Improving the Management of Rib Fractures and Compliance with the Rib Fracture Pathway

Dr Farzana Rahman, Dr N. Maxwell, Dr S. Shidane, Dr M. Bhagalia, Mr A. Abu

Introduction & Background:

Since 2019, there hasbeen anincreasein the number of patients with Rib fractures admitted to Whipps Cross, for local management at a district general hospital, than being transferred directly to the Regional Centre for trauma, Royal London hospital (RLH)

Rib fractures areamong the most commoncauses of thoracictrauma, associated with a high risk of morbidity and complications, primarily if not managed early and well1

Complications include atelectasis to severe pneumonia and mortality, which can beprevented to a degree by early and effective pain management as per evidence-based medicine 2

Methodology & PDSA Cycles: o Conducted a retrospective data collection from January 2021 to September 2021 o Obtained PACS database of radiologically proven Rib fractures, o Correlated databases with patient case notes online to collect data to compare management with recommended published pathway guidelines. o Inclusion criteria: Patients presenting to Whipps Cross hospital, Age > 16 years old

Act: Reflect on results, Plan next cycle after improved awareness of Rib fracture Pathway

Study:

Analyse Data: Better adherence improves patient outcomes with Rib Fractures

Aims of Audit:

Plan: Identify current compliance with published Rib fracture pathway

Do: Increase awareness of pathway via posters in ED, Doctor offices, emails and teaching

§ Investigate the compliance with the published Rib fracture pathway.

§ Identify ways to improve the current pathway

Referrals Made:

1) Referrals to Pain Team:

40% were referred to the Pain team

70% -patients were referred when only prescribed paracetamol with no adjuvant medications e.g. PRN Oramorph prescribed

Only 15.5% of all patients were prescribed the PCA

Morphine

2) Referrals to ITU/ Anaesthetics: 75% were appropriate however 25% too premature.

3) Referrals to Trauma Consultant at MTC – RLH: 4 patients were transferred to RLH due to Poly trauma: i. Of which 75% were referred to by GS SHOs rather than ED delaying treatment times for patients.

Results:

Act: Reflect on results, provide pain scores in published new guidelines .

Study: Analyse data –lack of prescribing due to lack of assessment & understanding of pain ladders.

Plan: Identify reasons for ineffective pain control within 48 hours of admission

Do: Include standardised pain scoring for assessment of Pain –e.g., PIC Scores.

Act: Amend current pathway –include guidance in referrals, & trauma referrals/ Pain team and anaesthetics.

Study: Analyse data –current pathway focuses more on management than on acceptance of referrals.

Plan: Identify cause of non-compliance, Work with clinical effectiveness leads to improve published guidelines

Do:

Questionnaires to SHOs – that are responsible for accepting referrals

Discussion & Lessons Learnt:

1) Referrals: o Currently in Whipps Cross –admitting more patients with Rib Fractures o When patients have poly trauma –should be discussed with Trauma consultant/ referrals should be made (Ideally by ED):

§ Ensures patients that require transfer to RLH → transferred early, o Identified a need to include this within the Rib Fracture pathway

§ If trauma consultant agrees for local management → To be managed at Whipps.

2) Radiology: o CT Chest allows better understanding of the Rib Fracture injuries: o Pneumothorax, haemothorax, flail segments etc. o Identified a need to include guidance for when to request CT Chest within guidance

3) Pain management:

Initiating early treatment → Results in improved outcomes, shorter hospital stays, reduced risks of complications forming

Prescribing effective analgesia:

Follow current Tiers of management

Referrals to Pain Team – available 9-5: o Ensure we are prescribing analgesia before referrals – many patients are easily managed with Tier 1 medications and only 15% were initiated on PCA

Proposed

• Increased awareness with current Rib Fracture pathway

• Including a standardised Pain score to assess pain to aid in prescribing

Next Steps:

• Re-audit to assess whether improvement with prescribing after sharing Rib Fracture pathway in ED, Gen surgery Doctor offices.

• Eventually working with Clinical effectiveness lead → Update the current Rib Fracture guidelines

References:

Kim, M. and Moore, J.E. (2020). Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Current Anesthesiology Reports, 10(1), pp.61–68.

Yazkan, R., Ergene, G., Tulay, C.M., Gunes, S. and Han, S. (2012). Comparison of Chest Computed Tomography and Chest X-Ray in the Diagnosis of Rib Fractures in Patients with Blunt Chest Trauma. Journal of Academic Emergency Medicine

Acknowledgements:

Thanks to the department of General Surgery and Anaesthetics at Whipps Cross Hospital

For Further information: Contact Dr F Rahman: Farzana.Rahman12@nhs.net