RIB fracture triage pathway decreases ICU utilization, pulmonary complications and hospital length of stay

Abstract

IntroductionRib fractures are one of the most frequent causes of morbidity following blunt injury to the chest. Many of these patients require ICU care and often develop pulmonary complications. Prior studies have attempted to identify changes in predicted lung volumes or utilized the number of rib fractures to guide clinical decisions. A rib fracture triage pathway was developed to identify which patients will benefit from ICU level of care and shorten hospital length of stay for patients that do not require ICU care. MethodsThe triage pathway utilized patient's age, number of rib fractures, significant cardiopulmonary co-morbidities, and incentive spirometry volumes to determine admission disposition. The triage pathway was implemented on November 2016. All patients with rib fractures from November 2015 to 2017 were identified in the trauma registry. Data was collected on patients age, gender, Glasgow Coma Scale on arrival (GCS), injury severity score (ISS), number of rib fractures, incentive spirometry volumes, days in intensive care (ICU), ventilator days, length of stay (LOS), complications, and mortality. Patients with severe TBI, those arriving intubated, or died within 48 h were excluded. The patients remaining were 278 patients in the pre triage pathway group and 370 in the post triage pathway. ResultsThere was no difference in age, gender, GCS, ISS, predicted incentive spirometry or number of rib fractures. The post treatment patients required significantly lower ICU admissions (64% vs 75%, p = 0.003), significantly lower pulmonary complication (5.1% vs 10.4%, p = 0.01), and significantly shorter hospital length of stay (6.8 d vs 7.5, p = 0.001) with no difference in mortality (1.6% vs 2.5%, p = 0.42) or readmission (0.3% vs. 0.7%, p = 0.4). Patient post triage protocol were also more likely to be discharge home (81% vs 70%, p = 0.0009) with less patients going to a skilled nursing facility (13% vs 21%, p = 0.01). ConclusionsDeveloping a rib fracture treatment and triage pathway can decrease ICU and hospital resource utilization and decrease pulmonary complications without increase in readmissions or mortality. Patients are more likely to be discharge home over a skilled nursing facility further decreasing health care cost. Level of Evidence IV Retrospective Study, Prognostic