Refinement of an evidence informed care bundle for blunt chest injury

Ms Sarah Kourouche1, Professor  Kate Curtis1,2,3, Associate Professor Thomas Buckley1, Dr Belinda Munroe1,3

1University Of Sydney, Camperdown, Australia, 2The George Institute for Global Health,  Sydney, Australia, 3Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, Australia

Background: Blunt chest injuries, especially rib fractures, are associated with high rates of morbidity and mortality. In 2012, a Chest Injury Protocol (ChIP) was introduced at a Level 1 Trauma Centre in Australia. However, uptake of this protocol was poor (only 68%). One of the identified barriers to use of the protocol was a lack of information on what care to initiate for the patient. To address this gap, a review of the literature to enable inclusion of evidence-based treatment options in the protocol was conducted.

Objective: To determine the levels of evidence for blunt chest injury management and develop a blunt chest injury care bundle.

Methods: A literature review of primary research articles using MEDLINE, CINAHL, and Scopus from 1990 – April 2017 was conducted. Additional studies were identified by hand-searching bibliographies.

A two-step selection process was performed. All published and unpublished primary research studies were included according to the PICO: investigated human patients with blunt chest trauma in acute settings (P), Received any intervention for blunt chest injury (I), any comparator (C), and with any resulting outcomes (O).

A two-step data extraction process using pre-defined data fields, including study quality indicators. Each study was appraised using a quality assessment tool and scored for level of evidence.

Results: The search yielded a total of 1893 citations. Following duplicate removal, 1544 records were screened, and 215 full-text articles were reviewed.  Interventions identified in the literature included surgical rib fixation, incentive spirometry, multimodal analgesia, and epidural and paravertebral blocks. The level of evidence for interventions varied from weak to strong recommendations.

Conclusions: The review provided the supportive evidence to inform and develop the ChIP bundle.


Sarah Kourouche has a keen interest in trauma; having worked in emergency and trauma for many years. She completed her Bachelor of Nursing in 2004; she has worked in St George Hospital since in the areas of orthopaedics, intensive care, operating theatres, emergency and trauma as a trauma case manager. She completed a Master’s degree in Emergency and Trauma Nursing through the University of Newcastle in 2010. She has been teaching at the Sydney Nursing School since 2013; teaching preregistration in both the Bachelor and Master’s programs. She is currently working towards a PhD through the University of Sydney investigating the implementation of a care bundle for patients with blunt chest injury.