Changes

February 2022 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

Goals

To support primary healthcare professionals to:

• Support people with complex rehabilitation needs after traumatic injury following discharge from secondary care.  
• Coordinate rehabilitation care where appropriate.
• Follow up people at appropriate intervals to monitor progress against the rehabilitation plan. 
• Refer people to the specialist rehabilitation team where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

NICE quality standards

Rehabilitation after critical illness in adults

• Adults in critical care at risk of morbidity have their rehabilitation goals agreed within 4 days of admission to critical care or before discharge from critical care, whichever is sooner. 
• Adults at risk of morbidity have a formal handover of care, including their agreed individualised structured rehabilitation programme, when they transfer from critical care to a general ward.
• Adults who were in critical care and at risk of morbidity are given information based on their rehabilitation goals before they are discharged from hospital.
• Adults who stayed in critical care for more than 4 days and were at risk of morbidity have a review 2 to 3 months after discharge from critical care.

[NICE, 2017]

Transition between inpatient hospital settings and community or care home settings for adults with social care needs

• Adults with social care needs who are admitted to hospital have existing care plans shared with the admitting team.
• Older people with complex needs have a comprehensive geriatric assessment started on admission to hospital.
• Adults with social care needs who are in hospital have a named discharge coordinator.
• Adults with social care needs are given a copy of their agreed discharge plan before leaving hospital.
• Adults with social care needs have family or carers involved in discharge planning if they are providing support after discharge.

[NICE, 2016]

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

What is it?

• Rehabilitation is a process of assessment, treatment and management with ongoing evaluation by which the individual (and their family/carers) are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society and quality of living [BSRM, 2018].
• Complex rehabilitation refers to multiple needs involving coordinated multidisciplinary input from two or more allied health professional disciplines, and could also include [NICE, 2022]: 
  • Vocational or educational social support.
  • Emotional, psychological and psychosocial support.
  • Equipment or adaptations.
  • Ongoing recovery from injury that may change the person's rehabilitation needs (for example, restrictions on weight-bearing, cast immobilization in fracture clinic).
  • Further surgery and readmissions to hospital.
• Traumatic injury is any injury that requires admission to hospital at the time of injury. This includes [NICE, 2022]:
  • Musculoskeletal injuries.
  • Visceral injuries.
  • Nerve injuries.
  • Soft tissue damage.
  • Spinal injury.
  • Limb reconstruction.
  • Limb loss.
• Note: complications from some minor injuries can also require hospital admission.

How common is it?

• In England, 45,000 people are affected by very severe or major trauma every year, [NICE, 2022].
  
  • A further 500,000 people experience less severe trauma, and a proportion of those will need hospital admission because of pre-existing conditions, disability, frailty, or because the functional impact of injuries and environmental factors means that they are not able to manage in their own home.
• Trauma affects all age groups [NICE, 2022]. However, a review of the Trauma Audit Research Network (TARN) database (which collects data on patients suffering from trauma in England and Wales, Ireland and some hospitals from Continental Europe) of people presenting to hospitals in England between 2021 and 2017 (n = 307,307), found that [Dixon, 2020]:
  • The overall median age of people in the study was 63.6 years (51.5% were male). 
    • The median age for people solely cared for in a major trauma centre (MTC) was 56.6 years (60% were male), and people cared for outside of MTCs was 72.1 years and predominately female (53.2%).
  • The main mechanism of injury in adults, particularly in older people, was a fall from less than 2 metres (57.8% of all TARN cases). 
    • Falls from less than 2 metres accounted for 43.9% of injury mechanisms in MTCs, and 72.4% in non-specialist hospitals respectively.
    • In people aged over 65 years treated at non-specialist hospitals or local emergency hospitals the median age was 83.4 years, and 86.9% of these people sustained falls from 2 metres or less.
  • Paediatric trauma accounted for less than 5% of trauma cases.
• A review of data from the TARN database from 2008 to 2017 found over 40,000 cases of adolescent trauma. Of these around 77% were in males and 80% were aged 16-24 years [Roberts, 2020]. 
  • The most common causes were road traffic collisions (50%) and intentional injury (20%).

What are the complications?

• Complications of traumatic injury include: 
  • Reduced quality of life (both physically and mentally).
  • Problems with mobility, pain, breathing, swallowing, eating, drinking, toileting, cognitive function, speech, language and communication, and sensory problems.
  • Depression, anxiety, and other psychological difficulties. 
• Complications may be influenced by pre-existing medical conditions. 
• Major trauma is the commonest cause of death in children and in adults aged under 40 years. 

[NICE, 2022]

Scenario: Management

From birth onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of rehabilitation after traumatic injury.

Search dates

January 2017 - December 2021

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• Exp Rehabilitation/ Exp Major trauma/
• (trauma$ adj5 (burn$ or accident$ or wound$ or injur$ or fractur$)).ti,ab.
• (polytrauma$ or poly-trauma$ or traumatolog$).ti,ab.
• (trauma$ adj3 (severe or severely or major or multiple)).ti,ab.
• ((complex$ or multiple or critical$) adj3 (injur$ or wound$ or burn$ or fractur$)).it,ab.
• Exp Patient discharge/ Exp Transitional care/ Exp selfcare/ Exp aftercare/ Exp community health services/

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work(occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug & amp; Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium(HMIC)

Patient experiences

• Healthtalkonline
• BMJ - Patient Journeys
• Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary(BNF)
• electronic Medicines Compendium(eMC)
• European Medicines Agency(EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency(MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.