term unmet needs is high. Evidence shows self-management support can improve patients ’ confidence to manage these needs but traditionally this support starts post-hospital. Starting self-management support early could prepare patients and families for successful transitions from hospital. The skills and commitment of clinicians have been shown to contribute to the success or failure of self-management approaches. The aim of this project was to explore the feasibility of integrating self-management support in an acute major trauma setting by evaluating the impact of an educational intervention on clinicians’ knowledge, attitudes and behaviours regarding self-management support and identifying any barriers and facilitators to integrating self-management into daily practice. Two improvement cycles were carried out over a 1-year period involving 18 allied health professionals (AHPs) in an acute major trauma centre in London, UK. An educational intervention, ‘Bridges Self-Management Programme’ was modified for the setting. The impact was evaluated using (1) a clinician questionnaire to evaluate knowledge and attitudes; (2) case reflection forms and (3) peer review to observe interactions to integrate self-management support. Questionnaire data were summarised and pre-training and post-training scores compared; the qualitative data from written case reflections, verbal and written feedback from training and group discussions was described and analysed thematically. The result of two improvement cycles has shown it was feasible to improve AHP’s knowledge, attitudes and change behaviours regarding self-management support in the acute trauma setting, but difficult to sustain change beyond 6 months. Key barriers such as the pressure to discharge patients and support within the wider multidisciplinary team (MDT) were identified. Facilitators included the introduction of a new key-worker, to enable shared team approaches and paperwork to involve patients and families in goal setting and treatment planning. The main learning was to ensure sustainability mechanisms from the outset, engage the wider MDT in training, and integrate self-management language and principles into team processes.

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation: A scoping review on the implementation of TQIPs across income levels

“…The implementation of a multi-hospital injury surveillance program in Mozambique was driven by local data collectors that enhanced the sustainability of the project [16]. Tailoring programs to local conditions is often made di cult by individuals' resistance to change [9,29]. An educational self-management intervention in a trauma centre in the UK revealed that the roll-out of support was hindered by team members preferring to continue with established practices, which limited widespread adoption [29].…”

“…Prioritising patient care during implementation was widely addressed [19,29,32,36]. A Dutch evaluation of the implementation of the Transmural Trauma Care Model found that patients' experience improved as more focus was placed on day-to-day issues patients encountered [32].…”

“…A Dutch evaluation of the implementation of the Transmural Trauma Care Model found that patients' experience improved as more focus was placed on day-to-day issues patients encountered [32]. However, time constraints were a key barrier to providing improved patient care [9,15,17,22,23,26,29,32]. A Peruvian study on the status of in-hospital TQIPs revealed the "prevalence of dual practice" [9 p.966], surgeons working at both public and private institutions, meant that clinicians did not have time to effectively participate in emerging QI initiatives.…”

“…Increased staff education and training strengthened the implementation climate of QI interventions [14,16,17,20,21,25,27,29,30,36,38]. An integrated self-management support paper emphasised successful training as accessible to staff at all levels, with a focus on exibility [29]. Professional hierarchies acted as a barrier to the continued education of all staff [9,21,29,30].…”

Embedded rehabilitation in major trauma: Retrospective pre-post observational study of service and patient outcomes

“…The coordination role provided by the dedicated therapy team across the MTC through completion of the rehabilitation prescription increases the identification and assessment of individuals who would benefit from a range of therapeutic interventions from appropriately trained clinicians and professional services. Consequently, we anticipate the changes to outcomes to not only be due to changes to rehabilitation, but to actually reflect the wider cultural change in modern trauma care involving greater integration of supportive and associated services, resulting in improved multidisciplinary team working [20][21][22] . It is also possible that other factors contributed to improved outcomes but were not able to be studied, such as improved expertise, equipment changes and improvements to the identification and management of trauma prior to arrival.…”