Major trauma is the term used to describe a serious injury that could cause permanent disability or death1(Nice Guideline, 2016). According to National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2007, it is the fourth largest cause of death in the UK, and the number one cause of death in the first four decades of life7. A series of recent high-profile reports, including the National Audit Office (NAO)’s Major trauma care in England, has made trauma a national priority for the NHS (8. Implementing trauma systems: Key issues for NHS). There has been focus on developing trauma care in the last few years with the National Health Service (NHS) Outcomes Framework (Department of Health (DoH) 2013)6 Domain 3 being focused on survival for major trauma. In order to improve and further develop high-quality trauma care, trauma centres need to review their activities continuously and patients’ experiences should be mandatory in such an evaluation.5
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As good trauma care involves getting the patient to the right place at the right time for the right care (NHS UK, 2014), major trauma centres (MTC) are set up to provide the specialized care with doctors from multidisciplinary specialization. Effective and Rapid treatment of trauma patients is important for reducing short-term as well as long-term mortality and morbidity [2–4] and for avoiding physical, psychological and financial impact to the patients as well as to their family members. The initial assessment of major trauma patients’ is challenging with minutes making the difference between life and death and this involves rapidly identifying injuries, completing investigations and accessing specialist care as soon as possible after arriving the hospitals. 9 After the emergency resuscitation procedures, when the patient becomes stable in his own condition, he will be transferred to the ward for further routine medical treatment until discharge.
Many studies had been done concerning with trauma patients at emergency department. O’ Brien and Fothergill- Bourbonnais (2004) explored that a dynamic combination of efficiency and caring on the part of trauma team members created an environment in which patients felt safe 10. Jay (1996) described that touch, company and information were important in coping and regaining control as well as the need to trust the healthcare professionals11. Other studies of Franzen et al (2008) and Wiman et al (2006) presented that participants were more confident, satisfied and gained comfort from professionals who treated them with both good physical care and psycho-social care12. Despite the previous great studies about the trauma patient care at emergency department, little is known about the actual encounter of major trauma patients on the full trauma team care of emergency departments in UK. Basically, realizing the needs of major trauma patients during their admission at major trauma centers is necessary to make improvement of existing emergency departments in the UK.
Aim and Objectives
The aim of this study was to understand the trauma patients’ personal experience of trauma center during the emergency and then at the stable periods.
The objectives of this study were to narrate the real image of major trauma patients at emergency centers, to realise their needs in receiving the health services of emergency departments and to listen to their feedbacks which would be helpful in developing high quality trauma care centers in the UK.
Design and Setting
This study was a qualitative interview study designed to capture the major trauma patients’ admitted experience at emergency departments. The study had a hermeneutic phenomenological approach14 as the researcher considered that being the major trauma patient at ED can reflect the real situation and needs of the patients at the major trauma centers (MTC) in the UK. In the methodology of Van Manen, a phenomenological descriptive sensitivity is combined with an interpretive understanding of the lived experience and how this is given meaning. Hermeneutic phenomenology is the study of life world and may be accessed and studied through the four lifeworld essentials; live body, lived time, lived space, and lived other. These existentials are described as the fundamental structure of every person’s lifeworld.14
This qualitative study was conducted at a trauma ward of Major Trauma Center (MTC) of National Health Service (NHS) in London, UK.
Study Context and Participants
Ten patients admitting to the trauma ward after receiving full major trauma care of MTC were interviewed. The participants were selected by using the pragmatic convenience sample irrespective of gender, ethnicity and socioeconomic status allowing to include a diverse group of patients if they fit with the inclusion and exclusion criteria.
Inclusion criteria were: (1) Age- 18 years or older (2) Major Trauma Patient (ISS- 16 or greater) (3) Glasgow Coma Scale Score- 13 or above (4) Revised Trauma Score- 10 or above (5) trauma code 15 initiated in the emergency department (6) physically and cognitively capable of participating in an interview in English (7) Required admission to hospital. Those who comatose or sedated during the initial trauma treatment, who were still having severe illness physically or mentally, who admitted directly to intensive care unit or discharged from the ED were excluded from the study.
All patients admitted at the trauma ward at the time of study were considered and a member of trauma care team selected the potential participants based on their medical condition, inclusion and exclusion criteria. Then, they were invited to get involve in the study by letting know the aim as well as potential benefit of the study and those that agreed to see the researcher were approached. The researcher did not have access to the patients’ medical records, so all mechanism of injury, diagnosis and personal experience of health services were according to the patients’ understanding. Each patient was assigned a pseudonym.
The ethical issues concerned with this study was the confidentiality of the patient and emotional distress that could be resulted by reflecting frustrating traumatic event again. The researcher was a fulltime MSc Health Management student during the study and identified herself as being independent from the hospital or providing trauma care in the ED. Before each interview, written informed consent form was obtained from every single patient and for the sake of participant’s confidentiality, a code was given to each form and used for further data processing. Consent forms and data were kept separately. The impact of discussing a sensitive topic was reassured by informing the patient that participation was voluntary and that consent could be withdrawn at any time without jeopardizing their treatment or care.
Interview and Data Collection
One-on-one semi-structured tape-recorded interviews were conducted as soon as the patient felt they could participate in the interview session ranging between first and third weeks after the injury event. The reason behind semi-structured interview was to know the actual experience and feedbacks of trauma patients within the boundary of research aim and objectives. In response to several patients’ expressed concern that they did not know where to begin in telling their story starting from the initial arrival to ED to trauma ward, open-ended questions were asked to explore their emotional, medical and social encounters at the time of emergency as well as during their stable period. Questions such as “Can you talk me through what you remember about arriving in A & E” “Can you remember how you were feeling when it first happened” were asked. Follow up questions, “Can you give an example” “What was it that made you feel like you were in good hands”, were used to clarify thoughts, feeling and experiences if this information did not appear in the narrated story 16. Finally, participants were asked what they would change at the emergency department for their feedbacks and opinion. Each interview lasted from 30 to 60 mins and were transcribed verbatim.
Data analysis of this study followed Colaizzi’s analytical approach: abstracting approach: abstracting from patients’ words to formulate the essential meanings in the experiences; meanings were then grouped into categories, and finally themes emerged17. After several readings, transcripts were analysed line by line to identify key words and phrases that were subsequently color coded. Codes were operationally defined to be consistent throughout the study10. The codes were grouped into categories and sub categories. Truth-value, applicability, consistency, and neutrality were used in this study to ensure trust worthiness of the data and subsequent analysis10,17.
The overall experiences of major trauma patient in the emergency department was a mixture of personal emotions and pain due to trauma, perceptions of receiving health service as well as support from major trauma care team and their feedbacks or opinions upon this experience. The encounters were described along continuum from the time of emergency up to the stable period at ward by various aspects. There were 4 themes arose during the analysis of the data: Emotional Aspect, Medical-Technical Aspect, Environmental Aspect, Social Aspect.
Theme 1: Emotional Aspect
Due to the impact of trauma, the participants attained various frustrating emotions during their emergency period and described in details about their emotional experiences.
Participants described in details how they had the accident, who were there at the time of injury and how they reached to the hospital. Sometimes they used the phrase “I can’t remember”, there were some intermittent gaps and approximations of their experience and hallucinations or feeling of detachment and they gave the reasons for not being able to recall. One of the participants expressed that “Your mind is on the other things. Yeah, about 10%, that’s all I remember”. (P-5) Some were due to pre-hospital analgesia and illustrated as “felt a bit in the clouds”.
I encountered tragedies
Participants expressed powerful emotional distress by being in shock, in pain, uncertain and stressed as they experienced during their emergency period. They could not believe that they were having the accident which made them in shock and it was overlapped with the pain due to the injuries. The participants got the feeling of on their own to “get through” the experiences. Descriptions of the tragedies included words like “So frightening”, “So Scary”, “In shock really. Couldn’t believe it had actually happened”. Moreover, their stress was converged with the lack of medical knowledge or uncertainty about the extent of their injury as well as the treatment offered to them initially. One answered that “I said my goodbyes” even when he got to A & E. It was true that their burden of emotional trauma did not end after their recovery as they were still concerned about their psychological distress: “I don’t think I’ll ever forget it. That’s going to go to me grave this is.” “It is still in the background. I’m suppressing it”. (P-2, 5)
I was worried
When the whole situation was out of control, the only thing participants could do was being worried about their concerned cases individually. In this analysis, not only the current situation but also the future potential complications were found as the factors that made the participants to be worried. They were initially concerned with the conditions of themselves, their family members and some police related accident records for insurance thereafter they became stressed about repeated injury or future potential operations as a complication of current trauma during their stable period: “Oh no. It’s gone but I still think It could come back at any time” “Also in the distance future, am I going to end up having a hip replacement because of this? That’s quite painful as well”. (P-5)
Theme 2: Medical- Technical Aspect
Despite the above emotional experiences, most of the participants felt like they were in safe hands due to well organized effective trauma care team and their caring nature to the patients during the emergency period. The participants described this process as “top quality care” for having the best service and communication compared to the previous experiences at A & E. The positive atmosphere of participants relating with medical- technical aspect came from the trauma care team’s “all in harmony”, “everything went so quick” and “good pain management” activities.
All in Harmony
Almost all of the participants described their satisfaction for the dynamic combination of efficiency, consistency, alertness and team work of emergency department. The important thing for the patients’ feeling of safe during initial resuscitation was the belief that they were being cared by well-organized expert trauma care team. Patients recognized that the whole team was in control with a large number of staff each with their own role working with compassion. One participant illuminated that “the amount of people around me. It wasn’t one or two, it was at least ten! They all had a job to do and they did it, in sequence and sometimes in parallel, they just knew what to do and they did it” “in A & E they were all in harmony with each other”. (P- 4)
Everything went so quick
The fast pace of the staff, the quick actions in emergency period and no need to wait for investigation procedures made an impression on patients. The phrase “When I got here it didn’t feel like I had a long wait or anything like that, I was constantly being attended to” suggested that combination of efficient delivery of care, good communication by the staff and quickness of the processing created the positive view of trauma patients in ED. (P-6)
As the patients varied, the results would also be different which elaborated both positive and negative perceptions of pain management experience. Although there were remarkable expressions of pain during the initial period with the words like: “really bad” “absolutely horrendous”, most of the patients figured out that awareness of pain in the emergency department was well controlled and admitted that they never felt like in real agony despite their major trauma later. But there was a patient who regretted for having “morphine” as he said “It felt like my body, my whole body was exploding, …terrible, I just wanted to roll up and die”. And a participant suggested to be gentler in doing procedures as he felt the pain even after all.
Theme-3: Social Aspect
Patients experienced feelings of confidence, comfort and certainty about their situation as well as their medical treatment due to formal and consistent communication by responsible doctor and nurse during the emergency period. They noted that they were in safe hands and rapid attention was appreciated. “…. kept you up-to-date with everything. They didn’t do anything outside the normal procedure without involving you into the discussion”.
Combination of pastoral and humoristic communications created “feeling better” experience of the participants by being taken care with respect and kindness as individuals, always keeping reassured by one of the team members and being never left alone. Repeated descriptions of staff availability with the words like “as careful as possible”, “helpful”, “it was all open so if I needed anything I just had to, there was someone there watching all the time as well” reflected great communication of staff and professionals in ED. Humors were sometimes made to get more engagement between the staff and patients and to reduce stress of being in an holistic care: “ They were joking with me about how heavy I was (laughs) yeah I think it was 5 of them that out me from the stretcher onto the bed”. (P- 6)
Having family besides was a great reassurance for the patients and a sense of relief could be obtained that staff were asking to contact anyone the patients wanted to be with. However not every participant would like to be with their family as they worried that their family might have shocked and frightened to see his condition.
This form of communication was usually found during stable condition of patients before discharge. Although there were positive feedbacks concerning with communication at initial health service of emergency department, most of participants didn’t satisfy with the service in trauma ward especially complained for lack of information and proper communication. “I’m a bit disappointed, moved from the A & E department to here where no one has been to see me, no doctors have been to see me, and no one has advised me anything”. (P-4)
Theme 4: Environmental Aspect
Since from the time participants get to major trauma center, they had encountered with holistic hospital environment as well as various kind of people around him which let them perceive their own opinion about the surroundings. This involves all of building elements such as walls, ceilings, windows and floors as well as specific ED equipment. What patients saw, heard, smelled and felt were added to how they experienced from environmental aspect of emergency department.
As most of the participants were with hard collars once they reached to the ED for their major trauma, their initial scene of hospital environment was restricted apart from ceiling, sky and bright lights. Most of the participants gave good reviews for A & E environment being spacious, clean, and comfortable. One used the phrase “Brightness. Just the ambience of the place. I don’t know whether it’s because it’s new, but it made me feel safe”. (P- 4). There were some disturbances that participants mentioned during their emergency period: “Sort of noisy….. Oh my god all these machines beeping” where noise was major factor with the collection of machines around. (P-1)
Being in the major trauma care centre, participants experienced not only with the staff and professionals but also with the other emergency patients encountering every single thing they behaved. Some participants received it as noise by saying as “Lots of people talking to each other. One would start and when that one stopped the other one started” while the other one perceived those moaning as feeling lucky for not being that person: “I think there was a guy next to me who had suffered burns or something like that and then there was another guy next to me who had got stabbed you know. I think I could just hear a lot of shouting in pain from the other patients. I’m quite lucky. I’m not that person”. (P- 8)
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