J.C. Robenstine1, A. Mahajan1, J.J. Como1, A.J. Elliot1, A.J. Shaughnessy1, A.H. Tran1, P.J. Podugu1, H.J. Carrane1, H. McKillen2, V.P. Ho1, E. Tseng1 1MetroHealth Medical Center, Trauma, Critical Care, Burns, And Emergency General Surgery, Cleveland, OH, USA 2Northeast Ohio Medical University, Rootstown, OH, USA
Introduction: Older adults with multiple rib fractures are at high risk for clinical decompensation. While scoring systems can help clinicians manage these patients, some are cumbersome for clinical use and require information not easily known at the time of admission. In 2018, we implemented a simple institutional practice management guideline (PMG) to standardize management of these patients. We hypothesized that PMG implementation would improve clinical outcomes for older adults with multiple rib fractures.
Methods: All blunt trauma patients aged 60 and older with at least 3 rib fractures were included, including 5 years pre- and 5 year post-PMG implementation, with a 6-month washout period (2012-2023). The point-based system from our PMG is in Figure 1. Underlying lung disease is defined any chronic pulmonary condition such as chronic obstructive pulmonary disease, asthma, restrictive lung disease, or lung cancer, and this information was obtained from the patient, family or friends, or chart review. Post-PMG implementation, patients with 3 or more points were monitored until they could consistently achieve a predetermined incentive spirometry volume (15ml x ideal body weight in kg). We compared pre- and post-PMG outcomes, including hospital length of stay (LOS), ICU LOS, unplanned ICU admissions, intubations, unplanned intubations, and mortality. We present comparisons of median [IQR] or percent (%).
Results: We included 1386 patients (683 pre, 703 post). Groups were similar in age, sex, comorbidities, and injury severity. Implementation of the PMG was associated with a significant decrease in intubations (9% vs 6%, p=0.03) and decreased ICU LOS (1 [0-5] vs 0 [0-3], p<0.01). Hospital LOS, unplanned ICU admission, unplanned intubations, and mortality were similar.
Conclusion: Multiple treatment algorithms exist to care for patients with rib fractures. Our institutional PMG was not only simple to use at bedside but also resulted in decreased ICU LOS and fewer intubations without an increase in hospital LOS.