Implementation of a Geriatric Rib Fracture Pathway in Trauma

Abstract

PROBLEM: Geriatric trauma patients who have sustained rib fractures are at increased risk for pulmonary dysfunction, prolonged hospitalization, and death. The current literature supports a standardized care approach of evidence-based interventions in this patient population to help improve outcomes. Leadership of a large academic Level 1 Trauma Center, with the highest admission rate of adult traumas in the state, recognized poorer outcomes in geriatrics with rib fractures, and preliminary collated data showed a significant lack of established evidence-based practices on the Trauma Critical Care Unit. PURPOSE: The purpose of this quality improvement (QI) project was to implement and evaluate the use of an evidence-based rib fracture pathway in the geriatric trauma population to determine the compliance of pathway use by staff and possible effects on patient outcomes. METHODS: The project was implemented over a 14-week period from September to December 2020, after the completion of education and training of all staff on the Trauma Critical Care Unit. Eligible patients included patients aged 65 years and older with two or more rib fractures without high risk of respiratory complications due to admitting injury. Weekly chart audits were performed to assess compliance of the geriatric rib fracture pathway based on provider orders placed within 24 hours of admission and nursing documentation of pain assessments, deep breathe and cough, and incentive spirometry. RESULTS: Before the implementation of the project, 85% of nurses (n=49) and 100% of providers (n=12) completed the necessary education and training of the Geriatric Rib Fracture Pathway. After competency training, there was an increase in staff compliance with all components of the pathway including provider orders placed within 24 hours (p<.001) and documentation of the following nursing interventions – pain assessment (p=.068), deep breathe and cough (p<.001), and incentive spirometry (p=.006). CONCLUSIONS: This pilot QI project suggested an increase in staff compliance with the implementation of a rib fracture pathway for geriatric trauma patients after completion of staff education and training. The Geriatric Rib Fracture Pathway is a safe and useful tool in identifying this target population, as well as in early adoption of evidence-based interventions to improve patient outcomes.