Chest trauma clinical practice guideline protects against delirium in patients with rib fractures.

Introduction: Traumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated with rib fractures, evidence-based interventions have been implemented, including effective pain management, pulmonary hygiene, and early walking. Vancouver General Hospital, a level 1 trauma center in British Columbia, Canada, developed a comprehensive multidisciplinary chest trauma clinical practice guideline (CTCPG) to optimize the management of patients with rib fractures. This prospective cohort study aimed to assess the impact of the CTCPG on pain management interventions and patient outcomes. Methods: The study involved patients admitted between January 1, 2021 and December 31, 2021 (post-CTCPG cohort) and a historical control group admitted between November 1, 2018 and December 31, 2019 (pre-CTCPG cohort). Patient data were collected from patient charts and the British Columbia Trauma Registry, including demographics, injury characteristics, pain management interventions, and relevant outcomes. Results: Implementation of the CTCPG resulted in an increased use of multimodal pain therapy (99.4% vs 96.1%; p=0.03) and a significant reduction in the incidence of delirium in the post-CTCPG cohort (OR 0.43, 95% CI 0.21 to 0.80, p=0.0099). There were no significant differences in hospital length of stay, ICU (intensive care unit) days, non-invasive positive pressure ventilation requirement, ventilator days, pneumonia incidence, or mortality between the two cohorts. Discussion: Adoption of a CTCPG improved chest trauma management by enhancing pain management and reducing the incidence of delirium. Further research, including multicenter studies, is warranted to validate these findings and explore additional potential benefits of the CTCPG in the management of chest trauma patients. Level of evidence: IIb.

A simple "passive awareness" intervention to decrease the cost of thoracoscopic lobectomy.

In thoracic surgery, disposable instruments are significant drivers of cost. There is variation in disposable instrument use among surgeons. It was hypothesized that a "passive awareness" intervention (displaying a pricing list of disposable instruments in the operating theater) would decrease operative costs. A current price list of disposable instruments used in thoracoscopic lobectomy was displayed in the thoracic surgery operating theater. Consecutive patients who underwent thoracoscopic lobectomy 6 months prior to price list display (Period 1) and 6 months following price list display (Period 2) were analyzed. Descriptive statistics were used to describe case distribution and lobectomy costs. T test and linear regression were used to examine the impact of surgeon, lobe removed, and time period. Over the study period, 71 patients underwent thoracoscopic lobectomy (Period 1: n = 36, Period 2: n = 35). Median per-lobectomy disposables cost decreased from $2063.22 (Interquartile range [IQR] $788.49) in Period 1 to $1885.92 (IQR $552.26) in Period 2; p = 0.03. There was a significant reduction in the median number of "high cost disposables" between Periods 1 and 2 (5.5-5.0, respectively; p = 0.04). In multiple linear regression, there was a decrease in total per-lobectomy cost of $286.21 (p = 0.03) and a decrease in stapler cartridge cost of $266.89 (p = 0.03) when controlling for surgeon and lobe. There was a significant reduction in disposable instrument expenditure per thoracoscopic lobectomy following posting of instrument costs in the operating theater. These findings suggest that a simple passive awareness intervention is effective in influencing surgeon behavior to reduce disposable instrument costs.