Delendra Wijayanayaka studied medicine at the University of Auckland. He passed the fellowhsip examination and completed the general surgery training program while at Middlemore Hospital in 2019. He now works as a Fellow in Wellington Hospital.
COMBAT Clinical Pathway Reduces Rib Fracture Morbidity in a New Zealand Tertiary Centre
Aims: Chest trauma is a highly morbid condition and is responsible for as much as 25% of traumatic deaths1. We hypothesised that a structured, standardised approach to managing chest trauma patients through a clinical pathway may mitigate against some of the preventable morbidity and improve clinical outcomes.
Methods: We introduced the COMBAT Clinical Pathway at Middlemore Hospital in December 2018. It is a clinical pathway standardising the care provided to rib fracture patients by surgeons, anaesthetists, physiotherapists, and nurses. We performed a retrospective analysis of all patients admitted under General Surgery with rib fractures between 1 January and 30 June 2017 (Group 1) and compared these with patients admitted between 1 January and 30 June 2019 (Group 2), after the COMBAT protocol was instituted. The primary end-point was rates of lower respiratory tract infection. The secondary endpoints were length of stay, rates and length of admission to critical care, other complications, and mortality.
Results: There were 85 patients in Group 1, and 86 patients in Group 2. Ages and comorbidities were similar in both groups. The mean number of ribs fractured per patient was 4 in each group. Group 2 had significantly more patients with a flail segment (12.8% vs. 3.5%, p=0.027).
After COMBAT was introduced, there was a significant reduction in the rates of lower respiratory tract infections (23/85 [27.1%] vs. 12/86 [14.0%], p=0.034).
There was a trend towards reduced length of stay, but this did not meet statistical significance (6.96 vs. 5.80 days, p=0.207). Other complication and mortality rates were similar in the two groups.
Conclusion: The introduction of the COMBAT Clinical Pathway was associated with a reduction in the rate of lower respiratory tract infection in rib fracture patients.
Reference 1Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma: analysis of 515 patients. Ann Surg 1987;206:200-5.