Title : From STUMBL to standard: Improving rib fracture management through guideline adherence in an acute surgical unit
Abstract:
Background: Blunt chest wall trauma is a common presentation to an acute surgical take, accounting for up to 10–15% of emergency department attendances globally, with rib fractures present in the majority of cases. These injuries are associated with significant morbidity due to impaired ventilation, ineffective cough, and risk of pulmonary complications. Evidence-based guidelines, including the Northern Ireland Major Trauma Network (NIMTN) Clinical Practice Guideline 26, recommend early multimodal analgesia, physiotherapy, and use of risk stratification tools such as the STUMBL score to guide management.
Aim: To evaluate compliance with NIMTN rib fracture management guidelines and assess documentation and utilisation of the STUMBL score on admission in an acute surgical unit.
Methods: A two-cycle retrospective audit was conducted. Cycle 1 included patients admitted between September–October 2025, followed by an intervention comprising formal teaching and implementation of a rib fracture electronic order set. Cycle 2 included patients from November–December 2025. Data were collected from admission documentation, electronic prescribing records, and patient notes, focusing on STUMBL score use, adherence to guideline-recommended therapies, and early physiotherapy involvement.
Results: A total of 25 patients were included (13 in Cycle 1, 12 in Cycle 2), with a mean age of 65 years. STUMBL score documentation improved from 15% (2/13) in Cycle 1 to 75% (9/12) in Cycle 2. Compliance with guideline-recommended prescribing improved significantly, with 83% (10/12) of patients in Cycle 2 receiving >50% of recommended interventions compared to 38% (5/13) in Cycle 1. Full compliance was achieved in 50% of Cycle 2 patients. Early physiotherapy review within 24 hours remained high in both cycles (77% vs 83%). There was no change in the use of erector spinae plane (ESP) blocks. Length of stay remained similar between cycles.
Conclusion: Targeted interventions, including education and electronic order set implementation, significantly improved adherence to rib fracture management guidelines and use of the STUMBL score. Despite improved prescribing practices, uptake of regional anaesthesia remained unchanged, highlighting an area for further improvement. Future work should focus on linking guideline adherence to patient outcomes, including respiratory complications and critical care admission.
