The Management of Patients with Polytrauma During Hospitalization and After Discharge Amongst South African Physiotherapists

Abstract

Background: Trauma has been described as an “epidemic” in South Africa. It is a resource intensive and health and economic burden. Patients with polytrauma present with multiple orthopaedic injuries and long-term complications. Rehabilitation is the tool that has been employed to mitigate the injuries that patients with a traumatic injury present with. There is adequate reporting of rehabilitation of patients with a traumatic injury in developed countries. On the other hand, studies in these countries, that describe the physiotherapy management in patients with polytrauma are of a low level of evidence. There has been no reporting on physiotherapy management of patients with polytrauma in South Africa. Aim: To describe the management that physiotherapists in South Africa provide to patients with polytrauma during their hospitalisation and after hospital discharge. The objectives were to a) describe the demographics of the physiotherapists and the patients that they treat, b) describe the respiratory and neuromusculoskeletal management of these patients during hospitalization, c) describe the neuromusculoskeletal management of these patients after discharge from the hospital, d) identify the outcome measures used by physiotherapists in patient care, and d) describe the barriers and facilitators that the physiotherapists encounter during patient management. Methods: A descriptive cross-sectional study was done. A study-specific questionnaire was developed, and content and face validation were done. The questionnaire was captured on REDcap and the link to the questionnaire was circulated to members of the South African Society of Physiotherapy, Trauma Society of South Africa, Physiotherapy Association of South Africa, and the Izandla Consulting Physiotherapy Network by their respective secretariats. The inclusion criteria were physiotherapists who a) work at a trauma centre in the public or private healthcare sector in South Africa and b) frequently encounter and treat patients with polytrauma in centres not known to be formal trauma centres in South Africa. Purposive sampling was used and thereafter snowball sampling was used due to poor response rate to the initial survey invitation. The data collection duration was for ten months from July 2023 to May 2024. Descriptive statistics were used to summarise the data collected. Categorical data are reported as numbers and percentages. Continuous data are reported as median and interquartile range for non-normally distributed data. Missing data was treated as missing. Information obtained through participant responses to the open-ended questions in the questionnaire were analysed using an inductive approach to thematic content analysis. Results: Sixteen questionnaires were received but only 12 questionnaires contained enough information to be included in the analysis. All participants were female and 83% worked in the private sector. Participants reported a median of 6.5 (3-13.8) years of experience working with patients with iii polytrauma. All participants reported that they see more male than female patients who are admitted with polytrauma injury. Most of their patients are aged between 21 and 40 years. Fifty percent of the participants (n=6) reported that they ‘always’ managed patients with a chest injury. Most participants (n=5, 42 %) reported that they ‘sometimes’ manage patients with injuries to the abdomen, and most participants (n=7, 58 %) reported that they ‘often’ manage patients with injuries to the pelvis. Forty two percent of the participants (n=5) reported that they ‘always’ treat patients who are intubated. Whereas 50% of the participants (n=6) reported that they ‘always’ treat patients who have undergone surgical intervention. Most participants (n=8, 67%) reported that they ‘always’ do active breathing exercises for pulmonary care of their patients. Positioning for ventilation-perfusion matching (n=8, 67%), suction (n=7, 58%) and incentive spirometry (n=7, 58%) were ‘often’ used by many participants in patient care. Most participants (n=8, 67%) reported that they ‘never’ used a cough assistive device or intermittent positive pressure breathing. Most participants (n=9, 75%) reported that they ‘often’ use bridging for in-bed rehabilitation. Additionally, 50% of the participants (n=6) reported that they ‘often’ incorporate active assisted exercises and active exercises for the upper limbs and lower limbs. Whereas 33% of the participants (n=4) reported that they ‘always’ incorporate active assisted exercises in their treatment. Most participants reported that they ‘always’ include muscle strength training with a theraband (n=10, 83%) or the patient’s bodyweight (n=11, 92%) as part of patient management. Factors that influenced participants’ ability to mobilise their patients include type of injuries sustained, outcomes of discussions with the doctors, the patient’s level of alertness, and time to surgery. Most participants (n=9, 75%) reported that they ‘always’ use sit-to-stand activities. In addition, 83% of the participants (n=10), reported that they ‘always’ include gait re-education as mobilisation strategies during in- patient care. Some participants (n=4, 33%) ‘always’ included education to the patient’s family and education. Furthermore, 42% of the participants (n=5) ‘always’ pain management strategies in their patient management prior to hospital discharge. Some indicated that they educated their patients about their home exercise programmes (n= 2, 17%), attending follow up services after discharge (8%, n=1), and prevention of chronic pain. Eight participants (67%) provided outpatient physiotherapy services for patients recovering from polytrauma. Four participants (33%) reported that they ‘always’ use gait re-education, balance re- education and range of motion exercises. Five participants (42%) reported that they ‘always’ use strength training as rehabilitation strategies in these sessions. Only 50% participants (n=6) reported that they ‘always’ assess the level of pain that their patients experienced. Thirty three percent of the participants (n=4) reported that they ‘often’ assess their patients’ functional ability. iv Seven barriers to patient care were identified namely language barriers, early discharge, limitation of funding, long distance between the patients’ place of residence and the hospital, lack of equipment, delayed information on surgical plan, and infections.Eight enablers to patient care were identified as supportive members of the multidisciplinary team, well-equipped gym, early mobilisation, weaning from mechanical ventilation, ability to screen wards, family involvement in care, education and advocacy. Conclusion: This study contributes new knowledge on the current physiotherapy management of patients with polytrauma in South Africa during their in-patient stay and after their discharge home. Findings should be interpreted with caution due to the low response rate. A foundation is laid for future research investigating the selection and efficacy of specific physiotherapy treatment interventions used in the management of these patients with polytrauma in South Africa, on their clinical and rehabilitation outcomes.