Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score

Abstract

Background: To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named “PIC Protocol” and “PIC Score,” emphasizing continual assessment of pain, incentive spirometry, and cough ability. Objective: The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination. Methods: This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05. Results: There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score. Conclusions: The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients.

Reviving a successful blunt chest wall injury protocol

“…1 While no difference was found in in-hospital mortality for the patients in this study, the use of the PIC protocol did result in a 57% reduction in unanticipated transfers to a higher level of care related to respiratory decline. 1 While the translation of evidencebased practice to bedside care is essential, it is difficult to sustain. 10 Factors that impact this include time constraints, clinician behaviors, staff motivation, organizational support, and the need for continuing education.…”

“…Any significant changes to the PIC score prompt reassessment and notification of the trauma team. Each patient on the protocol had a magnetic PIC scoreboard placed in their room as a reminder to participate in care measures 1. While no difference was found in in-hospital mortality for the patients in this study, the use of the PIC protocol did result in a 57% reduction in unanticipated transfers to a higher level of care related to respiratory decline 1…”

“…The use of patient protocols and a systematic approach has been shown to improve outcomes 9. The CWI protocol named PIC created by the trauma team demonstrated success in improving care since its implementation in 2014 1. This protocol was developed based on the evidence both in the literature and from the trauma team data that reviewed over 1,000 patients from 2 years before and after the introduction of the PIC protocol.…”

“…The organs most commonly affected by a CWI include the heart, lungs, trachea, esophagus, and great vessels, such as the aorta 3. Complications related to acute respiratory distress syndrome and pneumonia lead to increased morbidity and mortality 1…”

“…3 Complications related to acute respiratory distress syndrome and pneumonia lead to increased morbidity and mortality. 1 Damage to major organs occurs from the mechanism of injury. This could be a low-energy mechanism, such as falling from a standing position, or a high-energy mechanism, such as an MVC.…”