Addressing barriers to the implementation of an Acute Pain Service rib fracture pathway: effect on quality and outcomes of care for trauma patients.

Abstract

Successful clinical pathway implementation requires effectively addressing barriers to delivery prior to pathway introduction, and critical evaluation of impact post-delivery. We aimed to assess whether the implementation of an Acute Pain Service pathway, designed to address barriers identified prior to introduction, influenced the delivery of regional analgesia to high-risk rib fracture patients or was associated with changes in secondary clinical outcomes (respiratory complications, delirium, mortality, length of stay, and pain scores) and processes (Acute Pain Service consults, timely provision of regional analgesia, and use of non-regional analgesic modalities). A quality improvement project was conducted and evaluated using retrospective observational data at a tertiary care trauma center between July 2018 and June 2023. System and process interventions were made to address potential hurdles to effective pathway implementation. Pre-pathway and post-pathway delivery of regional analgesia (truncal block or epidural) to patients with Rib Fracture Scores ≥6 was assessed using run charts, as well as statistically with pre-post comparisons. After pathway implementation, the use of regional analgesia increased from 16.4% to 19.7%, with run charts demonstrating a meaningful shift near the end of the study period; pre-post comparisons did not suggest a statistically significant change (p=0.195). Acute Pain Service consult rates increased from 46.7% to 49.6% (p=0.37). The implementation of an Acute Pain Service rib fracture analgesic pathway at a tertiary care trauma center did not substantially increase the proportion of patients who received a regional catheter for analgesia or lead to improvements in clinical outcomes. Further addressing structural aspects of care and refining patient selection criteria may be necessary to achieve better outcomes.