Problem: Patients aged 65 and older face an elevated risk of pulmonary complications following rib fractures resulting in increased morbidity, mortality and Intensive Care Unit (ICU) transfers. The Trauma Surgery Service (TSS) at a 420-bed academic medical center with a level II trauma designation initiated an upstream intervention to predict decline in this population and standardize level of care (LOC) determinations. The team relied on provider-driven LOC determination on admission but lacked a method for detecting early pulmonary decline after patient admission. Purpose: This project aimed to standardize admission practices for geriatric rib fracture patients and detect pulmonary decline among those aged 65 and older on the TSS. Methods: The team selected and provided education on the Pain, Incentive spirometry, and Cough (PIC) protocol and QR codes to nursing and providers through handouts, brief lecture and emails over a two-week period. Providers chose the patient's injured incentive spirometry (IS) goal as 50% of the reference on the IS insert with an alert level of 500mL. Nursing intervention orders (NIOs) were used to identify PIC patients, their established IS goals and alert levels. Nursing evaluated their patients’ PIC scores every four hours. Patients scoring under five or those with an alert level of less than 500mL required notice to the provider. Results: 32 patients met the inclusion criteria and nursing adherence rates ranged from 10-57%. The injured IS goals and alert level were documented with 90.6% accuracy. Providers recorded the patient’s injured IS goal and alert level in their notes on 66% of patients; LOC was determined by IS capacity on 22%. Conclusions: Clinical observations suggested a reduction in rapid response calls due to earlier detection of pulmonary decline.