Association of Hospital-Level Intensive Care Unit Use and Outcomes in Older Patients With Isolated Rib Fractures

Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?

INTRODUCTION

It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.

STUDY DESIGN

Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days.

RESULTS

110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05).

CONCLUSION

Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.

Isolated Rib Fractures in Elderly Falls: Not As Deadly As We Think

BACKGROUND

Rib fractures in elderly patients have been associated with high morbidity and mortality; however, many of these patients had substantial mechanisms of injury, which may have contributed to these high rates.

OBJECTIVE

The purpose of this study was to determine the morbidity and mortality of elderly patients with isolated rib fractures who fell from standing.

METHODS

A single-institution retrospective study was conducted in a Level I trauma center using the trauma registry and a separate elderly fall from standing database. Admitted patients 65 years or older who presented with rib fractures after a fall from January 2013 to June 2017 were included. Patients with a nonthoracic Abbreviated Injury Scale score greater than 2 were excluded from the study.

RESULTS

Of 129 patients with isolated rib fracture, 94% (n = 121) had comorbidities and 71% (n = 92) had two or more comorbidities. Almost half (41.9%; n = 54) were taking antiplatelet and anticoagulant medications, 78.3% (n = 101) were caused by a mechanical fall, and 7% (n = 9) were caused by syncope. Data showed 72.9% (n = 94) had three or more rib fractures. The mortality rate of patients was 3.9% (n = 5). Three patients had dementia at death, four had do-not-resuscitate order, and only two deaths were directly related to pulmonary status. Patients who developed pneumonia (14.7%; n = 19) and required mechanical ventilation for a median of 11 days (3.9%; n = 5) were fewer than those in in previous studies.

CONCLUSION

The morbidity and mortality associated with rib fractures are significantly less than reported in the literature when additional injuries are excluded.