Audit of care in patients who sustained rib fractures against a simple scoring system

Abstract

It is essential that patients who have sustained rib fractures receive an appropriate level of care (as defined by the Intensive Care Society levels 0- 31). This is because of the high mortality in patients who acquire pneumonia after this injury. A recent study proposed a simple scoring system, which can be used on admission to identify patients who are at greatest risk of morbidity and mortality (Table 1).2 It assesses age, number of rib fractures, pulmonary contusion, and presence of bilateral fractures. Patients with scores of 7 or 8 are at greater mortality risk, and may benefit from ICS level 3 care. Patients with scores >=5 are more likely to require longer lengths of stay, longer ventilation periods and may benefit from level 1-2 care. The scoring system should assist in earlier implementation of appropriate treatment strategies. This is a retrospective audit of levels of care received by patients admitted with rib fractures to intensive care units of the Royal Derby Hospital (RDH) against this scoring system. The scoring system was applied retrospectively to patients who sustained rib fractures and were admitted to the ICU (level 3) and Step- Down-Unit (SDU, level 1-2) over one year from January 2012. The scores calculated were correlated with the level of care received by the patient. (Table Presented) All patients scoring >=5, required either epidural anaesthesia or morphine PCA. No patients required care escalation after admission. The 30-day mortality rate was 0%. Results indicated that patients at the RDH are receiving the appropriate level of care as judged by the scoring system. There would be value in applying this scoring system prospectively to the initial patient assessment to formalise selection of the level of care required. However other comorbidities caused by trauma must be considered simultaneously and level of care cannot be determined by rib fractures in isolation. This scoring system may assist in delivering appropriate level care more efficiently, and is likely to make more appropriate use of finite intensive care recourses.