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

Abstract

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.

Keywords: ICU; Length of stay; PIC protocol; Rib fractures; Trauma.