Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score

Implementation of a Modified Pain, Inspiration, Cough Protocol in Patients With Traumatic Rib Fractures

INTRODUCTION

Patients with blunt chest wall injuries and rib fractures are known to have high rates of atelectasis, pneumonia, pulmonary contusion, and can develop acute respiratory distress syndrome. This can lead to ventilator requirement and dependence, deconditioning secondary to uncontrolled pain, and increased hospital length of stay (LOS). Many studies in the literature have developed triage algorithms in patients with rib fractures to guide disposition and management, and several institutions have gone on to describe their institution-specific management protocols to decrease complications related to traumatic rib fractures. The purpose of our study was to examine rates of in-hospital complications in patients with traumatic rib fractures before and after the implementation of a modified PIC (pain, inspiration, cough, designated as mPIC) protocol at our institution.

METHODS

A retrospective review of patients presenting to our hospital with traumatic rib fractures were reviewed between 2019 and 2022, with inclusion of 820 patients. Information was collected on patients' demographics, mPIC score, components of their multimodal pain regimen, whether a local nerve block was performed, LOS, intubation rates, and early mobilization. Statistical analyses were performed and all results with a value of P value of <0.05 deemed statistically significant.

RESULTS

Our results show that implementation of our mPIC protocol was associated with dramatically reduced rates of intubation in patient with traumatic rib fractures (18.2% versus 3.0%, P < 0.001), regardless of patient's age, sex, race, or number of rib fractures. Furthermore, we also observed that patients with an Injury Severity Score (ISS) greater than 25 were less likely to be intubated after protocol implementation, (65.0% versus 16.7%, P < 0.001). We were able to see an associated significant decrease in overall LOS after implementation of the protocol, 5 d versus 4 d (P < 0.001); this association was seen even when stratified by race, age, number of rib fractures, sex, and ISS. We noted that with the addition of a multimodal pain regimen, other than the use of oxycodone, there was no associated overall difference in LOS preprotocol or postprotocol implementation. We also found that the implementation of early mobilization also correlated with a decreased overall LOS (P < 0.001).

CONCLUSIONS

Patients with traumatic rib fractures have many pulmonary complications that lead to increased use of hospital resources, increased hospital LOS and increased ventilator dependence. With implementation of our standardized mPIC protocol at our institution, we observed factors such as multimodal analgesia and early mobilization contributed to an associated statistically significant decrease in hospital LOS, even when stratified by age, sex, race, number of rib fractures, and moderate ISS or higher. We were also able to see an associated decrease in intubation rates among patients with traumatic rib fractures. Implementing such a protocol can, therefore, aid in diminishing the potential morbidities associated with traumatic rib fractures.

Does PIC score pick correctly? Evaluation of a modified-PIC based admission a single institution retrospective cohort study

INTRODUCTION

The Pain, Inspiratory effort, Cough score (PIC) has been developed and widely adopted to guide clinical prognostication for patients with chest wall injury. To date, the efficacy, accuracy, and safety of a PIC based triage system has not been validated. Therefore, this study sought to evaluate the use of a modified-PIC score to triage and down-grade trauma patients with chest wall injury at a single institution.

METHODS

A retrospective study was conducted at a large, Level I Trauma Center on patients with chest wall injuries admitted between 1/1/2018-10/31/20,222. On 12/1/2020, our institution implemented a modified-PIC triage tool including the PIC score, age, and severity of chest wall injury. The Pre-PIC (1/1/2018-11/20/2020) and Post-PIC (1/1/2021-10/31/2022) groups were composed based on admission date and outcomes between the two were compared.

RESULTS

2,627 patients comprised the Pre-PIC group and 2,212 patients comprised Post-PIC. The groups didn't differ significantly in demographics or mechanisms of injury except for COVID status. Post-intervention, a greater proportion of patients were triaged to the intermediate care unit instead of the ICU or floor. There were no significant differences in hospital length of stay (LOS), ventilator days, unplanned ICU admission, or mortality in Pre-PIC vs Post-PIC. ICU LOS, rates of ARDS, and cardiac arrest with return of spontaneous circulation (ROSC) were significantly lower in Post-PIC. Multivariable models demonstrated significantly lower ARDS rates and ICU free days. ICU LOS trended towards significance as well.

CONCLUSIONS

This is the largest study, to date, evaluating the impact of a modified-PIC triage system on clinical outcomes. The results suggest a modified-PIC triage system may lead to decreased ICU days, ARDS rates, and rates of cardiac arrest w/ ROSC, potentially improving hospital resource allocation. Further prospective and multi-center studies are needed to validate our understanding on the impact of a chest wall scoring system on triage and outcomes.

Improving the Diagnosis of Rib Fractures in the Emergency Department: A Quality Improvement Project in a District General Hospital in the United Kingdom

Background Falls in older people are a common presentation in emergency departments (ED) in the United Kingdom. They can lead to multiple injuries, including chest wall injuries (CWIs). Untreated CWI carries significant morbidity and mortality. However, its diagnosis remains challenging during the initial ED encounter. This led to a quality improvement project (QIP) to improve the diagnosis of CWI in patients presenting to William Harvey Hospital, a district general, trauma-unit ED in Willesborough, England. Methods The QIP was run from February 2020 to April 2021 for 14 months. A series of plan-do-study-act (PDSA) cycles were completed to increase the proportion of CWIs diagnosed during the initial ED encounter to 90%. The primary interventions involved designing a new thoracic trauma proforma and the introduction of the modified pain, inspiratory effort, and cough (PIC) score to evaluate and triage patients with CWI. Other interventions included the delivery of an education programme on CWI. The secondary aims were to increase modified PIC score use and to reduce the time between ED presentation and computerised tomography (CT) scanning. Results A total of 147 patients were included in three PDSA cycles. The diagnosis of CWI during the initial ED encounter increased from 61% at baseline to 91%. The median time from ED attendance to the first CT reduced from 477 minutes to 169 minutes. Lastly, following the introduction of the thoracic trauma proforma, the modified PIC score was used in 26% of cases of CWI by the end of the QIP period. Conclusion Our QIP led to improvement in the early diagnosis of CWIs in ED, with significant improvements in door to CT time and the creation of a thoracic injury pathway in the trust leading to multi-specialty improvement of care of such patients.

A novel, evidence-based, comprehensive clinical decision support system improves outcomes for patients with traumatic rib fractures

BACKGROUND

Traumatic rib fractures are associated with high morbidity and mortality. Clinical decision support systems (CDSS) have been shown to improve adherence to evidence-based (EB) practice and improve clinical outcomes. The objective of this study was to investigate if a rib fracture CDSS reduced hospital length of stay (LOS), 90-day and 1-year mortality, unplanned ICU transfer, and the need for mechanical ventilation. The independent association of two process measures, an admission EB order set and a pain-inspiratory-cough score early warning system, with LOS were investigated.

METHODS

The CDSS was scaled across nine US trauma centers. Following multiple imputation, multivariable regression models were fit to evaluate the association of the CDSS on primary and secondary outcomes. As a sensitivity analysis, propensity score matching was also performed to confirm regression findings.

RESULTS

Overall, 3,279 patients met inclusion criteria. Rates of EB practices increased following implementation. On risk-adjusted analysis, in-hospital LOS preintervention versus postintervention was unchanged (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 0.97-1.15, p = 0.2) but unplanned transfer to the ICU was reduced (odds ratio, 0.28; 95% CI, 0.09-0.84, p = 0.024), as was 1-year mortality (hazard ratio, 0.6; 95% CI, 0.4-0.89, p = 0.01). Provider utilization of the admission order bundle was 45.3%. Utilization was associated with significantly reduced LOS (IRR, 0.87; 95% CI, 0.77-0.98; p = 0.019). The early warning system triggered on 34.4% of patients; however, was not associated with a significant reduction in hospital LOS (IRR, 0.76; 95% CI, 0.55-1.06; p = 0.1).

CONCLUSION

A novel, user-centered, comprehensive CDSS improves adherence to EB practice and is associated with a significant reduction in unplanned ICU admissions and possibly mortality, but not hospital LOS.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Reviving a successful blunt chest wall injury protocol

This article describes a quality improvement project that assessed nurses' knowledge and practices for patients admitted with a blunt chest wall injury and utilized interactive learning to revive the use of the protocol.