Implementation, evaluation and refinement of an intervention to improve blunt chest injury management

Prof. Kate Curtis1,2,6, Dr Connie Van1, A/Prof Stephen Asha2,5, Dr Mary Lam3, Dr Annalise Unsworth2, Dr Louise Atkin5, Dr Madison Reynolds6

1Sydney Nursing School, Sydney, Australia, 2St George Clinical School, Faculty of Medicine, University of New South Wales, High Street, , Kensington, Australia, 3Faculty of Health Psychology, Health Information Management, Genetic/Bioinformatics. University of Technology, Sydney, Australia, 4Centre for Behaviour Change, University College London, London, England, 5Emergency Department, St George Hospital, Kogarah, Australia, 6Trauma Service, St George Hospital, Kogarah, Australia

Failure to treat even one rib fracture early with sufficient analgesia, physiotherapy and respiratory support can lead to pneumonia, respiratory failure and/or death. Introduction of an early notification protocol for isolated blunt chest injured patients (ChIP) in our major trauma centre initiated consistent, multidisciplinary, tailored patient care that reduced the odds of patients developing pneumonia by 56%. The overall uptake of the protocol however was poor (68%) and factors which hindered or helped activation unknown.


– To determine factors influencing protocol uptake

– Identify evidence informed interventions to improve protocol use

– Re-implement and evaluate protocol compliance

Methods: Two methods were used in this mixed methods study conducted from 2012-2016.

1) Review of 603 linked trauma registry and medical records to identify any patient characteristics influencing protocol activation, and

2) Survey of 99 hospital staff to identify implementation barriers and facilitators. The survey was mapped to the Theoretical Domains Framework (TDF), known to impact clinician behaviour change.

Quantitative data were analysed using descriptive statistics, qualitative data coded in NVivo10.  Interventions to change target behaviours were sourced from the Behaviour Change Technique Taxonomy in consultation with stakeholders.

Principle findings: Eligible patients who did not receive ChIP were not different in demographic or clinical characteristics to those that did. Fifteen facilitators and 10 barriers were identified by staff. Seven interventions were selected to address target behaviours including modelling, training, persuasion and social influence. A multifaceted relaunch strategy, including video, targeted the motivation of activators and responders and the empowerment of nursing staff. In the 4 months post relaunch, uptake improved to 91% (p=.001).

Conclusions: Behaviour change theory may be used to improve clinical protocol implementation in the ED context. Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions.


Kate has been an emergency and trauma nurse clinician since 1994 and is Professor of Trauma and Emergency Nursing at the University of Sydney, where she leads the Paediatric Critical Injury Research Program. She is an honorary Professorial Fellow at the George Institute for Global Health and in 2011 was awarded the Frank McDermott Award for research completed and published in the last 10 years judged to have led to the greatest improvements in care of severely injured patients in Australia and NZ. Kate’s translational research program continues to focus on improving the way we deliver care to patients and their families and she is the world’s most published author in the field of Trauma and Emergency Nursing. Kate is also on the Editorial Board of the Australasian Journal of Emergency Nursing and a Fellow of the College of Emergency Nursing Australasia.