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Creation of a formal chest wall injury program improves compliance with rib fixation indications
Vladislav Muldiiarov1, Sophie Bouldoukian1, Hason Khan1
1Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
Background:
Surgical stabilization of rib fractures (SSRF) improves outcomes but remains underutilized. This study evaluated the impact of the creation of a dedicated, institutional chest wall injury program on SSRF utilization, hypothesizing such a program would increase utilization of SSRF for those patients meeting criteria.
Methods:
We conducted a single-center, retrospective study of adults with radiographically confirmed rib fractures presenting to a Level I trauma center between January 2016 and April 2023. Patients were classified by the Chest Wall Injury Society SSRF operative criteria and whether or not they underwent SSRF. Basic demographics were obtained. The chest wall injury program was developed in 2020 with elements including standardized guideline adoption, daily multidisciplinary rounds to identify candidates early, and establishment of a dedicated outpatient follow-up clinic. Additionally, the program facilitated consistent documentation of SSRF candidacy and improved interdisciplinary communication regarding treatment plans. The primary outcome was the relationship between operative and non-operative cases when SSRF criteria were met.
Results:
A total of 3488 patients were included, of whom 1629 met operative indications for SSRF. Overall, 457 patients (28.1%) underwent fixation. Compared to non-operative patients, the SSRF group had similar age and predominantly sustained blunt trauma. Implementation of the dedicated chest wall injury program in 2020 was associated with a significant increase in SSRF utilization among eligible patients, rising from 21.5% to 32.1% in 2020 (rise of 10.6%). Utilization continued to increase each subsequent year, reaching 45.3% by 2023. Among patients meeting SSRF criteria, SSRF utilization increased from 19.8% before 2021-41.1% from 2021 onward (p < 0.001). In multivariable logistic regression adjusting for age and gender, the 2021-onward period remained independently associated with receipt of SSRF (adjusted OR 2.82, 95% CI 2.25-3.52; p < 0.001).
Conclusion:
Establishing a dedicated chest wall injury program was associated with higher adherence to SSRF guidelines and increased operative management of eligible patients.
Level Of Evidence:
Level IV, therapeutic/care management.