Effects of an Integrated 'Fast Track' Rehabilitation Service for Multi-Trauma Patients: A Non-Randomized Clinical Trial in the Netherlands.

Ans I E Bouman,Ton Ambergen,Henk A M Seelen,Pieter E Vos,Silvia M A A Evers,Henk Van De Meent,Peter R G Brink,Bea Hemmen,Andrea Martinuzzi

doi:10.1371/journal.pone.0170047

Abstract

ObjectivesThe effects on health related outcomes of a newly-developed rehabilitation program, called ‘supported Fast Track multi-trauma rehabilitation service’ (Fast Track), were evaluated in comparison with conventional trauma rehabilitation service (Care as Usual).MethodsProspective, multi-center, non-randomized controlled study. Between 2009 and 2012, 132 adult multi-trauma patients were included: 65 Fast Track and 67 Care as Usual patients with an Injury Severity Score ≥16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. The Fast Track program involved: integrated coordination between trauma surgeon and rehabilitation physician, shorter stay in hospital with faster transfer to a specialized trauma rehabilitation unit, earlier start of multidisciplinary treatment and ‘non-weight bearing’ mobilization. Primary outcomes were functional status (FIM) and quality of life (SF-36) measured through questionnaires at baseline, 3, 6, 9 and 12 months post-trauma. Outcomes were analyzed using a linear mixed-effects regression model.ResultsThe FIM scores significantly increased between 0 and 3 months (p<0.001) for both groups showing that they had improved overall, and continued to improve between 3 and 6 months for Fast Track (p = 0.04) and between 3 and 9 months for Care as Usual (p = 0.03). SF-36 scores significantly improved in both groups between 3 and 6 months (Fast Track, p<0.001; Care as Usual, p = 0.01). At 12 months, SF-36 scores were still below (self-reported) baseline measurements of patient health prior to the accident. However, the FIM and SF-36 scores differed little between the groups at any of the measured time points.ConclusionBoth Fast Track and Care as Usual rehabilitation programs were effective in that multi-trauma patients improved their functional status and quality of life. A faster (maximum) recovery in functional status was observed for Fast Track at 6 months compared to 9 months for Care as Usual. At twelve months follow-up no differential effects between treatment conditions were found.Trial RegistrationISRCTN68246661

Highlights

In recent decades, mortality rates in patients with severe injuries have dropped significantly due to advances in medical technology and improved trauma management in the pre-hospital and hospital phases [1,2,3]
The Functional Independence Measure (FIM) and Short-form 36 health survey questionnaire (SF-36) scores differed little between the groups at any of the measured time points. Both Fast Track and Care as Usual rehabilitation programs were effective in that multitrauma patients improved their functional status and quality of life
CAU, Care as Usual; FIM, Functional Independence Measure; FT, Fast Track; HADS, Hospital Anxiety and Depression Scale; Interquartile Range (IQR), interquartile range; ISS, Injury Severity Score; MMSE, Mini-Mental State Examination; SD, standard deviation; SF-36, Short Form 36 health survey questionnaire. a Values are numbers unless stated otherwise. b Significant p-value set at 0.05, two-tailed: 1) independent sample t-test, 2) Pearson’s Chi-square test, 3) one-way ANOVA, 4) Mann-Whitney U-test. c Scores of 25 or higher are considered as normal cognitive functioning

Summary

Introduction

Mortality rates in patients with severe injuries have dropped significantly due to advances in medical technology and improved trauma management in the pre-hospital and hospital phases [1,2,3]. Since a larger number of patients survive their injuries, rehabilitation services have become more important for enhancing a patient’s functional health status, quality of life (QoL) and reintegration into society. Khan and colleagues aimed to identify studies reporting rehabilitation outcomes for patients with multiple trauma, especially where the approaches were effective. They found some low-quality evidence, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, from observational studies to support multidisciplinary intervention in this population [7, 8]. There is a lack of comparative studies investigating outcomes between different trauma rehabilitation programs

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