Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: A retrospective case-control study

Abstract

Introduction: This single-centre retrospective case-control study aimed to assess the effectiveness of a multidisciplinary clinical pathway for blunt chest trauma patients admitted in emergency department (ED).

Patients and methods: All consecutive blunt chest trauma patients with more than 3 rib fractures and no indication of mechanical ventilation were compared to a retrospective cohort over two 24-month periods, before and after the introduction of the bundle of care. Improvement of analgesia was the main outcome investigated in this study. The secondary outcomes were the occurrence of secondary respiratory complications (pneumonia, indication for mechanical ventilation, secondary ICU admission for respiratory failure or death), the intensive care unit (ICU) and hospital length of stay (LOS).

Results: Sixty-nine pairs of patients were matched using a 1:1 nearest neighbour algorithm adjusted on age and indices of severity. Between the two periods, there was a significant reduction of the rate of uncontrolled analgesia (55 vs. 17%, P<0.001). A significant increase in the rate of primary ICU transfer during the post-protocol period (23 vs. 52%, P<0.001) was not associated with a reduction of secondary respiratory complications or a reduction of ICU or hospital LOS. Only the use of non-steroidal anti-inflammatory drugs appeared to be associated with a significant reduction of secondary respiratory complications (OR=0.3 [0.1-0.9], P=0.03).

Conclusion: Implementation of a multidisciplinary clinical pathway significantly improves pain control after ED management, but increases the rate of primary ICU admission without significant reduction of secondary respiratory complications.

Keywords: Blunt chest trauma; Clinical pathways; Epidural analgesia; Non-invasive ventilation; Outcome.