Rib Fixation for Multiple Rib Fractures: Healthcare Professionals Perceived Barriers and Facilitators to Clinical Implementation

Rib fractures occur in 10–39% of patients with blunt chest trauma, accounting for 10% of all trauma admissions [1‐3]. Rib fractures are associated with morbidity and long-term impaired quality of life [1, 4‐6]. A typical pattern of multiple fractures is a flail chest, which is defined as three or more consecutive ribs fractured in at least two places [7, 8]. Other fracture patterns with three or more fractured ribs are often called multiple rib fractures.

Increasingly, surgical stabilization of rib fractures (SSRF) of a flail chest shows superior results over nonoperative treatment [9‐12]. For patients with multiple rib fractures without a flail chest, particularly low-level evidence suggests that SSRF results in shorter Intensive Care Unit (ICU) and hospital stays, lower rates of pneumonia and empyema, reduced need for opioid analgesics and mechanical ventilation, and earlier return to work and social activities [13‐16]. Currently, a multicenter randomized controlled trial investigates the effects of SSRF versus nonoperative treatment of multiple rib fractures in patients without a flail chest (FixCon trial) [17].

Concomitantly to growing evidence, an implementation strategy should be developed to successfully implement SSRF as a treatment for multiple rib fractures [18]. Barriers and facilitators possibly influencing the implementation of SSRF should be identified, such as experience, knowledge, and available resources, to ensure that the implementation strategy includes relevant determinants, is feasible, and is tailored to the context [19]. Therefore, this study identified barriers and facilitators of healthcare professionals (HCPs) to SSRF for treatment of trauma patients with multiple rib fractures. The secondary aim was to compare barriers and facilitators between groups of HCPs.

Sixty-one HCPs participated: 32 surgeons, 19 non-surgical physicians, and 10 residents with various backgrounds (Table 1). Most HCPs were aged 36–45 years (n = 28; 46%). The majority were male (n = 51; 84%), and most were (trauma) surgeons (n = 28; 46%). The median clinical experience was 10 years (P₂₅–P₇₅ 6–14) for (trauma) surgeons, 10 years (P₂₅–P₇₅ 5–15) for non-surgical physicians, and 0 years (P₂₅–P₇₅ 0–4) for residents About half of the HCPs worked in a hospital participating in the FixCon trial (n = 33; 54%). Twenty-four (39%) respondents performed SSRF themselves, whereas for 29 (48%) respondents, a colleague performed SSRF.

Sixteen barriers and two facilitators for implementing SSRF were identified. Most barriers concerned lacking scientific evidence for the indication and (cost-)effectiveness of SSRF. Surgeons perceived fewer barriers and more facilitators than non-surgical physicians and residents; especially in the workload and organizational aspects. Facilitators were the assumption that SSRF alleviates respiratory problems, and for surgeons, the feeling that they are supported by colleagues for SSRF. Barriers and facilitators differed between surgeons from centers that do and do not participate in the FixCon trial. Differences consisted mostly of the extent to which they were convinced that patients with multiple rib fractures benefit from SSRF; e.g., surgeons from non-FixCon trial centers expected SSRF to increase the length of hospital stay, contrasting evidence showing that SSRF is associated with equal or shorter hospital length of stay [12, 27].

To the best of our knowledge, this is the first study investigating barriers and facilitators to implementing SSRF for trauma patients with multiple rib fractures including surgeons and non-surgeons. A previous study surveyed 450 surgeons in 2007 for their opinion about SSRF and sternal fracture repair [28]. Many respondents reported that the scientific literature was insufficient for the indication for SSRF, which is similar to our findings. Interestingly, a large majority of respondents in that survey stated that they did not know any published randomized trials about SSRF. Although many studies about SSRF have been published since then, this unawareness of the scientific literature for the indication of SSRF could also have played a role in our study. Several studies have described barriers and facilitators for implementing rib fracture management protocols [29‐31]. For example, a dedicated rib fracture consultation service was started when it was realized that many trauma patients who could have benefitted from SSRF were missed [29]. Consequently, embedding consultation with a team of dedicated surgeons who regularly perform SSRF was included in the care of patients with rib fractures. Insufficient knowledge, experience, and availability of staff were considered barriers to SSRF, which is similar to the barriers found in the current study. Another study showed that an important facilitator for an analgesic protocol for rib fractures patients was the practical fact that starting the new protocol became the least labor-intensive method for initiating patient care upon admission [31].

Although not for SSRF specifically, several barriers and facilitators were described for the implementation of a chest injury care bundle, including a standard set of interventions for patients with chest injuries [32]. HCPs identified that new interventions must be evidence-based, easy to follow, and easily accessible [32]. Also, the belief that the intervention improves patient care and the support from colleagues was considered very important. Our findings share these themes.

A strategy for implementing SSRF for patients with multiple rib fractures is most likely to succeed when it enhances the identified facilitators and focuses on diminishing the barriers [18, 33, 34]. Not surprisingly, the most important barrier to implementation was the lack of evidence. At the time of the survey, there was a paucity of data from clinical trials about SSRF in patients with multiple rib fractures without a flail chest. However, several trials were recently published [12, 35] and more are expected soon [17, 36]. With increasing scientific evidence for the (cost-)effectiveness of SSRF becoming available, the barrier related to lack of evidence will likely diminish. Nevertheless, as the field of implementation science has shown multiple times, sound scientific evidence alone does not guarantee uptake [18, 33, 34]. Likely, disseminating SSRF also relies heavily on the opinion and practices of colleagues and mentors. Our results demonstrate that surgeons perceived the fewest barriers in knowledge and experience, and generally felt most facilitated by their close colleagues and their organization. An implementation strategy is likely to be most successful when it allows surgeons to disseminate their knowledge and experience to their colleagues, residents, and non-surgical colleagues in the anesthesia and pulmonology departments. As for organizational aspects, the strategy should focus on optimizing the planning of SSRF in a busy operation room schedule and providing regular feedback about the implementation of SSRF to all HCPs involved.

This study has several strengths and limitations. A strength includes the use of the widely-used MIDI to identify barriers and facilitators. Another strength is the diversity of HCPs that completed the questionnaire which allowed subgroup analyses. However, non-surgical physicians could potentially have confounded the overall results concerning aspects more specific to surgery. Another limitation includes that some respondents were invited via the FixCon trial network, who might be more positive about SSRF because of their connection with a surgeon who is involved in a clinical trial specifically studying SSRF for multiple rib fractures. Because our questionnaire study was performed anonymously and with an open link, we have no insight into the response rate and we were unable to determine whether non-responders differed from responders. Also, although IP addresses were registered, double submissions could theoretically not be completely prevented. The study is limited by the relatively small number (n = 61) of respondents, which raises the suspicion that the non-responders were less interested and therefore less positive about SSRF in general than the respondents. In addition, most respondents (87%) worked in a center that already performs SSRF. Potentially, the results of this study are not directly generalizable to HCPs working in a center that does not have an established SSRF program. As a final limitation, 16% of the respondents were residents with relatively limited experience, which might have affected their insights into barriers and facilitators. Despite these limitations, the questionnaire results provide important insights to develop implementation strategies. However, potentially other not surveyed factors could become apparent later in the implementation process. In the end, changing behavior is a complex process, for which an implementation strategy provides a starting point. Naturally, when progressing in the implementation process, continuing awareness for identifying new barriers and facilitators is warranted.

In conclusion, successfully implementing SSRF for trauma patients with multiple rib fractures requires growing scientific and clinical knowledge. Besides this, developing implementation strategies for SSRF for multiple rib fractures should aim at overcoming the other barriers and enhancing the facilitators identified in this study.