Frailty, Comorbid Burden, and Physiologic Factors Associated With Intensive Care Unit–Level Respiratory Complications in Older Adults With Rib Fractures: A Retrospective Trauma Quality Improvement Program Study

BackgroundTraditional intensive care unit (ICU) triage criteria for older trauma patients with rib fractures emphasize age and rib fracture count but do not account for physiologic vulnerability, pre-injury frailty, and comorbid burden. We aimed to develop a risk score incorporating these variables to identify ICU-level respiratory complications in older adults with rib fractures.MethodsWe conducted a retrospective cohort study using the 2022 American College of Surgeons Trauma Quality Improvement Program (TQIP) dataset. Patients aged 65-89 years with blunt trauma and ICD-10-identified rib fractures were included after exclusion of patients with major physiologic instability or confounding injuries. The primary outcome was a composite of unplanned ICU admission, unplanned intubation, acute respiratory distress syndrome, or mechanical ventilation. Multivariable logistic regression was used to derive a risk score based on frailty, comorbid conditions, and physiologic variables, with discrimination assessed using the area under the receiver operating characteristic curve.ResultsThe final analytic cohort included 35 341 patients, among whom ICU-level respiratory complications occurred in 1523 (4.3%). A rib fracture-only model demonstrated poor discrimination (AUROC 0.51), while a model based on frailty, comorbid conditions and physiologic variables showed improved discriminatory performance (AUROC 0.66). Complication rates increased stepwise across FRAIL-ICU score categories, from 2.3% in low-risk patients to 9.5% in high-risk patients.DiscussionThe FRAIL-ICU score outperforms rib fracture count alone in predicting ICU-level respiratory complications and provides meaningful risk stratification that may assist in risk stratification to inform ICU triage decisions beyond traditional age- and injury-based criteria.