Prospective single-center paradigm shift of surgical stabilization of rib fractures with decreased length of stay and operative time with an intrathoracic approach.

INTRODUCTION: Intrathoracic surgical stabilization of rib fractures allows for a novel approach to rib fracture repair. This approach can help minimize muscle disruption, which may improve patient recovery compared with traditional extrathoracic plating. We hypothesized patients undergoing intrathoracic plating (ITP) to have a shorter length of stay (LOS) and intensive care unit (ICU) LOS compared with extrathoracic plating (ETP). METHODS: A prospective observational paradigm shift study was performed from November 2017 until September 2021. Patients 18 and older who underwent surgical stabilization of rib fractures were included. Patients with ahead Abbreviated Injury Scale score ≥3 were excluded. Patients undergoing ETP (July 2017 to October 2019) were compared with ITP (November 2019 to September 2021) with Pearson χ 2 tests and Mann-Whitney U tests, with the primary outcome being LOS and ICU LOS. RESULTS: Ninety-six patients were included, 59 (61%) underwent ETP and 37 (38%) underwent ITP. The most common mechanism of injury was motor vehicle collision (29%) followed by falls (23%). There were no differences between groups in age, comorbidities, insurance, discharge disposition and injury severity score (18 vs. 19, p = 0.89). Intrathoracic plating had a shorter LOS (10 days vs. 8 days, p = 0.04) when compared with ETP but no difference in ICU LOS (4 days vs. 3 days, p = 0.12) and ventilator days. Extrathoracic plating patients more commonly received epidural anesthesia (56% vs. 24%, p < 0.001) and intercostal nerve block (56% vs. 29%, p = 0.01) compared with ITP. However, there was no difference in median morphine equivalents between cohorts. Operative time was shorter for ITP with ETP (279 minutes vs. 188 minutes, p < 0.001) after adjusting for numbers of ribs fixed. CONCLUSION: In this single-center study, patients who underwent ITP had a decreased LOS and operative time in comparison to ETP in patients with similar injury severity. Future prospective multicenter research is needed to confirm these findings and may lead to further adoption of this minimally invasive technique. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Evaluating the Need for Prolonged Telemetry Monitoring in Patients With Isolated Sternal Fractures.

INTRODUCTION: Isolated sternal fractures (ISFs) often result from deceleration or chest wall trauma. Current guidelines recommend screening ISF patients for blunt cardiac injury (BCI) with electrocardiogram (ECG) and troponin. If either is abnormal, 24-h telemetry monitoring is recommended. This study sought to determine if ISF patients with abnormal ECG will manifest any cardiac-related complications within 6 h of hospital arrival. METHODS: A retrospective study was performed at a single level I trauma center. Patients with diagnosed sternal fracture and an Abbreviated Injury Scale <2 for head/neck, face, abdomen, and extremities were included. Patients with multiple rib fractures or hemopneumothorax were excluded. Demographic data, ECG, troponin, and echocardiogram results were collected. The primary outcome was cardiac-related complications or procedures. Complications included hypotension, arrhythmia, and hemodynamic instability. Procedures included sternal stabilization, cardiac catheterization, or sternotomy/thoracotomy. Descriptive statistics were performed. RESULTS: One hundred twenty-nine ISF patients were evaluated, 68 (52.7%) had an ECG abnormality. Eight patients had elevated troponin (6.2%). One patient (0.78%) suffered a cardiac-related complication (arrhythmia); however, this was 82 h into hospitalization. Two patients suffered noncardiac complications (urinary tract infection and acute kidney injury) (1.55%). Three patients had echocardiogram abnormality (2.33%), but no patients sustained a BCI or underwent a BCI-related procedure. CONCLUSIONS: After ISF, <1% of patients suffered a cardiac-related complication and none had BCI. These findings suggest 24-h monitoring for patients with ISF and abnormal ECG may be unnecessarily long. A prospective multicenter study to evaluate the validity of these results is needed prior to change of practice.

No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture.

BACKGROUND: A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs. METHODS: The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed. RESULTS: 14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529). CONCLUSIONS: Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.

An improved patient safety reporting system increases reports of disruptive behavior in the perioperative setting.

BACKGROUND: Patient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. We hypothesized that an upgraded reporting system that included the ability to report positive behaviors would increase behavioral reports in the perioperative environment. METHODS: We performed a retrospective assessment of prospectively collected reports from the Patient Safety Net (PSN) event reporting system (2/2010-2/2015) and the RL Solutions RL6 system (8/2015-4/2018). RESULTS: Under the PSN system, 0.8 behavioral events per quarter were submitted, compared to 7.4 behavioral events per quarter with the RL6 system. The average length of reports increased from 61 to 185 words. Reports were most often submitted by nursing staff (66%), and about attending physicians (36%). 22% of reports under the RL6 system were positive; 46% of these positive reports were about physicians. CONCLUSION: After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. We believe that a robust reporting system has contributed to a culture of safety at our institution.

Identification of substance use disorders in burn patients using simple diagnostic screening tools (AUDIT/DAST-10).

INTRODUCTION AND OBJECTIVES: Substance use is disproportionately high in burn patients and associated with adverse outcomes. Screening methods for substance use disorders may help predict or avoid adverse outcomes. The University of Utah Burn Center records self-reported Alcohol Use Disorders Identification Tests (AUDIT) and Drug Abuse Screening Tests (DAST-10) for all adult burn admissions. This study assessed for association between AUDIT/DAST-10 scores and burn patient outcomes. METHODS: A retrospective chart review of adult burn patients admitted to the University of Utah from 05/01/2014-06/30/2017. Patient demographics, injury data, and substance use data were collected and analyzed. RESULTS: 322 patients underwent AUDIT/DAST-10 screening (n = 322). 56 (17.4%) had positive AUDIT screens (score ≥ 8). 15/50 with alcohol use at time of injury (TOI) had negative AUDIT screens. Median AUDIT score with TOI alcohol use was 12, without TOI alcohol use was 1. 30/55 patients offered alcohol counseling accepted. 14 patients (4.3%) had positive DAST-10 screens (score ≥3). 9/25 with drug use at TOI had negative DAST-10 screens. No patients without TOI drug use had DAST-10 scores >2. 9/11 patients offered drug counseling accepted. Mean standardized length of stay (LOS) per TBSA burn injury was 1.7 days for positive AUDIT, 1.6 days for negative AUDIT. Median standardized LOS was 1.4 days for positive DAST-10, 1.7 days for negative DAST-10. CONCLUSIONS: AUDIT and DAST-10 screens can identify burn patients with problematic substance use, allowing early intervention. Positive screening scores do not independently predict longer hospital stays, increased wound severity, or treatment noncompliance.