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Background: We initiated a multidisciplinary clinical pathway targeting patients greater than 45 years of age with more than 4 rib fractures. The purpose of the current study was to evaluate the effect of this pathway on infectious morbidity and mortality., Methods: This was a prospective cohort study. Data evaluated included patient demographics, injury characteristics, pain management details, lengths of stay, morbidity, and mortality. Univariate and multivariate analyses were performed using a significance level of P < .05., Results: When adjusting for age, injury severity score, and number of rib fractures, the clinical pathway was associated with decreased intensive care unit length of stay by 2.4 days (95% confidence interval [CI] -4.3, -0.52 days, P = .01) hospital length of stay by 3.7 days (95% CI -7.1, -0.42 days, P = .02), pneumonias (odds ratio [OR] 0.12, 95% CI 0.04 to 0.34, P < .001), and mortality (OR 0.37, 95% CI 0.13 to 1.03, P = .06)., Conclusions: Implementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, and mortality.

Background: Recent studies have demonstrated increased morbidity in elderly patients with rib fractures after blunt trauma. As a first step in creating a multidisciplinary rib fracture clinical pathway, we sought to determine the relationship between increasing age, number of rib fractures, and adverse outcomes in blunt chest trauma patients, without major abdominal or brain injury., Study Design: We performed a retrospective cohort study involving all blunt patients greater than 15 years old with rib fractures, excluding those with Abbreviated Injury Scores (AIS) greater than 2 for abdomen and head, admitted to an urban Level I trauma center during 20 months. Outcomes parameters included the number of rib fractures, Injury Severity Score (ISS), intrathoracic injuries, pulmonary complications, number of ventilator days, length of stay in the intensive care unit (ICU), hospital stay, and type of analgesia., Results: Of the 6,096 patients admitted, 171 (2.8%) met the inclusion criteria. Based on an analysis of increasing age, number of rib fractures, and adverse outcomes variables, patients were separated into four groups: group 1, 15 to 44 years old with 1 to 4 rib fractures; group 2, 15 to 44 years old with more than 4 rib fractures; group 3, 45 years or older with 1 to 4 rib fractures; and group 4, 45 years or more with more than 4 rib fractures. The four groups had similar numbers of pulmonary contusions (30%) and incidence of hemopneumothorax (51%). Ventilator days (5.8 +/- 1.8), ICU days (7.5 +/- 1.8), and total hospital stay (14.0 +/- 2.2) were increased in group 4 patients compared with the other groups (p < 0.05). Epidural analgesia did not affect outcomes. Overall mortality was 2.9% and was not different between groups., Conclusions: Patients over the age of 45 with more than four rib fractures are more severely injured and at increased risk of adverse outcomes. Efforts to decrease rib fracture morbidity should focus not only on elderly patients but those as young as 45 years. Based on these data we have initiated a multidisciplinary clinical pathway focusing on patients 45 years and older who have more than four rib fractures.