Seeking support after hospitalisation for injury: a nested qualitative study of the role of primary care

Background: In the UK, studies suggest that the transition from hospital to home after an injury can be a difficult time and many patients report feeling inadequately prepared. Patients often use primary care services after hospital discharge. These consultations provide opportunities to consider problems that patients experience and to facilitate recovery. Little is known, however, about how patients and service providers view care after hospital discharge and the role played by primary care services, specifically GPs. Aim: To identify good practice and unmet needs in respect of post-discharge support for injured patients. Design and setting: Qualitative study using semi-structured interviews at four sites (Bristol, Leicester/ Loughborough, Nottingham, and Surrey). Method: Qualitative interviews with 40 service providers and 45 hospitalised injured patients. Results: Although there were examples of well-managed hospital discharges, many patients felt they were not provided with the information they needed about their injury, what to expect in terms of recovery, pain control, return to work, psychological problems, and services to help meet their needs. They also described difficulty accessing services such as physiotherapy or counselling. Service providers identified problems with communication between secondary and primary care, lack of access to physiotherapy, poor communication about other services that may help patients, GP service and resource constraints, and difficulties in providing information to patients concerning likely prognosis. Conclusion: Discharge from hospital after an injury can be problematic for patients. Changes in both secondary and primary care are required to resolve this problem

Understanding and meeting information needs following unintentional injury: comparing the accounts of patients, carers and service providers

Objective. To explore information needs of unintentional injury patients and their carers over time, across services, and how such needs are met from the perspectives of patients, carers and service providers

Providing effective trauma care: the potential for service provider views to enhance the quality of care (qualitative study nested within a multicentre longitudinal quantitative study)

Objective: To explore views of service providers caring for injured people on: the extent to which services meet patients’ needs and their perspectives on factors contributing to any identified gaps in service provision

Seeking support after hospitalisation for injury: a nested qualitative study of the role of primary care

Background In the UK, studies suggest that the transition from hospital to home after an injury can be a difficult time and many patients report feeling inadequately prepared. Patients often use primary care services after hospital discharge. These consultations provide opportunities to consider problems that patients experience and to facilitate recovery. Little is known, however, about how patients and service providers view care after hospital discharge and the role played by primary care services, specifically GPs. Aim To identify good practice and unmet needs in respect of post-discharge support for injured patients. Design and setting Qualitative study using semi-structured interviews at four sites (Bristol, Leicester/ Loughborough, Nottingham, and Surrey). Method Qualitative interviews with 40 service providers and 45 hospitalised injured patients. Results Although there were examples of wellmanaged hospital discharges, many patients felt they were not provided with the information they needed about their injury, what to expect in terms of recovery, pain control, return to work, psychological problems, and services to help meet their needs. They also described difficulty accessing services such as physiotherapy or counselling. Service providers identified problems with communication between secondary and primary care, lack of access to physiotherapy, poor communication about other services that may help patients, GP service and resource constraints, and difficulties in providing information to patients concerning likely prognosis. Conclusion Discharge from hospital after an injury can be problematic for patients. Changes in both secondary and primary care are required to resolve this problem

Improving recovery - Learning from patients’ experiences after injury:A qualitative study

Objectives: To explore experiences of patients after injury and identify implications for clinical care and support within the hospital setting and primary care. Design: Semi-structured telephone administered qualitative interviews with purposive sampling and thematic qualitative analysis. Participants: Patients who have experienced an unintentional injury and attended hospital. Setting: Bristol, Surrey and Swansea. Results: Key issues that emerged were: most patients reported mixed experiences of hospital care but some described the delivery of care as depersonalising; the need for clinicians to provide adequate, timely and realistic information to patients about their injury and treatment to inform their expectations of recovery; the impact of pain at the time of the injury and for an extended period afterwards; the experience of injury on patients' emotional state with possible implications for longer term mental health issues; the pivotal role of physiotherapy care in providing practical and individualised strategies for recovery; and the importance of social support for recovery. Conclusions: Trauma patients' recovery needs to be supported by information protocols. The social circumstances of patients need to be considered at the point of discharge and during recovery. There is a need to identify people who may be experiencing mental health issues for timely referral to assessment services and appropriate care. Signposting to support groups may also be helpful for those with life changing injuries. Improved pain management would help alleviate discomfort and stress. Physiotherapy has a key role to play in supporting patients in recovery. © 2013 Elsevier Ltd. All rights reserved

Psychological morbidity and health related quality of life after injury: multicentre cohort study

Purpose To demonstrate the impact of psychological morbidity 1 month post-injury on subsequent post-injury quality of life (HRQoL) in a general injury population in the UK to inform development of trauma care and rehabilitation services. Methods Multicentre cohort study of 16–70-year-olds admitted to 4 UK hospitals following injury. Psychological morbidity and HRQoL (EQ-5D-3L) were measured at recruitment and 1, 2, 4 and 12 months post-injury. A reduction in EQ-5D compared to retrospectively assessed pre-injury levels of at least 0.074 was taken as the minimal important difference (MID). Multilevel logistic regression explored relationships between psychological morbidity 1 month post-injury and MID in HRQoL over the 12 months after injury. Results A total of 668 adults participated. Follow-up rates were 77% (1 month) and 63% (12 months). Substantial reductions in HRQoL were seen; 93% reported a MID at 1 month and 58% at 12 months. Problems with pain, mobility and usual activities were commonly reported at each time point. Depression and anxiety scores 1 month post-injury were independently associated with subsequent MID in HRQoL. The relationship between depression and HRQoL was partly explained by anxiety and to a lesser extent by pain and social functioning. The relationship between anxiety and HRQoL was not explained by factors measured in our study. Conclusions Hospitalised injuries result in substantial reductions in HRQoL up to 12 months later. Depression and anxiety early in the recovery period are independently associated with lower HRQoL. Identifying and managing these problems, ensuring adequate pain control and facilitating social functioning are key elements in improving HRQoL post-injury

What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? A qualitative study set within the UK National Health Service

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16–70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants’ interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying ‘their best’ despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care

Psychological morbidity and return to work after injury: multicentre cohort study

Background: The benefits of work for physical, psychological and financial wellbeing are well documented. Return to work (RTW) after unintentional injury is often delayed, and psychological morbidity may contribute to this delay. The impact of psychological morbidity on RTW after a wide range of unintentional injuries in the UK has not been adequately quantified. Aims: To quantify the role of psychological factors including anxiety, depression and post-traumatic distress on RTW following unintentional injuries. Design and Setting: Longitudinal multi-centre prospective study in Nottingham, Bristol, Leicester and Guildford, UK Method: Participants (n=273) were 16-69 year olds admitted to hospital following unintentional injury and, in paid employment prior to injury. They were surveyed at baseline, 1, 2, 4 and 12 months following injury on demographic and injury characteristics, psychological morbidity and RTW status. Associations between demographic, injury and psychological factors and RTW status were quantified using random effects logistic regression. Results: The odds of RTW reduced as depression scores one month post-injury increased (OR 0.87, 95%CI 0.79, 0.95) and as length of hospital stay increased (OR 0.91, 95%CI 0.86, 0.96). Those experiencing threatening life events following injury (OR 0.27, 95%CI 0.10, 0.72) and with higher scores on the crisis social support scale (OR 0.93, 95%CI 0.88, 0.99) had a lower odds of RTW. Multiple imputation analysis found similar results except crisis social support did not remain significant. Conclusion: Primary care professionals can identify patients at risk of delayed RTW who may benefit from management of psychological morbidity and support to RTW

Mental health and other factors associated with work productivity post injury in the UK: multicentre cohort study

Introduction: Mental health conditions are a major contributor to productivity loss and are common post-injury. This study quantifies post-injury productivity loss and its association with pre and post-injury mental health, injury, demographic, health, social and other factors. Methods: Multi-centre, longitudinal study recruiting hospitalised 16-69-year-old employed individuals with unintentional injuries, followed-up at 1,2,4 and 12 months. Participants completed questionnaires on injury, demographic factors, health (including mental health), social factors, other factors and on-the-job productivity upon return to work (RTW). Odds ratios were estimated for above median productivity loss, using random effects logistic regression. Results: 217 adults had made a RTW at 2,4 or 12-months post-injury: 29% at 2-months, 66% at 4-months, and 83% at 12-months. Productivity loss reduced over time: 3.3% of working time at 2-months, 1.7% at 4-months, 1% at 12-months. Significantly higher productivity loss was associated with pre-injury psychiatric conditions (OR 21.40, 95% CI: 3.50, 130.78) and posttraumatic stress avoidance symptoms at 1-month (OR for one-unit increase in score 1.15, 95%CI 1.07, 1.22). Significantly lower productivity loss was associated with male gender (OR 0.32, 95%CI 0.14, 0.74), upper and lower limb injuries (vs other body regions, OR 0.15, 95% CI: 0.03, 0.81), and sports injuries (vs. home, OR 0.18, 95% CI: 0.04, 0.78). Pre-injury psychiatric conditions and gender remained significant in analysis of multiply imputed data. Conclusions: Unintentional injury results in substantial productivity loss. Those with pre-injury psychiatric conditions, females and posttraumatic stress avoidance symptoms experience greater productivity loss and may require additional support to successfully RTW

The UK Burden of Injury Study - a protocol

Background Globally and nationally large numbers of people are injured each year, yet there is little information on the impact of these injuries on people's lives, on society and on health and social care services. Measurement of the burden of injuries is needed at a global, national and regional level to be able to inform injured people of the likely duration of impairment; to guide policy makers in investing in preventative measures; to facilitate the evaluation and cost effectiveness of interventions and to contribute to international efforts to more accurately assess the global burden of injuries. Methods/Design A prospective, longitudinal multi-centre study of 1333 injured individuals, atttending Emergency Departments or admitted to hospital in four UK areas: Swansea, Surrey, Bristol and Nottingham. Specified quotas of patients with defined injuries covering the whole spectrum will be recruited. Participants (or a proxy) will complete a baseline questionnaire regarding their injury and pre-injury quality of life. Follow up occurs at 1, 4, and 12 months post injury or until return to normal function within 12 months, with measures of health service utilisation, impairment, disability, and health related quality of life. National estimates of the burden of injuries will be calculated by extrapolation from the sample population to national and regional computerised hospital in-patient, emergency department and mortality data. Discussion This study will provide more detailed data on the national burden of injuries than has previously been available in any country and will contribute to international collaborative efforts to more accurately assess the global burden of injuries. The results will be used to advise policy makers on prioritisation of preventive measures, support the evaluation of interventions, and provide guidance on the likely impact and degree of impairment and disability following specific injuries