O. Pyke1, J. A. Vosswinkel1, J. E. McCormack1, E. Huang1, R. Jawa1 1Stony Brook University Medical Center,Trauma,Stony Brook, NY, USA
Introduction: Blunt thoracic trauma in older adults is often associated with adverse outcomes. As a quality improvement initiative in 2013, direct admission of older patients with clinically important thoracic trauma to the ICU was suggested. We evaluated the effects of this counsel on outcomes.
Methods: A retrospective review of the trauma registry at a Regional Trauma Center was performed for patients age > 55 years with blunt thoracic trauma, admitted between 2011 and 2014. Burns, emergency department (ED) deaths, patients intubated in the ED or pre-hospital, direct transfers to the inpatient trauma service, and patients with hospital length of stay (LOS) < 48 hours were excluded. Clinically important thoracic trauma was defined as ≥ 1 of the following risk factors: major chest injury, limited vital capacity (VC) on bedside incentive spirometry, or ≥ 2 comorbidities.
Results: After the recommendation (POST), 1239 patients met inclusion criteria, with 56 ICU admissions. Prior to the recommendation (PRE), 920 patients met criteria, with 132 ICU admissions. On analysis of ICU admissions, the POST-recommendation group was older (76.5+10.8 vs 72.1+11.1 years, p=0.011). The frequency of ≥ 2 comorbidities (72.0% vs. 58.9%) and ISS (17.6+8.7 vs. 20.7+10.3) was similar (p=ns). Chest injury characteristics were similar (p=ns) between POST and PRE groups: sternal fractures (15.2% vs 21.4%), pneumothorax/hemothorax/both (12.9% vs 23.2%), thoracic spine injury (24.2% vs 35.7%), chest AIS≥ 3 (60.6% vs 58.9%), and rib fractures (85.6% vs 76.8%). However, the POST group had more isolated rib fractures (37.9% vs 16.1%, p=0.003). Unplanned ICU (UP-ICU) admission (19.7% vs 39.3%, p=0.005), ICU length of stay (LOS) (6.7+7.8 vs 13.8+18.5 days, p<0.001), hospital LOS (12.8+10.2 vs 24.7+32.3 days, p<0.001), need for mechanical ventilation (16.7% vs 32.1%, p=0.018), and complication rate (27.3% vs 55.4%, p<0.001) were lower POST recommendation. In-hospital mortality was 3.8% POST vs 10.7% PRE, p=0.065. Subset analysis of ICU admissions age ≥65 years re-demonstrated these benefits (table) as well as reduced in-hospital mortality (4.8% vs. 15.4%, p=0.035) POST recommendation.
Conclusion: Admission of older individuals with clinically significant blunt thoracic trauma directly to the ICU was associated with reduced UP-ICU, ICU LOS, hospital LOS, need for mechanical ventilation, and complication rates. A further mortality benefit was noted in patients aged ≥65 years. Closer patient monitoring and frequent pulmonary toilet, likely contributed to improved outcomes. We recently introduced a guideline whereby patients age ≥65 years with ≥3 rib fractures, unless bedside VC exceeds 1000-1500 mL, are directly admitted to the ICU.
