Institutional learning curve for operative chest injury management as defined by outcomes

Background: Expanded use of surgical stabilization of chest injuries has raised interest in how to evaluate rib plating and the expected early course of chest wall injury program development. Prior work has used operative time to approximate an institutional learning curve for such programs. However, patient-centered and outcome-based evidence for institutional learning is lacking. We hypothesized that pulmonary complications, readmissions, and ventilator-free days (VFDs) can be used to delineate institutional learning curves for a chest wall stabilization program. Methods: A single-center retrospective review of all chest wall stabilization operations at a level 1 trauma center was performed. Serial data on all operative chest injuries was collected following the initiation of an operative chest injury program. Clinical outcomes including pulmonary complications, readmissions, and VFDs were used to determine success and misstep, and learning curves were plotted using cumulative summation (CUSUM) modeling calibrated using anticipated incident rates of 5%, 10%, 20%, and 25% for respective outcomes. Results: Over 7 years, 168 patients underwent chest wall stabilization, of which 19% experienced a pulmonary complication post-operatively, and 8.3% required readmission. CUSUM curves for pulmonary outcomes and readmission demonstrated no clear morphology, with respective 20% and 10% incidence curves trending parallel to the X-axis. The CUSUM curves for VFDs demonstrated distinct inflection towards serial successes for all incidence rates after operation 86. Conclusions: VFDs appear to be a clinically relevant outcome for illustrating an institutional learning curve for chest wall stabilization procedures, while pulmonary complications and readmissions in this analysis suggest stable incidence rates over time. Future multi-institutional study may help illuminate trends and programmatic milestones for institutions seeking to establish a comprehensive chest wall injury program.