CWIS e-Delphi Survey: Statement revisions
Please find a list of the revisions (highlighted in red font in this round) made to each statement in response to round 2. This can be used when completing the round 3 survey.
1) The following statements relate to patients with rib fractures NOT REQUIRING mechanical ventilation:
a) Early intervention (defined as within 24 hours of presentation to the Emergency Department) aimed at volume expansion and secretion removal should be encouraged, with an emphasis on patient education and self-management where feasible. This may take many forms including, but not limited to: supported cough, incentive spirometry, active cycle of breathing, bubble PEP, IPPB, NIV, CPAP and mobilisation.
b) Where tolerated, unrestricted positioning including alternate side-lying, and very early mobilisation (to a chair / walking) should be encouraged and should be tailored to the patient’s specific injuries, tolerance and clinical presentation.
2) The following statements relate to patients with rib fractures REQUIRING mechanical ventilation:
a) Early intervention aimed at volume expansion and secretion removal should be encouraged as appropriate, according to local practice guidelines. This may take many forms including, but not limited to MHI, VHI and mobilisation.
b) Where tolerated, unrestricted positioning including alternate side-lying, and very early mobilisation (to a chair / walking) should be encouraged and should be tailored to the patient’s specific injuries, tolerance and clinical presentation.
3) The following statements relate to patients with isolated rib fractures and NO concurrent fracture of the scapula and/or clavicle and/or floating shoulder:
a) Bilateral passive and active range of movement exercises of upper extremity and shoulder girdle WITHOUT restriction should be encouraged from the time of admission, within the limits of pain b) There should be no restriction on weight-bearing on the upper limbs, within the limits of pain and tailored to the patient’s specific injuries.
c) When clinically indicated, scapula stability should be assessed, and stabilising exercises should be encouraged, within the limits of pain and tailored to the patient’s specific injuries.
4) The following statements relate to patients with rib fractures AND concurrent fracture of the scapula and/or clavicle and/or floating shoulder:
a) In the presence of ANY concurrent orthopaedic injuries in the shoulder girdle complex, range of movement and weight-bearing restrictions will be dictated by the orthopaedic injuries and NOT the rib fractures/pattern. These restrictions should be discussed with the orthopaedic team, including duration of any range of movement / weight-bearing limitations and resumption of normal activity.
5) The following statements relate to patients with rib fractures with and without
concurrent upper limb orthopaedic injuries:
a) The use of rib belts to restrict chest wall movement should be discouraged.
b) Frequent and repeated assessment (at least daily) using objective measures should be utilised within the high-risk period (up to 5 days following presentation) to monitor clinical progression, response to treatment and identify deterioration. This can utilise measures such as oxygen saturations, spirometry volumes (either incentive spirometry or more formal bedside spirometry assessments such as forced vital capacity) OR a score such as PIC* / SCARF* could be used where available.
c) Predictors of poor outcome should be used to identify high risk patients and guide respiratory physiotherapy management. The use of a formal risk tool such as the STUMBL Score*, the PIC Score*
or the Rib Fracture Frailty index* should be considered.
d) Written information should be provided where clinically relevant to each patient at the
appropriate time in their admission which may include (but not limited to) details on chest injury, exercise programs, follow-up and warning signs.
6) The following statement relate to patients with rib fractures who have undergone surgical stabilisation of rib fractures (SSRF):
a) Within the limits of pain, respiratory interventions aimed at volume expansion and secretion removal can be initiated immediately post SSRF regardless of surgical incision, approach or device.
Clarification should be sought (for example; possible contraindications to positive pressure) from the treating surgeon regarding interventions as required.
b) Within the limits of pain, upper limb and general rehabilitation interventions can be initiated immediately post SSRF regardless of surgical incision, approach or device. Clarification should be sought from the treating surgeon regarding interventions as required (for example; possible concerns about the wound).
7) The following statement relate to patients with rib fractures with and without concurrent
upper limb orthopaedic injuries who are being discharged home:a) IF there are on-going limitations or impairments in respiratory, general mobility or upper limb function, a referral for ongoing outpatient therapy should be considered.
b) A referral for ongoing outpatient therapy should be considered, if return to work or high level function such as participation in sporting activity or heavy manual labour, is required.
c) Written advice regarding ongoing exercises to aid volume expansion and secretion removal to prevent respiratory deterioration should be considered where appropriate, to be completed by the patient independently on discharge.
d) Written advice regarding warning signs and who to contact in the event of on-going respiratory difficulties, or pain persisting past 6 weeks, should be provided where appropriate.
