Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation

Abstract

BackgroundIneffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. ObjectiveThe purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. MethodsThis is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test. Results/FindingsOver the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8–9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2–17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5–3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5–5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3–2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1–16.1]). ConclusionsHigh fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.