The processes of hospital discharge and recovery after blunt thoracic injuries: The patient’s perspective

Abstract Aims The aim of this study was to explore hospital discharge processes and the self‐management of recovery in the early post‐discharge period after blunt thoracic injury from a patient perspective. Design Qualitative interview study. Methods Interviews were conducted with participants recruited from 8 sites across England and Wales between November 2019–May 2020. Semi‐structured interviews were conducted between 5–8 weeks after hospital discharge, and in total, 14 interviews were undertaken. These interviews were recorded, transcribed and analysed using thematic coding. Results Three main themes were identified from the analysis: (a) challenges in the discharge process, (b) coping at home after discharge and (c) managing medications at home. Pain was a dominant thread running throughout all themes which represented an important quality and safety concern for all participants. Associated concerns included insufficient preparation and education for hospital discharge, ineffective communication and subsequent unsafe use of opioids at home highlighting unmet patient care needs.


| INTRODUC TI ON
For patients with blunt thoracic injury (BTI) presenting to major trauma services globally, recovery following discharge from hospital remains a challenging process (Marasco et al., 2015). BTI is defined as injury to the bony or soft tissues of the thorax or underlying organ systems caused through a blunt mechanism of injury (Baker & Lee, 2016). For younger individuals with BTI, common mechanisms include high velocity impact mechanisms (e.g. Falls from heights, road traffic collision etc.), whilst for older individuals, substantial injuries can also be sustained from simple low velocity mechanisms (e.g. falls from standing) (Kourouche et al., 2018).
Significant physical, psychological and socio-economic sequelae have been reported (Baker et al., 2018). It is likely that insufficient supportive care in the early post-discharge period contributes to the burden experiences by this patient population. Hospital discharge describes a transition where hospital care ends and responsibility for ongoing care needs is transferred onto other healthcare providers (primary care, social care services and domestic environments) and is an opportunity where patients can be prepared to optimize their own recovery at home Markiewicz et al., 2020;Waring et al., 2014Waring et al., , 2019.
There is a gap in the current trauma evidence base around the impact of the discharge process after BTI on early self-management and recovery at home. It is not possible for clinicians to optimize recovery for this patient group where there is little understanding of the patient experience in this recovery phase.

| BACKG ROU N D
Previous qualitative research in non-trauma populations identified several factors that often negatively impact on the discharge process (Waring et al., 2019). These included poor communication between health and social care, lack of assessment and planning, inadequate notice of discharge, inadequate involvement of the patient and family, over-reliance on informal care and lack of attention to the special needs of vulnerable groups (Waring et al., 2014). Although there has been substantial organizational work to improve the discharge process in high-risk patient groups over the past decade, there is a paucity of research into the patient's experience and the effectiveness of the discharge process for trauma patients with BTI in the UK (El-Eid et al., 2015).
In the general trauma population, previous research exploring the patient's transition from hospital care to manage their recuperation at home highlighted that inadequate knowledge and experience negatively impacts on an individual's ability to cope at home (Goldsmith et al., 2018a(Goldsmith et al., , 2018bKellezi et al., 2020;Sleney et al., 2014). Pain has been highlighted as contributing to patients not managing well at home following discharge with insufficient guidance, information and education on pain management impacting their self-management (Goldsmith et al., 2018a;Gualandi et al., 2019). Despite these findings, there is currently insufficient knowledge around the impact of hospital discharge on recovery and self-management after BTI and without this knowledge, it is not possible to critically review pathways for this patient group. The aim of this exploratory qualitative study was to describe the discharge and early post-discharge recovery experiences of patients with BTI.

| Design
A qualitative study using semi-structured telephone interviews was conducted. This manuscript has been developed following the Standards for Reporting Qualitative Research (SRQR) (O'Brien et al., 2014).

| Study setting
The study included eight geographically diverse sites across England and South Wales including both urban, suburban and rural areas. All sites were UK National Health Service hospitals that were receiving hospitals for major trauma patients. This study is a qualitative component of a mixed-methods study. Table 1 presents the context of the individual recruiting sites.

| Study sample and recruitment
Between November 2019-May 2020, semi-structured qualitative interviews were conducted with fourteen participants who had been admitted to hospital with BTI. Interviews were undertaken 5-8 weeks following hospital discharge. All participants were recruited into the "Rib Injury Outcomes Study" (RIOS) which aimed to investigate changes in Health-Related Quality of Life and painrelated outcomes in patients with blunt thoracic injuries over six months after hospital discharge. To provide context to this current publication, the quantitative components of this approach identified substantial levels physical burden of BTI during the first six months after hospital discharge which related to the development of chronic and neuropathic pain states. This had an overall negative impact on individual HRQoL over the first six months after hospital discharge with BTI. Eligibility for inclusion into RIOS was as follows:  The semi-structured interview topic guide was developed using the literature on qualitative interviewing techniques and previous qualitative work on recovery after BTI (Claydon et al., 2017;Sleney et al., 2014). These focussed interviews were flexible in length but aimed to be between 15-20 min in length to minimize the burden on the participant. Table 2 presents the four broad topics covered in the interviews.

| Data collection
Questioning was largely open-ended and where appropriate; participants were given flexibility to lead and direct the discussion.

| Data analysis
Data analysis was undertaken using a process of reflexive thematic analysis using an inductive approach (Braun & Clarke, 2006. Interview transcripts were uploaded into NVivo v.11 (QSR International Ltd), and initial data analysis was undertaken by EB. Subsequent discussion of codes and themes with GL, AX and CN resulted in a consensus on the names and definitions of codes, sub-themes and themes. Table 3 presents the six-stage approach to thematic analysis.
Thematic analysis focussed on identifying, examining and recording patterns in the data but also allowed for the abstraction and theorizing of themes from the data set. These patterns were important for describing the participants' experiences of recovery becoming "units of meaning" in the analysis. Themes were identified by drawing together components or fragments of participants' ideas or experiences which although meaningless when viewed in isolation, when combined, they form a comprehensive picture of the collective experiences of the participants (Braun & Clarke, 2006).

| Trustworthiness and rigour
Rigour was maintained throughout by achieving trustworthiness criteria which have been used to demonstrates that data collection was conducted using precise, consistent and an exhaustive approach How did the healthcare team involve you in planning you discharge from hospital? What written information and advice were you given prior to your discharge from hospital? 3

Managing symptoms at home
Did you experience any symptoms from the BTI in the first month after discharge from hospital? How prepared were you for managing your own recovery at home after discharge from hospital? What were the main challenges you had to overcome during the early post-discharge period?

Reflecting on your discharge
In what ways did you feel prepared for discharge from hospital?
Were there any aspects of your discharge that you feel could have been done differently to help you cope at home?

Conclusions
Do you have anything further you would like to add? Is there anything that you would like to ask me? (Nowell et al., 2017). During data collection, participants were encouraged to lead the conversation and discuss topics candidly. To ensure accuracy, dependability and credibility, prior to terminating the interview, EB summarized key discussion points from the interview to ensure participant's statements were accurately understood in the context and enable participants to elaborate further on key areas of personal interest.
To ensure transparency and rigour through the data analysis process, the data were transcribed professionally and checked for accuracy by a member of the research team (EB). Initial analysis was undertaken by one member of the research team (EB) as this study forms a component of a PhD research study and this was followed by an in-depth discussion of the data with GL formulating codes, sub-themes and overarching themes. Further discussion around definitions of themes and codes between EB, GL, AX and CN and subsequently code and theme names and definitions were confirmed. Both field notes and a self-critical reflexive journal were maintained throughout the data collection and analysis process to provide a clear audit trail of thoughts, decisions and choices made in these stages of the study.

| FINDING S
Of the fourteen participants with BTI recruited 10 were male, the predominant mechanism of injury was a fall of less than two metres.
Study interviews length varied from 12-42 min. Although all participants were polytrauma patients and therefore had injuries in more than one body system, in all cases the BTI was the primary injury of concern. In all cases, extra-thoracic injuries were classified as minor or moderate (1 or 2) using the Abbreviated Injury Score (AIS) (Baker et al., 1974). Table 4 presents participants' demographic profile developed during the data collection process. Further example quotations are presented in File S1.
Three main themes were identified from the analysis: (a) challenges in the discharge process, (b) coping at home after discharge and (c) managing medication at home. Table 5 presents the themes, sub-themes and codes identified during data analysis.

| Theme 1: Challenges in the discharge process
Two main sub-themes were identified which highlighted challenges patients experienced in the discharge process: (a) suboptimal care co-ordination in the interprofessional team; and (b) the patients' expectations of the discharge process.

| Theme 2: Coping at home after discharge from hospital
Many participants were concerned about factors influencing their recovery and the challenges of living with the symptoms of BTI during the early post-discharge period. This section will explore participants experiences surrounding the following two sub themes: (a) optimising your own recovery at home and (b) living with symptoms after discharge, identifying challenges and ways of overcoming these in the home environment. After regaining independence in their daily activities, participants consistently identified a change in behaviour whereby previously "normal" tasks required more "careful judgement" than before the injury happened.
In the early post-discharge period, sleep was identified as being an important factor in participants' recovery. For many participants, optimized sleep was essential to not only their physiological recovery, but their attitude towards recovery and coping with their injury Not all participants were aware of the addictive potential of the opioid analgesic agents that they were using. For some, weaning off these drugs was instinctive, but no one was given weaning guidance provided by a healthcare professional.
…If they did, I didn't hear it because possibly they

| Subtheme 3.3: Side effects and concordance
Many participants described the common side effects relating to opioid usage. For many, the associated constipation was challenging to manage at home and had the potential to impact on their progress of recovery.
Interestingly, one participant highlighted that despite having previously experienced these side effects when taking codeine, alternative options were not explored with them during the discharge process:

| D ISCUSS I ON
This study explored patients' perceptions of discharge from hospital and the early post-discharge recovery after BTI. We identified several factors in the discharge process which impacted on these individuals' post-discharge recovery and in so doing this adds emphasis to the need for adequate patient preparation for discharge. In these factors are care quality and patient safety issues that need to be managed in the discharge process for trauma patients with BTI in the future. Pain itself was a re-occurring concept in all interviews, and therefore, pain was a dominant theme throughout. It is important to recognize that these findings although specific to BTI are relevant to all injury patterns in trauma care (e.g. spinal cord injury, traumatic brain injury, limb trauma etc.) and these results will impact on the discharge pathways for all injury groups. This study has used the experiences of BTI patients to identify the wider needs of trauma patients.
Safety is a key component of patient care and the management of risk underpins clinical practice in all areas of health care. The most striking finding in this study was the potential risk of opioid overdose and the apparent lack of preparation for safe use of opioid analgesics that patients experienced in the discharge process. The early post-discharge period after surgical admission has previously been identified as a potentially vulnerable time for patients who are opioid naïve, unsupervised and may have escalating analgesic requirements (Baird et al., 2017(Baird et al., , 2019Mudumbai et al., 2019). Despite this risk, the rates of opioid overdose in 30 days for surgical discharge were 0.01% (N = 134/1,305,715) suggesting that the risk remains low in recently discharged surgical cases (Ladha et al., 2018). Education is an important factor in preparing patients for discharge from hospital and managing risk outside of the hospital setting (Goldsmith et al., 2018b). For these participants, the reality of self-management in the early post-discharge period was different to what they had expected. Providing greater information on safe opioid use and weaning advice could negate the risk of complications associated with unsafe opioid self-management (Bartels et al., 2016;Feinberg et al., 2018;del Portal et al., 2016;Stewart et al., 2019).
Participants highlighted high levels of psychological burden in the post-discharge recovery period. For many, this burden manifested itself as poor mental well-being with symptoms of anxiety and depression. In most cases, this is related directly to the experiences of pain and the limitations of the individual's potential for recovery. The level of psychological sequelae after BTI has previously been measured quantitatively with reports of high levels of poor mental function in both females and younger injured people (Marasco et al., 2015). The psychological burden after BTI has also been touched on in a previous qualitative interview study (Claydon et al., 2017). In this study, there were many similarities in the in the cause and presentation of psychological burden with the findings of this study.
Our participants identified the need for an integrated interprofessional approach to discharge planning and execution as an integral part of optimizing recovery in the early post-discharge period (Hesselink et al., , 2013(Hesselink et al., , 2014. Where process issues arouse, this commonly involved issues with communication both between professions and with the participants themselves (Goldsmith et al., 2018a(Goldsmith et al., , 2018bHesselink et al., 2012;Sleney et al., 2014).
Interestingly, in our study no participants identified nursing input in the discharge planning process. As the process of nursing care is the only constant throughout these trauma patients' hospital admission, it may be that they perceive the role of this professional group differently (Krook et al., 2020). Alternatively, even though discharge may be part of the nurse's role, participants did not experience any nursing input for another unidentified reason. Furthermore, several participants highlighted how the limited discharge education and information they were given often resulted in them being unsure how to manage their own recovery after discharge. Overall, these findings are important for future care planning in the UK NHS as there is a need for greater patient follow-up and rehabilitation after trauma, but without a commissioning driver, there will always be a disconnect that will leave these services underfunded (Kettlewell et al., 2020). In the meantime, it is important to consider how a patient pathway can be used to optimize the transfer of care responsibility from the secondary care setting to primary care providers (Waring et al., 2014). Although this will require greater integration of electronic patient records, it seems likely that the introduction of a "trauma patient passport" will help transfer important patient information and circumvent challenges in different healthcare systems. As a component of pathway-based care, patient passports will improve quality and safety in all levels of post-hospital discharge trauma care. This potential method to improving transition by integrating patient information in an accessible way has been successful in chronic disease management spanning both primary and secondary care (Philip et al., 2019).
Further research is needed to understand the feasibility and acceptability of this potential intervention in this population.

| Strengths and limitations
A strength of this research is the variation in the sample from a perspective of geographical location and the number of recruiting hospital sites. This allowed us to provide a broad picture of the complexities of recovery after BTI. Another strength is in the qualitative design which allowed a deeper understanding of the challenges experienced by this patient group through the rich data sources in this study.
During the sampling for this qualitative study, it was challenging to get younger participants to take part. The youngest participant was 48 years old, and many participants were aged 60 years or above. This leaves the potential for the views and perceptions of younger people with BTI to be missing in this study.
Despite this limitation, the exploration of experience in this sample of participants who were predominately older (>60 years) is valid, as previous research has highlighted the need to explore the experiences of BTI in this older population (Baker & Lee, 2016;Cubitt et al., 2019). Although the findings reported in this study are not generalizable to the BTI population, it is likely that the experiences of these participants are applicable to other BTI patients and the quality and safety issues identified in this study are not unique to this sample alone.
The duration of interviews varied substantially between participants with one interview lasting 12 min in length. Whilst the short duration of this interview may be considered a limitation, this study aimed to conduct focussed interviews last between 15-20 min each. Where participants had more to discuss, then this was encouraged but in the case of this 12-min interview, the participant had provided all the information relating to their experience that they wanted to provide and did not want to elaborate further.
This study was ongoing when the COVID-19 pandemic started in the UK. Although it was not possible to investigate how COVID-19 had influenced participants recruited into this study, it remains important to recognize and acknowledge how the COVID-19 pandemic impacted on these participants. These potential impacts include those relating to social isolation, mental well-being and physical illness (Baker & Clark, 2020).

| CON CLUS ION
This qualitative study explored patients' perception of the hospital discharge process and their early post-discharge recovery after BTI.
Whilst the burden of injury remains great, from a patient perspective, there are significant quality and safety risks associated with leaving hospital without adequate preparation. The trauma interprofessional team needs to consider further how a discharge pathway can be developed which aims to manage risk and optimize patient self-management of recovery in the early post-discharge period. This is particularly important in pain self-management which was key to all participants in this study and posed the greatest risk to patient safety.

ACK N OWLED G EM ENTS
It is important to acknowledge the involvement and contribution of the clinical research staff at each recruitment site who were essential in the initial identification and recruitment of participants to the Rib Injury Outcomes Study but are too numerous to mention individually.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to disclose.

AUTH O R CO NTR I B UTI O N S
EB, AX, CN, PH, GL: Conception and design, or acquisition, analysis and interpretation of data; manuscript drafting or revision; final approval of the version; and accountable for all aspects of the work.

E TH I C A L A PPROVA L
Ethical approval was granted by the "Hampshire A" South Central Research Ethics Committee in June 2018 (ref: 18/SC/0230).
Although informed written consent was gained during recruitment to the main study, participants included in this qualitative study were re-consented prior to data collection and further participant information was provided. Participants were given opportunities to ask questions both pre-and postinterview, and time was taken to ensure that the participant was comfortable with the process and interview content prior to closing the interview. Where required, participants reporting ongoing physical or psychological problems were sign posted to their local primary care clinician for further assessment.
Participants were offered a £10 shopping voucher as a gesture of thanks for the time taken to participate in this study.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data sets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

S U PP O RTI N G I N FO R M ATI O N
Additional supporting information may be found online in the Supporting Information section.