Rib Fracture Frailty Index: A risk stratification tool for geriatric patients with multiple rib fractures

The Effect of Frailty in Predicting Outcomes of Rib Fractures Among Elderly Patients

INTRODUCTION

Rib fractures are consequential injuries for geriatric trauma patients. Frailty has been associated with adverse outcomes in this population. The Rib Fracture Frailty Index (RFF) and 5-factor modified Frailty Index (mFI) are 2 validated frailty metrics. Research assessing inclusion of frailty metrics in geriatric rib fractures triage protocols is limited.

METHODS

A retrospective cohort study was performed for trauma patients ≥50 years old with rib fractures admitted to a Level I trauma center, which currently uses percent predicted forced vital capacity (FVC%) to triage rib fractures patients. Frailty metrics (RFF & mFI) were calculated retrospectively, stratifying patients as low, moderate, or severe frailty. Unfavorable discharge disposition (UDD) was defined as discharge to facility or death. Unadjusted and adjusted odds ratios were used to assess frailty with outcome variables.

RESULTS

In total, 834 patients were included from August 2018 - May 2023, with mean age of 69.1. A majority had low frailty (64.0 vs 40.3%), followed by moderate frailty (21.1 vs 30.7%), then severe frailty (14.9 vs 29.0%) for RFF and mFI, respectively. Age, sex, and ISS differed between groups. For RFF, increased frailty was associated with longer hospital and ICU length of stay. Neither frailty metric was associated with unplanned ICU transfer or intubation. In the adjusted analysis, frail patients were more likely to have UDD (OR 8.9, CI 3.4-23.0, P < .0001).

CONCLUSION

While both frailty metrics were predictive of UDD, neither was associated with ICU transfer or intubation, suggesting that frailty does not enhance the accuracy of our current protocol using FVC%.

Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis

BACKGROUND

Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population.

METHODS

A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF.

RESULTS

A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis.

CONCLUSION

Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures

Background

Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures.

Methods

All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding.

Results

A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001].

Conclusion

There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

Health care utilization outcomes in patients with blunt chest wall trauma following discharge from the emergency department: A retrospective, observational data-linkage study

BACKGROUND

Although much is published reporting clinical outcomes in the patients with blunt chest wall trauma who are admitted to hospital from the ED, less is known about the patients' recovery when they are discharged directly without admission. The aim of this study was to investigate the health care utilization outcomes in adult patients with blunt chest wall trauma, discharged directly from ED in a trauma unit in the United Kingdom.

METHODS

This was a longitudinal, retrospective, single-center, observational study incorporating analysis of linked datasets, using the Secure Anonymised Information Linkage databank for admissions to a trauma unit in the Wales, between January 1, 2016, and December 31, 2020. All patients 16 years or older with a primary diagnosis of blunt chest wall trauma discharged directly home were included. Data were analyzed using a negative binomial regression model.

RESULTS

There were 3,205 presentations to the ED included. Mean age was 53 years, 57% were male, with the predominant injury mechanism being a low velocity fall (50%). 93% of the cohort sustained between 0 and 3 rib fractures. Four percent of the cohort were reported to have chronic obstructive pulmonary disease, and 4% using preinjury anticoagulants. On regression analysis, inpatient admissions, outpatient appointments and primary care contacts all significantly increased in the 12-week period postinjury, compared with the 12-week period preinjury (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.33-1.99; p < 0.001; OR, 1.28; 95% CI, 1.14-1.43; p < 0.001; OR, 1.02; 95% CI, 1.01-1.02; p < 0.001, respectively). Risk of health care resource utilization increased significantly with each additional year of age, chronic obstructive pulmonary disease and preinjury anticoagulant use (all p < 0.05). Social deprivation and number of rib fracture did not impact outcomes.

CONCLUSION

The results of this study demonstrate the need for appropriate signposting and follow-up for patients with blunt chest wall trauma presenting to the ED, not requiring admission to the hospital.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF.

METHODS

A retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days.

RESULTS

50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days.

CONCLUSION

In this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

DeepBackRib: Deep learning to understand factors associated with readmissions after rib fractures

BACKGROUND

Deep neural networks yield high predictive performance, yet obscure interpretability limits clinical applicability. We aimed to build an explainable deep neural network that elucidates factors associated with readmissions after rib fractures among nonelderly adults, termed DeepBackRib . We hypothesized that DeepBackRib could accurately predict readmissions and a game theoretic approach to elucidate how predictions are made would facilitate model explainability.

METHODS

We queried the 2017 National Readmissions Database for index hospitalization encounters of adults aged 18 to 64 years hospitalized with multiple rib fractures. The primary outcome was 3-month readmission(s). Study cohort was split 60-20-20 into training-validation-test sets. Model input features included demographic/injury/index hospitalization characteristics and index hospitalization International Classification of Diseases, Tenth Revision , diagnosis codes. The seven-layer DeepBackRib comprised multipronged strategies to mitigate overfitting and was trained to optimize recall. Shapley additive explanation analysis identified the marginal contribution of each input feature for predicting readmissions.

RESULTS

A total of 20,260 patients met the inclusion criteria, among whom 11% (n = 2,185) experienced 3-month readmissions. Feature selection narrowed 3,164 candidate input features to 61, and DeepBackRib yielded 91%, 85%, and 82% recall on the training, validation, and test sets, respectively. Shapley additive explanation analysis quantified the marginal contribution of each input feature in determining DeepBackRib's predictions: underlying chronic obstructive pulmonary disease and long index hospitalization length of stay had positive associations with 3-month readmissions, while private primary payer and diagnosis of pneumothorax during index admission had negative associations.

CONCLUSION

We developed and internally validated a high-performing deep learning algorithm that elucidates factors associated with readmissions after rib fractures. Despite promising predictive performance, standalone deep learning algorithms are insufficient for clinical prediction tasks: a concerted effort is needed to ensure that clinical prediction algorithms remain explainable.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Barriers to and Facilitators for Acceptance of Comprehensive Clinical Decision Support System-Driven Care Maps for Patients With Thoracic Trauma: Interview Study Among Health Care Providers and Nurses

BACKGROUND

Comprehensive clinical decision support (CDS) care maps can improve the delivery of care and clinical outcomes. However, they are frequently plagued by usability problems and poor user acceptance.

OBJECTIVE

This study aims to characterize factors influencing successful design and use of comprehensive CDS care maps and identify themes associated with end-user acceptance of a thoracic trauma CDS care map earlier in the process than has traditionally been done. This was a planned adaptive redesign stage of a User Acceptance and System Adaptation Design development and implementation strategy for a CDS care map. This stage was based on a previously developed prototype CDS care map guided by the Unified Theory of Acceptance and Use of Technology.

METHODS

A total of 22 multidisciplinary end users (physicians, advanced practice providers, and nurses) were identified and recruited using snowball sampling. Qualitative interviews were conducted, audio-recorded, and transcribed verbatim. Generation of prespecified codes and the interview guide was informed by the Unified Theory of Acceptance and Use of Technology constructs and investigative team experience. Interviews were blinded and double-coded. Thematic analysis of interview scripts was conducted and yielded descriptive themes about factors influencing the construction and potential use of an acceptable CDS care map.

RESULTS

A total of eight dominant themes were identified: alert fatigue (theme 1), automation (theme 2), redundancy (theme 3), minimalistic design (theme 4), evidence based (theme 5), prevent errors (theme 6), comprehensive across the spectrum of disease (theme 7), and malleability (theme 8). Themes 1 to 4 addressed factors directly affecting end users, and themes 5 to 8 addressed factors affecting patient outcomes. More experienced providers prioritized a system that is easy to use. Nurses prioritized a system that incorporated evidence into decision support. Clinicians across specialties, roles, and ages agreed that the amount of extra work generated should be minimal and that the system should help them administer optimal care efficiently.

CONCLUSIONS

End user feedback reinforces attention toward factors that improve the acceptance and use of a CDS care map for patients with thoracic trauma. Common themes focused on system complexity, the ability of the system to fit different populations and settings, and optimal care provision. Identifying these factors early in the development and implementation process may facilitate user-centered design and improve adoption.

Factors related to early and rapid assessment of in-hospital mortality among older adult trauma patients in an earthquake

BACKGROUND

There is limited evidence for emergency physicians and emergency trauma surgeons regarding the determinants of early and rapid assessment of older adult in-hospital mortality due to earthquakes. This study explored factors related to the early and rapid assessment of the mortality among older adult earthquake trauma patients (OAETPs) and created a screening model.

METHODS

Data on 7,308 OAETPs from the West China Earthquake Patients Database were analyzed retrospectively. The 35 variables that can be obtained rapidly on arrival at the hospital were collected. Least absolute shrinkage and selection operator (LASSO) regression analysis was performed. Then, the nomogram for assessing the mortality of OAETPs was constructed.

RESULTS

We identified 10 independent mortality-related factors that contributed to the in-hospital mortality of OAETPs. The 10 factors included age (odds ratio [OR]=1.061, 95% confidence interval [CI]:1.031-1.090), dementia (OR=5.146, 95%CI: 1.169-17.856), coronary heart disease (CHD; OR=23.441, 95%CI: 4.799-83.927), malignant tumor (OR=8.497, 95%CI: 3.583-17.967), deep vein thrombosis (DVT; OR=7.110, 95%CI: 1.369-27.168), chronic kidney disease(CKD; OR=11.783, 95%CI: 5.419-24.407), pulse rate (PR; OR=1.036, 95%CI: 1.022-1.048), mean artery pressure (MAP; OR=0.960, 95%CI: 0.945-0.975), Glasgow Coma Scale (GCS; OR=0.864, 95%CI: 0.760-0.972), and Triage Revised Trauma Score (T-RTS, OR=0.485, 95%CI: 0.351-0.696).

CONCLUSION

The 10 mortality-related factors could be quickly obtained on hospital arrival and should be the focal point of future earthquake response strategies regarding hospitalized older adults with trauma. A nomogram was constructed based on the factors for screening OAETPs with a higher risk of in-hospital mortality.