1. 1
Impact of an Alternative Admissions Protocol for Multi-system Trauma
Patients with Pelvic Fracture on Patient Care Outcomes at a Level II
Trauma Center

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Introduction
Despite having an estimated incidence rate of 37 per 100,000 person-years and comprising only
3% of all skeletal fractures seen in the United States, pelvic fractures represent a significant
mortality risk for trauma patients. 1,2,3
Published mortality rates range from 5 to 50 percent.1,4,5
Because pelvic fractures most often result from high energy traumatic forces, patients frequently
present to the emergency department with injuries concomitant to their pelvic fracture.4,5
Research has shown that these concomitant injuries and not the isolated pelvic fracture tend to be
the primary causes of death in hemodynamically stable patients with poly-traumas.1,6,7,8
These
injuries have been shown to increase mortality from 10.8% to 31.1%. 5
Management of pelvic fracture patients regularly consists of hemodynamic stabilization and
early fixation of the fracture.5,9,10
This study aimed to assess the impact of an alternative
admissions protocol for multi-system trauma patients with pelvic fracture on patient care
outcomes; it was implemented at a level II trauma center in May 2007 following identification of
the potential for negative outcomes under the previous protocol. Figure 1 demonstrates each step
in the performance improvement plan following identification of the issue. Prior to
implementation, patients with pelvic fractures that would potentially require operative fixation
were hemodynamically stabilized and immediately transferred to a higher level of care because
the facility, did not have an in-house orthopedic surgeon specializing in operative fixation of
complex pelvic fractures. Under the new protocol, all patients diagnosed with a pelvic fracture
are admitted to the trauma department for stabilization, evaluation and treatment of their
associated injuries prior to transfer. An exception is made for those patients who are deemed
stable for transfer directly from the emergency department and who following written

3. 3
consultation from orthopedic surgery are given approval for transfer by both the trauma and
orthopedic departments.
It was hypothesized that although length of stay in the hospital and/or intensive care unit (ICU)
would increase, mortality would not increase and the newly implemented admissions protocol
would prove to be a viable alternative to the immediate transfer of all pelvic fracture patients.
Materials and Methods
This study followed a retrospective design whereby outcomes data (length of stay in the hospital,
length of stay in the intensive care unit (ICU), morbidity, mortality, and time spent in the
emergency department ( ED) ) were collected on trauma patients presenting to the facility and
diagnosed with a pelvic fracture during the 16 month period (January 1, 2006 to April 30, 2007)
directly prior to the initiation of the new pelvic fracture process and were compared to that from
comparable patients seen during the 16 month period following implementation of the new
process (June 1, 2007 to October 31, 2008). Patients presenting to the emergency department and
diagnosed with a pelvic fracture were identified and reviewed for study inclusion using the
Department of Acute Care Surgery, Trauma and Surgical Critical Care’s trauma registry.
SPSS 16.0 for Windows was used for the statistical analysis of all included patient care outcomes
data. T-tests, Mann Whitney U tests, and chi-square tests were used to compare the patient care
outcome means of the pre protocol implementation group to the post protocol implementation
group. Multiple logistic and linear regression were then used to adjust for age and the covariates:
injury severity score (ISS), and mechanism of injury (blunt, penetrating, thermal).
Results

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A total 172 patients met the inclusion criteria and were enrolled into the study for analysis. As
shown in table 1, there was a statistically significant increase in length of stay in the hospital
(6.72 days pre change and 10.32 days post change, p=0.01) and length of stay in the ICU (2.69
days pre change and 4.69 days post change, p=0.03). Additionally, there was a borderline
statistically significant increase in morbidities (0.42 pre change and 0.64 post change, p=0.05).
Notably a non-statistically significant decrease in the mortality rate was seen (0.10 pre change
and 0.04 post change, p=0.10). Furthermore, multiple logistic regression analysis, table 2,
revealed that mortality was borderline statistically significant (p=0.05).
Discussion
Following analysis it was shown that the new process proved to be an effective way to deal with
patients with pelvic fractures in the absence of having in house orthopedic surgeons who
specialize in the operative fixation of pelvic fractures. The hypothesis that an increase in both
hospital length of stay and ICU length of stay would be occur but not an increase in mortality,
was shown to be accurate and could not be rejected based upon the study’s findings. However
due to the sample size used in this study, in order to better ascertain the generalizability of the
alternative admissions protocol to other trauma facilities that lack in house orthopedic surgeons
specializing in operative fixation of pelvic fractures, a similar study on a larger population would
be warranted. This study also affirmed the findings of other published studies; Concomitant
injuries play an important role in the overall mortality rate of hemodynamically stable
polytrauma patients with pelvic fractures. 1,6,7,8
Early treatment as demonstrated here by hospital
admission and treatment of these associated injuries was substantial in reducing mortality rate in
this patient population.

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References
1. Chong, K., DeCoster, T., Osler, T., & Robinson, B. (1997). Pelvic fractures and
mortality. The Iowa Orthopedic Journal, 17, 110-114.
2. Heetveld, M. J., Harris, I., Sciilaphoff, G., & Sugrue, M. (2004). Guidelines for the
management of haemodynamically unstable pelvic fracture patients. ANX Journal of
Surgery, 74(7), 520-529.
3. Russell, G. V., Jr., Jarrett, C. A., & Routt, M. C., Jr. (2009, March 23). Pelvic factures. In
eMedicine [Medical reference]. Retrieved March 15, 2010, from
http://emedicine.medscape.com//overview
4. Durkin, A., Sagi, H. C., Durham, R., & Flint, L. (2006). Contemporary management of
pelvic fractures. The American Journal of Surgery, 192, 211-223.
5. Foster, J. (n.d.). Pelvic fractures: Emergency are to rehabilitation. Perspectives: Recovery
Strategies Fom the OR to Home, 3(1), 1, 4-6.
6. Lunsjo, K., Tadros, A., Hauggaard, A., Blomgren, R., Kopke, J., & Abu-Zidan, F. M.
(2007). Associated injuries and not fracture instability predict mortality in pelvic
fractures: A prospective study of 100 patients. The Journal of Trauma Injury Infection
and Critical Care, 62(3), 687-691.
7. Mechem, C. C. (2009, September). Fracture, pelvis. In eMedicine [Medical Reference].
Retrieved March, 2010, from http://emedicine.medscape.com//overview
8. Rittmeister, M., Lindsey, R. W., & Kohl, H. W., III. (2001). Pelvic fractures among
polytrauma decendents: Trauma-based mortality with pelvic fracture - a case series of 74
patients. Archives of Orthopedic Trauma Surgery, 121(1-2), 43-49.
9. Meighan, A., Gregori, A., Kelly, M., & MacKay, G. (1998). Pelvic fractures: The golden
hour . Injury, 29(3), 211-213.
10. Taeger, G., Ruchholtz, S., Waydhas, C., Lewan, U., Schmidt, B., & Nast-Kolb, D. (n.d.).
Damage control orthopedics in patients with multiple injuries is effective, time saving
and safe. The Journal of Trauma Injury Infection and Critical Care.

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Table I: Pelvic Fractures- Comparison of Means for selected outcome variables
Jan 1 2006-May 1 2007
N=96
June 1 2007-Oct. 1 2008
N=76
P-value
Hospital days 6.72 10.32 0.01
ICU days 2.69 4.69 0.03
Morbidities (%) 0.42 0.62 0.05
Mortalities (%) 0.10 0.04 0.10
Time spent in ED (minutes) 246.21 318.06 0.06

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Table II: Pelvic Fractures- Logistic and Linear Regression
*covariates include age, injury severity score and mechanism of injury (blunt, penetrating, thermal)
Age adjusted Beta P-value Covariate* adjusted Beta P-value
Hospital days 3.64 0.12 2.60 0.26
ICU days 1.99 0.10 1.21 0.26
Morbidities 0.20 0.27 0.11 0.53
Mortality -1.08 0.11 -1.46 0.05
Time spent in ED 71.71 0.01 73.86 0.01

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Figure I: Pelvic Fracture Transfers Performance Improvement Algorithm
Validated
Validated
Validated
Trauma Medical Director (TMD), Trauma Program Manager (TPM)
ISSUE: Identified: transfers of patients with pelvic fractures from ED may lead to
negative outcome.
PROBLEM CONFIRMED: Yes
ROOT CAUSE ANALYSIS: Lack of surgeons with specialty training for operative
repair of patients with complex pelvic fractures. Patients were transferred directly from ED due
to the difficulty of doing so once they were admitted. (EMTALA no longer applies once
admitted).
PLAN: Effective May 08, 2007 memo distributed from Orthopedics and Trauma
departments identifying process of admitting trauma patients with pelvic fractures. Ongoing
recruitment of trained orthopedic surgeon in operative repair of complex pelvic fractures
Written communication with Trauma Department, Family Practice and Department of
Emergency Medicine Residency programs orthopedic and trauma surgeons, ED, ICU,
orthopedic floor
MONITOR: Outcomes of transferred patients and
reported quarterly.
Problem solved: Yes Loop closed