Surgical stabilization of flail chest: Patient selection, hospital variation, and outcomes
Ioannis Karikis1, Griffin Olsen, Michelle Hong
1Department of Surgery, Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, MA.
Background:
Surgical stabilization of rib fractures (SSRF) is increasingly used for flail chest, yet practice remains heterogeneous. We aimed to identify predictors of SSRF, quantify hospital-level variation, and evaluate whether hospital SSRF volume and utilization rate are associated with outcomes in flail chest.
Methods:
Using ACS-TQIP 2017 to 2020, we conducted a retrospective cohort study of trauma patients older than or equal to 18 years with flail chest. Mixed-effects logistic regression evaluated predictors of SSRF and between-hospital variation. Hospitals that performed ≥1 SSRF were grouped into quintiles by SSRF case volume and by SSRF utilization rate (proportion of flail chest patients undergoing SSRF), and associations with in-hospital mortality, 28-day ventilator-free days, ICU length of stay (LOS), and hospital LOS were assessed using adjusted regression models.
Results:
Among 718 centers treating flail chest, 216 (30.1%) did not perform SSRF. Among 15,380 flail chest patients treated at 502 SSRF-performing trauma centers, 3,484 (22.7%) underwent SSRF. Older age (≥65 y), female sex, Black race, self-pay status, and traumatic brain injury (AIS head ≥3) were associated with lower odds of SSRF; pulmonary contusion, hemothorax, and higher Injury Severity Score were associated with higher odds. Median odds ratio was 3.08 (95% CI: 2.75-3.49), indicating that for two otherwise similar patients treated at two randomly selected hospitals, the median difference in odds of receiving SSRF was 3.08-fold. Higher hospital SSRF volume was associated with more ventilator-free days and shorter ICU and hospital LOS without mortality differences. Higher SSRF utilization rate was associated with fewer ventilator-free days and longer ICU and hospital LOS without mortality differences.
Conclusions:
SSRF use for flail chest varied widely across trauma centers. These findings suggest that not only whether patients receive SSRF, but also how hospitals use SSRF within their systems, may be critical to optimizing outcomes in flail chest.
Level Of Evidence:
Level III, therapeutic/care management.
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