A novel, evidence-based, comprehensive clinical decision support system improves outcomes for patients with traumatic rib fractures

Emma K. Jones, Ivana Ninkovic, Matthew Bahr, Sarah Dodge, Michael Doering, David Martin, Julie Ottosen, Tadashi Allen, Genevieve B. Melton, Christopher J. Tignanelli

Research output: Contribution to journalArticlepeer-review


BACKGROUND Traumatic rib fractures are associated with high morbidity and mortality. Clinical decision support systems (CDSS) have been shown to improve adherence to evidence-based (EB) practice and improve clinical outcomes. The objective of this study was to investigate if a rib fracture CDSS reduced hospital length of stay (LOS), 90-day and 1-year mortality, unplanned ICU transfer, and the need for mechanical ventilation. The independent association of two process measures, an admission EB order set and a pain-inspiratory-cough score early warning system, with LOS were investigated. METHODS The CDSS was scaled across nine US trauma centers. Following multiple imputation, multivariable regression models were fit to evaluate the association of the CDSS on primary and secondary outcomes. As a sensitivity analysis, propensity score matching was also performed to confirm regression findings. RESULTS Overall, 3,279 patients met inclusion criteria. Rates of EB practices increased following implementation. On risk-adjusted analysis, in-hospital LOS preintervention versus postintervention was unchanged (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 0.97-1.15, p = 0.2) but unplanned transfer to the ICU was reduced (odds ratio, 0.28; 95% CI, 0.09-0.84, p = 0.024), as was 1-year mortality (hazard ratio, 0.6; 95% CI, 0.4-0.89, p = 0.01). Provider utilization of the admission order bundle was 45.3%. Utilization was associated with significantly reduced LOS (IRR, 0.87; 95% CI, 0.77-0.98; p = 0.019). The early warning system triggered on 34.4% of patients; however, was not associated with a significant reduction in hospital LOS (IRR, 0.76; 95% CI, 0.55-1.06; p = 0.1). CONCLUSION A novel, user-centered, comprehensive CDSS improves adherence to EB practice and is associated with a significant reduction in unplanned ICU admissions and possibly mortality, but not hospital LOS. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.

Original languageEnglish (US)
Pages (from-to)161-171
Number of pages11
JournalJournal of Trauma and Acute Care Surgery
Issue number2
StatePublished - Aug 1 2023

Bibliographical note

Publisher Copyright:
© Wolters Kluwer Health, Inc. All rights reserved.


  • Rib fractures
  • clinical decision support
  • implementation science
  • length of stay
  • stepped wedge trial

PubMed: MeSH publication types

  • Journal Article
  • Research Support, U.S. Gov't, P.H.S.


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