The Implementation of a Rib Fracture Pathway at a Small District General Hospital to Improve Patient Care.

Abstract

Background and objective Rib fractures arecommon presentations to the emergency department following blunt thoracic trauma. Despite this injury causing significant morbidity and mortality, no national guidelines existto guide the acute management of this condition. In light of this, this quality improvement project was conducted at a district general hospital (DGH) with the aim of assessing the impact of using a simple rib fracture management pathway. Methods A retrospective review of paper notes and electronic databases of patients with a recorded diagnosis of "rib fractures" were reviewed. Following this, a management pathway was designed and then implemented, which incorporated BMJ Best Practices and local hospital needs. The study then assessed the impact of the pathway. Results Prior to implementing the pathway, a total of 47 individual patients were included in the statistical analysis. Of the patients analysed, 44% were older than 65 years. Of note, 89% received regular paracetamol for analgesia, 41% received regular nonsteroidal anti-inflammatory drugs (NSAIDs), and 69% received regular opioids. Advanced analgesics such as patient-controlled analgesia (PCA) and nerve blocks were poorly used; for instance, a PCA was used in only 13% of cases. Only 6% of patients received daily pain team reviews and only 44% of patients were seen by physiotherapists within the first 24 hours. Additionally, 93% of patients who were admitted under general surgery had a STUMBL (STUdy of the Management of BLunt chest wall trauma) prognostic score >10. Post-pathway implementation, a total of 22 individual patients were included in the statistical analysis. Of them, 52% were older than 65 years. The use of simple analgesia was unchanged. However advanced analgesia was better escalated, and PCAswere used 43% of the time. The involvement of other healthcare professionals improved; 59% were reviewed by the pain team in the first 24 hours, 45% received daily pain team reviews, and 54% received advanced analgesia. Conclusion Based on our findings, implementing a simple rib fracture pathway is effective at improving the management of rib fracture patients admitted to our DGH.