Improving rib fracture management in Morriston hospital: using QI to develop an erector spinae plane catheter service

INTRODUCTION: Trauma audit research network (TARN) data for 2018 indicated that we admitted 100 patients with chest wall injuries in our District General Hospital (DGH). Our own retrospective audit of pain team referrals confirmed long length of stay (median 14 days), with 59% requiring level 2/3 care and 11% mortality risk. We noticed that Regional anaesthesia was offered to less than 25% of patients despite 63% reporting severe pain and decided to introduce an erector spinae plane (ESP) catheter service for rib fractures. Our aims were to reduce length of stay and pain scores. METHODS: We set up an email alert system, where TARN data collectors notified us when patients were admitted through the emergency department with rib fractures. Using a secure social media app (Whatsapp), we organised a group of regional anaesthetists who were willing to provide an ESP service. Process mapping and driver diagrams helped to streamline the service. RESULTS: Mean length of hospital stay was reduced from 10 to 7 days after introduction of the service with significant reduction in variability. Mean pain scores improved from 8.9/10 to 5/10 with an average improvement of pain score of 2.78 points on a numerical scale out of 10. (n=9) CONCLUSIONS: This service improvement relied on a team of hospital clinicians who agreed to provide an extra pain service for patients with rib fracture. The reduction in LOS may be explained by improved respiratory physiology with ESP catheter placement. The ability to deep breathe, cough and engage in physiotherapy treatment are important factors in recovering from rib fractures. The small reduction in pain scores may be explained by the presence of other injuries. Ongoing improvements in training should improve reliability of catheter placement and reduce practitioner variation.