Acute management of adults following chest wall injury: An assessment of institutional clinical practice guidelines across the UK and synthesis of care recommendations

Objective: Chest wall injury causes significant morbidity and mortality. There is uncertainty regarding many aspects of clinical care for these patients, including optimal analgesia, acuity of monitoring and surgical fixation. Our aim in this work is to [1] objectively appraise the quality and extent of heterogeneity in UK major trauma centre (MTC) clinical practice guidelines regarding the management of chest wall injury; and [2] narratively summarise clinical and care process recommendations from these guidelines to provide a comparative description of recommendations between institutions.

Methods: All major trauma centres in England and Wales were contacted for their institutional clinical practice guidelines relevant to chest wall injury. A literature search was executed seeking eligible supra-regional, national or international consensus documents or guidelines to serve as reference standards. Interrogation of the reference standard guidelines was performed to identify key clinical and care processes against which two blinded assessors judged the clinical validity of institutional clinical practice guidelines as part of the Appraisal of Guidelines for Research & Evaluation II Global Rating Scale (AGREE II-GRS) tool.

Results: We received 17 institutional clinical practice guidelines and identified themes of care from seven reference standards identified during our literature search. Four institutional clinical practice guidelines were assessed as high-quality by pre-specified AGREE II-GRS criteria. Guidelines scored highly for the quality of their presentation of information (median (interquartile range [IQR]) AGREE II-GRS Item₅ score 5 (4.5-5.5)); however, the quality of guideline development methodology and the guideline completeness in comprehensively addressing the needs of this population was generally poor (median (IQR) AGREE II-GRS Item₁ methodology score 2.92 (2.33-5.25); AGREE II-GRS Item₃ completeness score 2.63 (1.75-5.25) respectively).

Conclusions: This work highlights the paucity of high-quality local clinical practice guidelines to inform the management of adults with chest wall injury admitted to UK MTCs. Although some degree of variation between local guidelines is acceptable, we have identified substantial heterogeneity in the clinical care recommendations between institutions.