Department of Surgery, University of California, Davis.
Department of Public Health Sciences, University of California, Davis.
JAMA Netw Open. 2020 Nov 2;3(11):e2026500. doi: 10.1001/jamanetworkopen.2020.26500.
The optimal level of care for older patients with rib fractures as an isolated injury is unknown.
To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020.
Admission to the ICU.
Composite of unplanned intubation, pneumonia, or death during hospitalization.
Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92).
In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.
老年患者肋骨骨折的最佳护理水平尚不清楚。
描述不同医院对孤立性肋骨骨折老年患者入住重症监护病房（ICU）与非 ICU 的差异，并评估医院 ICU 入院率的增加是否与改善结局相关。
设计、地点和参与者：这项队列研究纳入了 2015 年 1 月 1 日至 2016 年 12 月 31 日期间参与美国创伤中心国家创伤数据库的年龄 65 岁及以上、仅存在肋骨骨折的创伤患者。如果患者存在其他严重损伤、在急诊科（ED）进行插管或有辅助呼吸、或 ED 的格拉斯哥昏迷量表（GCS）评分<9，则排除这些患者。排除 ICU 入院患者少于 10 例的医院。数据分析于 2019 年 5 月至 2020 年 9 月进行。
入住 ICU。
住院期间计划外插管、肺炎或死亡的复合结局。
在 573 家医院的 23951 例患者（11066 例[46.2%]为女性；平均[标准差]年龄为 77.0[7.2]岁）中，ICU 使用比例的中位数（四分位距）为 16.7%（7.4%-32.0%），但范围从 0%到 91.9%不等。787 例（3.3%）患者发生了复合结局，其中 317 例（1.3%）需要计划外插管，180 例（0.8%）发生肺炎，451 例（1.9%）死亡。考虑到数据的分层性质，并根据 ICU 入院相关因素的倾向评分进行调整后，与 ICU 使用率最低的医院相比，在 ICU 使用率最高的医院（第 4 四分位）接受治疗与复合结局发生的可能性降低相关（调整后的优势比，0.71；95%CI，0.55-0.92）。
在这项研究中，孤立性肋骨骨折老年患者的入院地点在不同医院之间存在差异，但在 ICU 使用率较高的中心住院与改善结局相关。对于 ICU 使用率较低的医院，可能需要将更多此类患者收入 ICU。
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