Modification of a Clinical Practice Guideline for the Older Adult with Multiple Traumatic Rib Fractures

Abstract

Older adults comprise approximately 25% of all rib fracture injuries in the United States (Bonne & Schuerer, 2013). Older adults have compromised respiratory mechanics secondary to a loss of elastic recoil and increased dead space due to the aging process (Bordi, 2018). Rib fractures result in intense pain limiting respiratory efforts, which further exacerbates pulmonary dead space leading to the development of acute respiratory distress syndrome (ARDS), thereby increasing morbidity and mortality. Analgesic regimens vary from provider to provider. However thoracic epidural analgesia (TEA) is recognized as the gold standard, but intravenous (IV) opioid usage appears to be a first-line treatment (Bonne & Schuerer, 2013). Considering the opioid epidemic, regional anesthesia techniques are emerging as viable options for the resolution of pain associated with MTRFs. Literature supports the use of regional anesthesia techniques such as TEA, paravertebral blocks (PVB), and erector spinae plane blocks (ESPB). The scope of this Doctor of Nursing Practice (DNP) project was to modify a clinical practice guideline (CPG) for the analgesic management of older adults with MTRFs; this project was created for the anesthesia providers (n=4) of a Southeastern, AZ anesthesia practice. The algorithm, a part of this modified CPG, was developed based on the most current literature and encourages early regional anesthesia interventions. The Iowa Model served as the conceptual framework guiding the uncovering of evidence and recognizing emerging ideas to improve clinical practice. As a result, a modified CPG for the older adults with MTRFs was presented to the stakeholders (n=4) of the Southeastern, AZ anesthesia practice. The stakeholders completed a post-survey (n=3) which revealed an acceptance of this CPG and probable implementation to standardize the care of this patient population served at this Southeastern anesthesia practice.