Rib fractures are one of the most common thoracic injuries presenting to trauma centers. Traditionally, many state designation standards set limits on the number of rib fractures in patients to be admitted to Level IV trauma centers. The assumption was that these centers had limited surgical capabilities and might not have the expertise to manage them to achieve optimal patient outcomes. They were then forced to transfer these patients upstream to a higher-level trauma center.
And then, unfortunately, COVID came along, and things changed. Mainly for the worse. Due to reduced professional staffing throughout the entire continuum of health care, the upstream centers are saturated and have limited availability to absorb patients who don’t take advantage of their increased resources.
Both staffing and reimbursement issues strain rural EMS agencies. It is difficult to justify transferring a patient to a center that takes the only ambulance in the community out of service for a good portion of the day. Also, most current state trauma system standards do not fully appreciate non-surgeon clinicians’ interest and skill levels at those Level IV centers.
The Pennsylvania Trauma Systems Foundation recognized these issues at the centers in its state. In 2020, it opted to liberalize the number of rib fractures that could be treated at Level IV centers. It required hospitalists to be current in ATLS in order to admit these patients. The centers were also required to adhere to a chest injury guideline created for them.
To gauge the safety and effectiveness of this change, a retrospective state registry study was performed comparing patients admitted during the 2.5 years before the standards change to the 2.5 years after. Demographics, injury characteristics, length of stay, and mortality were compared between the groups. Patients were excluded if they had significant injuries in other body regions, were age < 18 years of age, or had complicated fractures (requiring supplemental oxygen on admission, concomitant pneumothorax or hemothorax, pulmonary contusion or laceration, or who did not require admission
Here are the factoids:
- Over 4,000 patients were recorded in the registry during the 5 years, but 3350 were excluded due to the definition of complex rib fractures
- A final total of 1,070 patients were included, with 710 admitted to Level III centers and 360 to Level IV centers
- This left 132 Level III patients and 228 Level IV patients in the pre- and post-standard groups, respectively
- The number of transfers out of the Level IV centers dropped significantly, from 56% to 21%
- Patients with <3 rib fractures had the same length of stay as those with more than three (3 vs 2, respectively)
- Mortality was extremely low and not significantly different based on the number of rib fractures
Bottom line: This study showed that the change in admission standards for rib fractures in Pennsylvania did not impact outcomes and resulted in significantly fewer transfers.
The key to a successful change like this involves education and protocols. The requirement that hospitalists be current in ATLS is beneficial because it gives them a better understanding of the physiologic effects and priorities in managing trauma patients. A well-designed practice guideline is critical so that all clinicians apply best practices in caring for these patients.
This is an important paper, and should be considered in any state where local resources are being challenged, and hospital reimbursements are declining. This type of standards change may breathe new life into many of our Level IV centers.