Protocolized Rib Fracture Triage Reduces ICU Admissions Without Compromising Outcomes in a Rural Level 1 Trauma Center

The objective of this study was to determine whether protocolized triage using the Rib Injury Guidelines (RIG) can safely reduce intensive care unit (ICU) admissions and improve institutional resource utilization in a rural, Appalachian, level 1 trauma center. This was a single-center retrospective cohort study that included a total of 1148 adult patients who presented to the institution with radiographically confirmed rib fracture(s) over the course of 2 years (557 pre-RIG, 591 post-RIG). Prior to RIG implementation, triage decisions were made at the discretion of the attending provider using a protocol based on three factors: ≥3 rib fractures, age >65, and incentive spirometry (IS) <1L or <15 mL/kg ideal body weight (IBW). Patients in the post-RIG group were of higher acuity with a significantly higher percentage having ≥3 rib fractures (53.3% vs 45.2%, P = 0.006) and thoracic injuries as their highest Abbreviated Injury Scale (AIS) score (56.0% vs 24.6%, P < 0.001). Despite this higher acuity, implementation of RIG was associated with a 28.9% decrease in ICU admissions from the ED (OR 0.711, 95% CI: 0.563-0.899, P = 0.004) without a corresponding increase in floor-to-ICU transfers ( P = 0.166), unplanned intubations ( P = 0.803), morbidity, or mortality ( P = 0.364). Additionally, it reduced the hospital charges incurred by each patient. These findings suggest that protocolized triage using RIG is feasible and safe in rural settings, improving resource utilization without compromising patient outcomes.