Surgical Rib Fixation Improves Survival in Functionally Dependent Trauma Patients

Surgical Rib Fixation Improves Survival in Functionally Dependent Trauma Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical Rib Fixation Improves Survival in Functionally Dependent Trauma Patients Yi-Yu Lin, Yi-Jung Chen, Chih-Po Hsu, Jen-Fu Huang, Ya-Chiao Lin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6639870/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Jul, 2025 Read the published version in World Journal of Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background Rib fractures are frequently encountered in trauma care and are particularly hazardous for functionally dependent patients, leading to increased morbidity and mortality rates. Surgical rib fixation (SRF) improves outcomes in selected populations; however, its role in functionally dependent individuals remains underexplored. Methods A retrospective cohort analysis was conducted using the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) dataset from 2020 to 2022. Patients with three or more rib fractures and documented functional dependency were included. Propensity score matching (3:1) was applied to reduce the selection bias between patients receiving SRF and those managed conservatively. The main outcomes of interest were in-hospital mortality, acute respiratory distress syndrome (ARDS), unplanned intensive care unit (ICU) admission, unplanned intubation, and ventilator-associated pneumonia (VAP). A subgroup analysis compared early (≤ 72 hours) versus late SRF. Results Among 18,639 eligible patients, 359 (1.9%) underwent SRF. Before matching, patients with SRF had higher injury severity scores (ISS), ICU admissions, and complication rates. After matching (294 SRF vs. 883 conservative patients), SRF was associated with significantly lower mortality (4.8% vs. 9.4%, p = 0.017) despite higher rates of ARDS (2.0% vs. 0.5%, p = 0.019), unplanned ICU admission (11.2% vs. 6.3%, p = 0.009), unplanned intubation (10.2% vs. 3.9%, p < 0.001), and VAP (3.1% vs. 0.8%, p = 0.007). In the subgroup analysis, early SRF led to fewer ventilator days ( p = 0.013), and shorter ICU ( p < 0.001), and hospital length of stays ( p < 0.001), with no difference in mortality compared with late SRF. Conclusion SRF in functionally dependent patients with rib fractures significantly reduces in-hospital mortality, despite a higher incidence of complications and prolonged ICU length of stays. Early SRF further improves clinical outcomes by decreasing ventilator duration and overall hospital length of stay. These findings support the consideration of SRF—particularly when performed early—as a beneficial strategy for managing rib fractures in functionally dependent patients. Future prospective studies are warranted to validate these results and establish clear patient selection criteria. surgical rib fixation trauma surgery functionally dependent patients Figures Figure 1 Background Rib fractures are common injuries in cases of multiple trauma, particularly among elderly and functionally dependent patients, and are associated with significant morbidity and mortality [1–3]. These fractures can cause severe pain, impaired ventilation, and increased risk of pneumonia or respiratory failure, especially in patients with pre-existing comorbidities [4,5]. Traditional management primarily involves pain control and supportive care; however, conservative treatment may be inadequate for frail individuals. Studies have shown that in patients over 65 years old with rib fractures, conservative management is associated with mortality rates of up to 20% and complication rates as high as 30% [6–8]. In recent years, surgical rib fixation (SRF) has gained attention as a method for stabilizing fractured ribs, improving pulmonary mechanics, and reducing complications [9]. Several studies have demonstrated that SRF can shorten hospital length of stays (LOS), reduce ventilator dependence, and improve long-term functional outcomes [10–12]. Current treatment guidelines recommend SRF in cases of chest wall instability, progressive respiratory failure, failure to respond to multimodal analgesia, flail chest, costochondral junction fractures, symptomatic rib fractures with non-union, and in patients undergoing thoracotomy for other indications (e.g., hemothorax) [13]. Most existing research and clinical guidelines have focused on younger or physically independent populations, leaving the benefits of SRF in functionally dependent patients largely unexplored. Functionally dependent patients are individuals who require assistance from another person or a device to perform basic activities of daily living, such as bathing, feeding, dressing, toileting, and walking. This dependency may result from various conditions, including neurological disorders (e.g., stroke, dementia), musculoskeletal issues (e.g., fractures, arthritis), chronic illnesses (e.g., heart failure, chronic obstructive pulmonary disease [COPD]), or postoperative recovery [14–16]. Owing to limited physiological reserves, these patients are at increased risk of complications following rib fractures. According to the literature, at least one-third of patients develop pulmonary complications after rib fractures, including acute respiratory distress syndrome (ARDS), pulmonary embolism, and ventilator-associated pneumonia (VAP) [17,18]. Given the potential of SRF to enhance chest wall stability and respiratory function, investigating whether it reduces mortality and long-term disability in functionally dependent patients is essential. This study addresses that gap by comparing outcomes between functionally dependent patients who underwent SRF and those who received conservative treatment. We hypothesized that SRF would lead to improved survival and better clinical outcomes compared to non-surgical management. To test this, we conducted a retrospective cohort analysis comparing mortality, pulmonary complications, and hospital course between patients who underwent SRF and those managed conservatively. Methods Study population This retrospective cohort study utilized the ACS-TQIP dataset from 2020 to 2022. Owing to its retrospective design, a pre-study sample size calculation was not applicable. The diagnosis and severity of injuries were determined using Abbreviated Injury Scale (AIS) diagnostic codes. The AIS codes used by the ACS-TQIP included versions from 1998, 2005, and 2015, with the 2005 version used for the majority of patients (2020 ACS-TQIP: 99.45% of patients and 99.47% of diagnoses; 2021 ACS-TQIP: 95.53% of patients and 95.64% of diagnoses; 2022 ACS-TQIP: 91.86% of patients and 92.12% of diagnoses). The ACS-TQIP also provides a conversion table to map 2015 diagnoses to the 2005 version. Consequently, we excluded patients with AIS diagnosis codes from 1998 and converted all diagnosis codes from the 2015 version to the 2005 version. AIS code 9, indicating “not possible to assign,” was treated as a missing value. After confirming the versions of the diagnosis codes, we included all patients with three or more rib fractures and a functionally dependent health status. Exclusion criteria included the following: (1) severe head injury (AIS ≥ 4) or injury severity “not possible to assign” (AIS = 9; Supplementary Table 1); (2) non-binary or unknown gender (3); age under 18 years or unknown (4); trauma mechanisms other than blunt trauma or unknown mechanisms; (5) data not from ACS verification level I, II, or III facilities or unknown the facility level; (6) prehospital cardiac arrest or unknown status; (7) transfer to another hospital from the emergency department (ED) or lack of discharge information; (8) death in the ED; and (9) in-hospital death within 24 hours or unknown length of stay (LOS). (Fig. 1 ) The main outcomes of interest in this study included mortality and the incidence of ARDS, unplanned intensive care unit (ICU) admission, unplanned intubation, and VAP. Secondary outcomes included total ventilator days, whether intubation was performed, total ICU LOS, whether the patient was admitted to the ICU, and overall hospital LOS. The follow-up period was limited to the index hospitalization. Discharge dispositions labeled as “not known/not recorded” were treated as missing values, whereas “mortality” and “transfer to hospice” were categorized as mortality, following practical guidance for the National Trauma Data Bank. [19] Covariate selection included patient demographics such as age, sex, and whether they underwent SRF (Supplementary Table 2). Data on patients’ vital signs and consciousness in the ED were collected, including systolic blood pressure, body temperature, pulse rate, respiratory rate, pulse oximetry, and Glasgow Coma Scale score. Injury-related data, such as Injury Severity Score (ISS), cause of injury, and ACS facility level, were also recorded. Early SRF was defined as surgery performed within 72 hours of hospital admission, whereas SRF performed after 72 hours was considered late. Relevant injuries included internal organ injuries of the head (Supplementary Table 1); thoracic injuries (4XXXXX), excluding superficial ones such as skin, subcutaneous tissue, pectoral muscle, and breast (Supplementary Table 3); and abdominal injuries (5XXXXX), excluding superficial ones such as skin, subcutaneous tissue, rectus abdominis, and vulva (Supplementary Table 4). Comorbidities included congestive heart failure, current smoking, chronic renal failure, cerebrovascular accidents, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, liver cirrhosis, and myocardial infarction. The primary and secondary outcomes were collected as described above (see Study population ). Statistical analyses were conducted by reporting continuous variables as medians with interquartile ranges, whereas categorical variables were presented as counts and percentages. The Mann–Whitney U test was used to compare continuous variables, and categorical variables were analyzed using the chi-square test with continuity correction. When expected values under the null hypothesis were less than five, Fisher’s exact test was used instead of the chi-square test. An initial comparison of variables between patients who underwent rib fixation surgery and those who did not revealed several significant differences in pre-treatment factors. To minimize potential bias, a 3:1 propensity score matching (PSM) approach was applied to balance these pretreatment factors. A standardized mean difference (SMD) > 0.1 was considered statistically significant. Following PSM, all target outcomes were compared. Additionally, a subgroup analysis was conducted to assess whether the timing of intervention affected outcomes. Statistical significance was defined as a P -value < 0.05, and all analyses were performed using R (version 2024.12.0 + 467). Results Table 1 lists the demographic characteristics of the patients. A total of 18,639 patients with rib fractures were included in this study, of whom 359 (1.9%) underwent SRF, whereas 18,280 (98.1%) received conservative treatment. The SRF group was significantly younger than the conservative treatment group (median age: 73.0 vs. 78.0 years, p < 0.001), and had a higher proportion of males (54.6% vs. 48.4%, p = 0.023). Patients in the SRF group also presented with a higher respiratory rate (median: 20.0 vs. 18.0 breaths/min, p < 0.001), lower pulse oximetry (median: 96.0% [93.0, 98.0] vs. 96.0% [94.0, 98.0], p < 0.001), and higher ISS (median: 14.0 vs. 10.0, p < 0.001) compared to those receiving conservative treatment. Fall were notably less frequent in the conservative treatment group (64.1% vs. 82.7%, p < 0.001). Although most comorbidities were comparable between the two groups, current smoking ( p < 0.001) and COPD ( p = 0.048) were significantly more prevalent in the SRF group. The median time to surgery among patients receiving SRF was 67.2 hours (IQR: 41.3–108.4). Compared to the conservative group, the SRF group had higher ICU admission rates (76.6% vs. 42.5%, p < 0.001), greater ventilator use (34.3% vs. 7.3%, p < 0.001), longer ICU LOS (median: 5.0 vs. 0.0 days, p < 0.001), and extended total hospital LOS (median: 13.0 vs. 6.0 days, p < 0.001). They also experienced significantly higher rates of complications, including ARDS (2.2% vs. 0.3%, p < 0.001), unplanned ICU admissions (12.6% vs. 4.6%, p < 0.001), unplanned intubations (10.9% vs. 3.0%, p < 0.001), and VAP (3.4% vs. 0.3%, p < 0.001). Despite these indicators of more severe illness and resource utilization, mortality rates were not significantly different between the two groups (6.1% vs. 7.4%, p = 0.410). Table 1 Characteristics of All Patients With Rib Fractures and Received Either SRF or Conservative Treatments Conservative treatment (n = 18,280) SRF (n = 359) P Value Age (years) 78.0 [70.0, 84.0] 73.0 [65.5, 81.0] < 0.001 a * Sex 0.023 b * Male 8846 (48.4) 196 (54.6) Female 9434 (51.6) 163 (45.4) Systolic blood pressure (mmHg) 141.0 [123.0, 160.0] 138.0 [122.0, 160.0] 0.129 a Body temperature (degree) 36.7 [36.4, 36.9] 36.7 [36.4, 36.9] 0.263 a Pulse rate (/min) 82.0 [71.0, 95.0] 88.0 [76.0, 101.0] < 0.001 a * Respiratory rate (/min) 18.0 [16.0, 20.0] 20.0 [18.0, 22.8] < 0.001 a * Pulse oximetry (%) 96.0 [94.0, 98.0] 96.0 [93.0, 98.0] < 0.00 a * Glasgow Coma Scale score 15.0 [15.0, 15.0] 15.0 [15.0, 15.0] 0.601 a Injury Severity Score 10.0 [9.0, 14.0] 14.0 [10.0, 20.0] < 0.001 a * Internal organ injuries of the Head 0.815 b Nil 17,148 (93.8) 336 (93.6) AIS = 2 470 (2.6) 11 (3.1) AIS = 3 662 (3.6) 12 (3.3) Thoracic injuries < 0.001 b * Nil 279 (1.5) 11 (3.1) AIS ≦ 3 17,575 (96.3) 312 (87.4) AIS ≧ 4 398 (2.2) 34 (9.5) Abdominal injury < 0.001 c * Nil 17,283 (94.6) 306 (85.2) AIS ≦ 3 837 (4.6) 44 (12.3) AIS ≧ 4 153 (0.8) 9 (2.5) ACS verification facility level < 0.001 b * I 11,084 (60.6) 265 (73.8) II 5654 (30.9) 81 (22.6) III 1542 (8.4) 13 (3.6) Injury mechanism < 0.001 b * Fall 15,126 (82.7) 230 (64.1) Motor vehicle accident 2592 (14.2) 111 (30.9) Other 562 (3.1) 18 (5.0) Comorbidities Congestive heart failure 2788 (15.3) 42 (11.7) 0.074 b Current smoking 2565 (14.1) 75 (20.9) < 0.001 b * Chronic renal failure 807 (4.4) 7 (2.0) 0.033 b * Cerebrovascular accident 1572 (8.6) 36 (10.1) 0.392 b Diabetes mellitus 5537 (30.4) 109 (30.4) 1.000 b Hypertension 12,959 (71.0) 252 (70.2) 0.791 b Chronic obstructive pulmonary disease 3952 (21.7) 94 (26.2) 0.048 b * Liver Cirrhosis 548 (3.0) 4 (1.1) 0.054 b Myocardial infarction 199 (1.1) 5 (1.4) 0.602 c Complication Acute respiratory distress syndrome 48 (0.3) 8 (2.2) < 0.001 c * Unplanned ICU admission 849 (4.6) 45 (12.6) < 0.001 b * Unplanned intubation 556 (3.0) 39 (10.9) < 0.001 b * Ventilator-associated pneumonia 59 (0.3) 12 (3.4) < 0.001 c * Ventilator use 1329 (7.3) 123 (34.3) < 0.001 b * ICU_admission 7754 (42.5) 275 (76.6) < 0.001 b * Total ventilator day 0.0 [0.0, 0.0] 0.0 [0.0, 3.0] < 0.001 a * Total ICU LOS (days) 0.0 [0.0, 3.0] 5.0 [1.5, 10.0] < 0.001 a * Total hospital LOS (days) 6.0 [4.0, 10.0] 13.0 [9.0, 19.0] < 0.001 a * Mortality 1356 (7.4) 22 (6.1) 0.410 b Continuous variables: median [interquartile range]; Categorical variables: numbers (percentages) ACS , American College of Surgeons, AIS abbreviated injury scale, ICU intensive care unit, LOS length of stay, SRF surgical rib fixation a Mann–Whitney U test b Chi-square test c Fisher’s exact test. *Statistical significance ( p < 0.05) Following 1:3 propensity score matching, 294 patients in the SRF group were matched with 883 patients who received conservative treatment (Table 2 ). Even after matching, SRF patients exhibited higher rates of ARDS (2.0% vs. 0.5%, p = 0.019), unplanned ICU admissions (11.2% vs. 6.3%, p = 0.009), unplanned intubations (10.2% vs. 3.9%, p < 0.001), and VAP (3.1% vs. 0.8%, p = 0.007). ICU LOS (5.0 vs. 1.0 days, p < 0.001) and total hospital LOS (12.0 vs. 8.0 days, p < 0.001) were also longer in the SRF group. Notably, mortality was significantly lower in the SRF group after matching (4.8% vs. 9.4%, p = 0.017). Table 2 Outcomes of Patients Received Either SRF Or Conservative Treatment in 1:3 Propensity Score Matching Analysis Conservative treatment (n = 882) SRF (n = 294) p Value Complication Acute respiratory distress syndrome 4 (0.5) 6 (2.0) 0.019 c * Unplanned ICU admission 56 (6.3) 33 (11.2) 0.009 b * Unplanned intubation 34 (3.9) 30 (10.2) < 0.001 b * Ventilator-associated pneumonia 7 (0.8) 9 (3.1) 0.007 c * Ventilator use 115 (13.0) 94 (32.0) < 0.001 b * ICU admission 474 (53.7) 223 (75.9) < 0.001 b * Total ventilation day (days) 0.0 [0.0, 0.0] 0.0 [0.0, 3.0] < 0.001 a * Total ICU LOS (days) 1.0 [0.0, 4.0] 5.0 [1.0, 9.0] < 0.001 a * Total hospital LOS (days) 8.0 [5.0, 12.0] 12.0 [9.0, 19.0] < 0.001 a * Mortality 83 (9.4) 14 (4.8) 0.017 b * Continuous variables: median [interquartile range]; Categorical variables: numbers (percentages) ICU intensive care unit, LOS length of stay, SRF surgical rib fixation a Mann–Whitney U test b Chi-square test c Fisher’s exact test. *Statistical significance ( p < 0.05) Subgroup analysis of the 359 patients who underwent SRF revealed that 196 (54.6%) received early SRF and 163 (45.4%) received late SRF (Table 3 ). Age, sex, initial vital signs, or most comorbidities had no significant differences, except for a higher prevalence of COPD in the late SRF group (31.9% vs. 21.4%, p = 0.033). Early SRF was associated with better outcomes, including lower rates of unplanned ICU admissions (8.7% vs. 17.3%, p = 0.022), fewer ventilator days (0.0 [0.0–2.0] vs. 0.0 [0.0–7.0], p = 0.013), shorter ICU LOS (4.0 vs. 7.0 days, p < 0.001), and reduced total hospital LOS (11.0 vs. 16.0 days, p < 0.001). Mortality rates were comparable between the early and late SRF groups (5.6% vs. 6.7%, p = 0.821). Table 3 Demographic Characteristics of Patients Who Received Either Early SRF or Late SRF Early SRF (n = 196) Late SRF (n = 163) p Value Age (years) 74.0 [64.8, 82.0] 71.0 [66.0, 80.5] 0.274 a Sex Male 111 (56.6) 85 (52.1) 0.457 b Female 85 (43.4) 78 (47.9) Systolic blood pressure (mmHg) 140.0 [122.0, 164.5] 136.0 [121.5, 154.2] 0.303 a Body temperature (degree) 36.7 [36.4, 36.8] 36.7 [36.4, 36.9] 0.562 a Pulse rate (/min) 88.0 [76.0, 101.0] 89.0 [76.0, 100.5] 0.669 a Respiratory rate (/min) 19.0 [17.0, 22.0] 20.0 [18.0, 23.0] 0.393 a Pulse oximetry (%) 96.0 [94.0, 98.0] 95.0 [93.0, 98.0] 0.120 a Glasgow Coma Scale score 15.0 [15.0, 15.0] 15.0 [15.0, 15.0] 0.003 a * Injury severity score 14.0 [9.0, 18.2] 14.0 [10.0, 20.5] 0.092 a Internal organ injuries of the head 0.238 c Nil 187 (95.4) 149 (91.4) AIS = 2 5 (2.6) 6 (3.7) ASI = 3 4 (2.0) 8 (4.9) Thoracic injuries 1.000 c Nil 6 (3.1) 5 (3.1) AIS = 1 170 (87.2) 142 (87.7) AIS = 2 19 (9.7) 15 (9.3) Abdominal injury 0.472 c Nil 163 (83.2) 143 (87.7) AIS = 1 28 (14.3) 16 (9.8) AIS = 2 5 (2.6) 4 (2.5) ACS verification facility level 0.674 b I 148 (75.5) 117 (71.8) II 42 (21.4) 39 (23.9) III 6 (3.1) 7 (4.3) Injury mechanism 0.571 b Fall 130 (66.3) 100 (61.3) Motor vehicle accident 56 (28.6) 55 (33.7) Other 10 (5.1) 8 (4.9) Comorbidities Congestive heart failure 24 (12.2) 18 (11.1) 0.868 b Current smoking 40 (20.4) 35 (21.5) 0.907 b Chronic renal failure 5 (2.6) 2 (1.2) 0.463 c Cerebrovascular accident 24 (12.2) 12 (7.4) 0.181 b Diabetes mellitus 60 (30.6) 49 (30.2) 1.000 b Hypertension 140 (71.4) 112 (68.7) 0.657 b Chronic obstructive pulmonary disease 42 (21.4) 52 (31.9) 0.033 b * Liver Cirrhosis 2 (1.0) 2 (1.2) 1.000 c Myocardial infarction 3 (1.5) 2 (1.2) 1.000 c Complications Acute respiratory distress syndrome 4 (2.0) 4 (2.5) 1.000 c Unplanned ICU admission 17 (8.7) 28 (17.3) 0.022 b * Unplanned intubation 16 (8.2) 23 (14.2) 0.098 b Ventilator-associated pneumonia 6 (3.1) 6 (3.7) 0.967 b Ventilator use 59 (30.1) 64 (39.3) 0.087 b ICU admission 145 (74.0) 130 (79.8) 0.245 b Total ventilator day 0.0 [0.0, 2.0] 0.0 [0.0, 7.0] 0.013 a * Total ICU LOS (days) 4.0 [0.0, 8.0] 7.0 [2.0, 12.5] < 0.001 a * Total hospital LOS (days) 11.0 [8.0, 15.0] 16.0 [11.0, 21.5] < 0.001 a * Mortality 11 (5.6) 11 (6.7) 0.821 b Duration between admission and SRF (hrs) 42.8 [26.5, 56.8] 113.8 [89.7, 143.4] < 0.001 a * Continuous variables: median [interquartile range]; Categorical variables: numbers (percentages) ACS , American College of Surgeons, AIS abbreviated injury scale, ICU intensive care unit, LOS length of stay, SRF surgical rib fixation a Mann–Whitney U test b Chi-square test c Fisher’s exact test. *Statistical significance ( p < 0.05) Discussion Our study evaluated the impact of SRF on clinical outcomes in functionally dependent patients with rib fractures. The findings revealed that patients who underwent SRF experienced higher rates of complications, including ARDS, VAP, unplanned intubation, and unplanned ICU admission. They also required longer ICU and hospital LOS. Despite these adverse events, SRF was associated with a significant survival benefit after propensity score matching. In functionally dependent patients with three or more rib fractures, SRF appears to offer the best chance of survival. However, clinicians should be aware that this population may face a heightened risk of postoperative complications. Performing early surgery once the patient's condition stabilizes may reduce the risk of complications. Careful perioperative management and tailored support are essential to minimize these risks. Rib fractures are known to be associated with significant morbidity and mortality, especially in older adults and individuals with comorbidities. The mortality burden is even more pronounced in elderly or frail populations. Bulger et al. ( 2000 ) reported that elderly patients with rib fractures had double the mortality rate of younger patients with similar injuries (22% vs. 10%, p < 0.001) [21]. Shibahashi et al. (2019) demonstrated that SRF significantly reduced in-hospital mortality in patients with multiple rib fractures compared with non-operative management (95% CI [confidence interval], -14.8% to -8.0%), particularly in those with flail chest. [20] A meta-analysis by Sawyer et al. ( 2022 ) further supported the mortality benefit of SRF (OR:0.63 (0.44, 0.03)) [21]. A systematic review also found that SRF reduced mortality in elderly patients, with a mortality rate of 4% in the surgical group compared to 8% in the conservative treatment group. [14] Our study contributes to the growing body of literature by focusing specifically on functionally dependent individuals—a group defined not solely by age but by baseline disability and dependence in activities of daily living. In our cohort, SRF was associated with significantly lower in-hospital mortality compared to conservative treatment, even after adjusting for age, comorbidities, and injury severity. This underscores the importance of considering functional status—beyond chronological age or frailty indices—when evaluating patients for surgical intervention. SRF was associated with increased ventilator use, longer ICU and hospital LOS, and higher rate of ARDS, unplanned ICU admission, unplanned intubation, and VAP in the current study. Feng et al. ( 2023 ) reported that among trauma patients with rib fractures, adverse outcomes, including respiratory complications and mortality, increased with the number of fractured ribs, particularly in older and frail individuals. [22] Similarly, Zhao at al (2025) found that SRF was not superior to conservative treatment in terms of ICU (MD [mean difference]1.01, 95% CI 0.08 to 1.94, p = 0.03) and hospital LOS (MD 1.92, 95% CI 0.82 to 3.01, p = 0.0006). [23] Conversely, a meta-analysis by Long et al. ( 2020 ) concluded that SRF was associated with significant reduced ICU (WMD [weighted mean difference] -5.72, 95% CI -7.31 to -4.13, p < 0.001) and hospital LOS (WMD − 8.48, 95% CI -11.34 to -5.63, p < 0.001), duration of mechanical ventilation (WMD − 4.93, 95% -8.79 to -1.07, p = 0.01), and risk of pneumonia (RR [relative risk] 0.4, 95% CI 0.3 to 0.53, p < 0.001). [24] Hisamune et al. ( 2024 ) found that, SRF reduced duration of mechanical ventilation (MD -4.62, 95% CI -7.64 to -1.60, p < 0.00001), ICU LOS (MD -3.05, 95% CI -5.87 to -0.22, p < 0.00001), and incidence of pneumonia (RR = 0.57, 95% CI 0.35 to 0.92, p = 0.02). These discrepancies suggest that complications are highly influenced by patient selection and perioperative care. [25] We also analyzed the effect of SRF timing and found that early intervention led to significantly fewer ventilator days, fewer unplanned ICU admissions, and shorter ICU and hospital LOS—without increasing mortality. These findings are consistent with previous reports. Wang et al. ( 2023 ) observed that early SRF led to shorter ICU and hospital LOS and fewer ventilator days. [26] Similarly, Simmonds (2022), using data from the ACS TQIP database, found that early SRF resulted in shorter ICU LOS, reduced ventilation days, and fewer complications such as tracheostomy, VAP, and unplanned intubation. [27] Although mortality rates did not differ significantly between early and late SRF groups in our cohort, the functional and resource-related advantages of early SRF are clinically meaningful. These benefits are especially important for functionally dependent patients, who are particularly vulnerable to prolonged immobility and respiratory compromise. Therefore, the timing of SRF should be a key consideration in clinical decision-making. Early intervention, when feasible, may enhance recovery and reduce complications in high-risk populations. The survival benefit observed in our study may be attributed to several factors. SRF improves chest wall stability, respiratory mechanics, and pain control, thereby enabling better pulmonary hygiene and earlier mobilization. [28, 29] These advantages are particularly important in functionally dependent patients with limited physiologic reserves. Although the SRF group experienced higher complication rates, these may reflect more intensive monitoring rather than the direct effects of surgery. In high-risk patients, even modest improvements in respiratory function and stability can translate to significant mortality reductions. Our findings support the selective use of SRF in this population. Given the complex interaction of injury severity, frailty, and comorbidities, a multidisciplinary approach to patient selection and perioperative management is critical. Future studies should aim to validate these findings through prospective, multicenter trials assessing short- and long-term outcomes, including post-discharge quality of life and functional status. Additionally, investigations into the cost-effectiveness of SRF and the development of standardized protocols for patient selection and perioperative care are warranted to better define its role in functionally dependent patients. Limitations This study has several limitations. First, its retrospective design introduces potential selection bias and unmeasured confounding, even after propensity score matching. Second, the ACS-TQIP database consists data from participating hospitals, which may not be representative of the entire healthcare system. Lastly, although we focused on in-hospital mortality and complications, long-term outcomes and quality-of-life measures were not assessed. Conclusion In summary, our study demonstrates that SRF in functionally dependent patients with rib fractures is associated with a significant reduction in in-hospital mortality compared to conservative management. Although patients in the SRF group experienced higher rates of certain in-hospital complications, the overall survival benefit supports the selective use of SRF in this high-risk population. These findings, in alignment with previous literature [14], highlight the potential of surgical intervention to improve outcomes in functionally dependent patients. Abbreviations SRF: surgical rib fixation ACS-TQIP: American College of Surgeons Trauma Quality Improvement Program ARDS: acute respiratory distress syndrome VAP: ventilator-associated pneumonia ICU: intensive care unit AIS: abbreviated injury scale ISS: injury severity score MVA: motor vehicle accident COPD: chronic obstructive pulmonary disease PSM: propensity score matching LOS: length of stay CI: confidence interval Declarations Ethics approval and consent to participate The ethical approval for this study was obtained from Jen-Ai Hospital Institutional Review Board (IRB 202500042B0) on 04.14.2025. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the ACS-TQIP but restrictions apply to the availability of these data, which were use d under license for the currently study and are not publicly available. Competing interests The authors declare that they have no competing interests. Funding No. Acknowledgement Not applicable. Author Contribution Yi Jung Chen, Chih Po Hsu, and Jen-Fu Huang conceived and designed the study. Yi Jung Chen, Chih Po Hsu, and Ya Chiao Lin collected and curated the dataset, and performed the statistical analysis. Yi Yu Lin prepared the visualizations, and drafted the manuscript. Jen-Fu Huang provided supervision and project administration. All authors contributed to interpretation of the data, critically revised the manuscript for important intellectual content, and approved the final version of the manuscript. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work. References Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma . 1994;37(6): 975-979. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma . 2000;48(6):1040-46. Marini CP, Petrone P, Soto-Sánchez A, Garcia-Santos E, Stoller C, Verde J. Predictors of mortality in patients with rib fractures. Eur. J. Trauma Emerg. Surg. 2021;47:1527-1534. Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J. Trauma. 2003;54:1058–63. Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half-a-dozen ribs: The breakpoint for mortality. Surgery . 2005;138(4):717–723. Bulger E, Arneson M, Mock C, Jurkovich GJ. Rib. Fractures in the elderly. J Trauma . 2000;48:1040-6. Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, Lemaire J, Martin M. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma . 2003;54:478-485. Cooper E, Wake E, Cho C, Wullschleger M, Patel B. Outcomes of rib fractures in the geriatric populations: a 5-year retrospective, single-institution, Australia study. ANZ J Surg . 2021;91(9):1886-1892. Paris F, Tarazona V, Blasco E, Canto A, Casillas M, Pastor J, Paris M, Montero R. Surgical stabilization of traumatic flail chest. Thorax . 1975;30:521-7. Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg . 2013;216(2):302–311 e1. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg . 2005;4(6):583–587. Marasco SF, Nguyen Khuong J, Fitzgerald M, Summerhayes R, Sekandarzad MW, Varley V, Campbell RJ, Bailey M. Flail chest injury–changing management and outcomes. Eur J Trauma Emerg Surg . 2023;49(2):1047–55. http://cwisociety.org/ (Accessed on Apr., 2025) Hoepelman RJ, Beeres FJP, Heng M, Knobe M, Link BC, Minervini F, Babst R, Houwert RM, van de Wall BJM. Rib fractures in the elderly population: a systemic review. Archives of Orthopaedic and Trauma Surgery . 2023;143:887-893. Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, French B, Gasparri M, Marasco S, Minshall C, Sarani B, Tisol W, VanBoerum DH, White TW. Consensus statement: surgical stabilization of rib fractures solloquium clinical practice guidelines. Injury . 2017; 48(2):307-321. Duong W, Grigorian A, Nahmias J, Farzaneh C, Christian A, Dolich M, Lekawa M, Schubl S. An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures. Eur J Trauma Emerg Surg . 2020;48:205-210. Alvarado F, Kaban J, Chao E, Meltzer JA. Surgical stabilization of rib fractures in patients with pulmonary comorbidities. Injury . 2023;54:1287-1291. Cheng R, Yang M, Zhang Y, Cho WC, Ma D, Chen D, Zhu Y, Shen J. Risk factors affecting pulmonary complications in elderly patients with isolated rib fractures. J Thorac Dis . 2025;17(2):542-550. Zain G. Hashmi, Amy H. Kaji, Avery B. Nathens. Practical Guide to Surgical Data Sets: National Trauma Data Bank (NTDB). JAMA Srug . 2018;153(9):852-853. Shibahashi K, Sugiyama K, Okura Y, Hamabe Y. Effect of surgical rib fixation for rib fracture on mortality: A multicenter, propensity score matching analysis. J Trauma Acute Care Surg. 2022;87(3):599-605. Sawyer E, Wullschleger M, Muller N, Muller M. Surgical rib fixation of multiple rib fractures and flail chest: a systemic review and meta-analysis. J Surgical Research . 2022;276:221-234. Feng LR, Lilienthal M, Galet C, Skeete DA. Frailty as a predictor of negative outcomes in trauma patients with rib fractures. Surgery . 2023;173:812-820. Zhao P, Ge Q, Zheng H, Luo J, Song X, Hu L. Clinical outcome analysis for surgical fixation versus conservative treatment on rib fractures: a systemic evaluation and meta-analysis. World J Emer Surg . 2025;20:10. Long R, Tian J, Wu S, Li Y, Yang X, Fei J. Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: A meta-analysis of randomized controlled trials. International J Surg . 2020;83:79-88. Hisamune R, Kobayashi M, Nakasato K, Yamazaki T, Ushio N, Mochizuki K, Takasu A, Yamakawa K. A meta-analysis and trial sequential analysis of randomized controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures. World J Emerg Surg. 2024;19(11). Wang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. J. Cardiothorac. Surg. 2023;18:118. Simmonds A, Smolen J, Ciurash M, Alexander K, Alwatari Y, Wolfe L, Whelan JF, Bennett J, Leichtle SW, Aboutanos MB, Rodas EB. Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review. J Trauma Acute Care Surg . 2022;94(4):532-37. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interactive Cardiovascular and Thoracic Surgery . 2005;4:583-87. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, Fitzgerald M. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. Journal of the American College of Surgeons. 2013;216(5):924-32. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTables.docx Cite Share Download PDF Status: Published Journal Publication published 10 Jul, 2025 Read the published version in World Journal of Emergency Surgery → Version 1 posted Editorial decision: Revision requested 30 May, 2025 Reviews received at journal 29 May, 2025 Reviews received at journal 24 May, 2025 Reviewers agreed at journal 16 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers invited by journal 14 May, 2025 Editor assigned by journal 12 May, 2025 Submission checks completed at journal 12 May, 2025 First submitted to journal 11 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6639870","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456767438,"identity":"478b59ac-d5f2-4492-83e6-d5d1f30b0421","order_by":0,"name":"Yi-Yu Lin","email":"","orcid":"","institution":"Jen-Ai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi-Yu","middleName":"","lastName":"Lin","suffix":""},{"id":456767439,"identity":"74253280-cc02-4760-9f0b-74d221800c8a","order_by":1,"name":"Yi-Jung Chen","email":"","orcid":"","institution":"Ministry of Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Yi-Jung","middleName":"","lastName":"Chen","suffix":""},{"id":456767440,"identity":"be38949d-85bd-4745-9085-7bb3e9ab1d3d","order_by":2,"name":"Chih-Po Hsu","email":"","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Chih-Po","middleName":"","lastName":"Hsu","suffix":""},{"id":456767441,"identity":"0b081ebf-4d54-402b-abb9-c0763b51b3d8","order_by":3,"name":"Jen-Fu Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYBACxgYGhg8ggoGB+QCQkJAhRgvjDIgWtgSQFh6iLIJq4TEAkwTVM7f3Hmzm3XFY3px/zedXN2oseBjYDx/dgNeKnnOJzbxnDhvunPF2m3XOMaDDeNLSbuB3VY75Y962w4wbbpzdZpzDBtQiwWOGX8v8N4bNQC32G26ceWac848YLTN4wFoSN5zvYX6c20aMlp4cw8a5benJG26wmTHn9knwsBHyi2H7GcOGt23WthvOH378OedbnRw/++Fj+LU0wFgSCWwSIJoNn3IQkIez+A8wfyCkehSMglEwCkYmAAC8aU4xXAUcHwAAAABJRU5ErkJggg==","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":true,"prefix":"","firstName":"Jen-Fu","middleName":"","lastName":"Huang","suffix":""},{"id":456767442,"identity":"c6713afa-e8ee-41ba-bbdb-098a380ecfde","order_by":4,"name":"Ya-Chiao Lin","email":"","orcid":"","institution":"Ministry of Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Ya-Chiao","middleName":"","lastName":"Lin","suffix":""},{"id":456767445,"identity":"5fb811bb-c290-4142-a225-dad45d189b61","order_by":5,"name":"Ling-Wei Kuo","email":"","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Ling-Wei","middleName":"","lastName":"Kuo","suffix":""},{"id":456767447,"identity":"30434d06-ecc5-4131-93e0-479f4bf6becc","order_by":6,"name":"Chi-Tung Cheng","email":"","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Chi-Tung","middleName":"","lastName":"Cheng","suffix":""},{"id":456767449,"identity":"93e7fe3c-370e-4acd-9d0b-bbb745a52a22","order_by":7,"name":"Chien-Hung Liao","email":"","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Chien-Hung","middleName":"","lastName":"Liao","suffix":""}],"badges":[],"createdAt":"2025-05-11 13:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6639870/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6639870/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13017-025-00634-2","type":"published","date":"2025-07-10T15:57:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83023541,"identity":"cb75bf7a-42a7-4a33-bcaf-ce94e536b96d","added_by":"auto","created_at":"2025-05-19 07:56:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38527,"visible":true,"origin":"","legend":"\u003cp\u003ePatient enrollment procedure. TQIP, Trauma Quality Improvement Program; AIS, Abbreviated Injury Scale; ICH, Intracranial Hemorrhage; ACS, American College of Surgeons; SRF, surgical rib fixation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6639870/v1/b181e80caaac12f3d8a7e8d5.png"},{"id":86699482,"identity":"8c2b7ed9-0775-401e-a6cf-ce30f962ea18","added_by":"auto","created_at":"2025-07-14 16:10:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1232414,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6639870/v1/a6e2ddd6-f8bd-499c-9117-fa4bce2b1721.pdf"},{"id":83023543,"identity":"b89afb45-a973-45f5-999d-0888b9dc69a2","added_by":"auto","created_at":"2025-05-19 07:56:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":69862,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6639870/v1/e8ffe5e5da991e017a9c1f07.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Rib Fixation Improves Survival in Functionally Dependent Trauma Patients","fulltext":[{"header":"Background","content":"\u003cp\u003eRib fractures are common injuries in cases of multiple trauma, particularly among elderly and functionally dependent patients, and are associated with significant morbidity and mortality [1\u0026ndash;3]. These fractures can cause severe pain, impaired ventilation, and increased risk of pneumonia or respiratory failure, especially in patients with pre-existing comorbidities [4,5]. Traditional management primarily involves pain control and supportive care; however, conservative treatment may be inadequate for frail individuals. Studies have shown that in patients over 65 years old with rib fractures, conservative management is associated with mortality rates of up to 20% and complication rates as high as 30% [6\u0026ndash;8].\u003c/p\u003e \u003cp\u003eIn recent years, surgical rib fixation (SRF) has gained attention as a method for stabilizing fractured ribs, improving pulmonary mechanics, and reducing complications [9]. Several studies have demonstrated that SRF can shorten hospital length of stays (LOS), reduce ventilator dependence, and improve long-term functional outcomes [10\u0026ndash;12]. Current treatment guidelines recommend SRF in cases of chest wall instability, progressive respiratory failure, failure to respond to multimodal analgesia, flail chest, costochondral junction fractures, symptomatic rib fractures with non-union, and in patients undergoing thoracotomy for other indications (e.g., hemothorax) [13]. Most existing research and clinical guidelines have focused on younger or physically independent populations, leaving the benefits of SRF in functionally dependent patients largely unexplored.\u003c/p\u003e \u003cp\u003eFunctionally dependent patients are individuals who require assistance from another person or a device to perform basic activities of daily living, such as bathing, feeding, dressing, toileting, and walking. This dependency may result from various conditions, including neurological disorders (e.g., stroke, dementia), musculoskeletal issues (e.g., fractures, arthritis), chronic illnesses (e.g., heart failure, chronic obstructive pulmonary disease [COPD]), or postoperative recovery [14\u0026ndash;16]. Owing to limited physiological reserves, these patients are at increased risk of complications following rib fractures. According to the literature, at least one-third of patients develop pulmonary complications after rib fractures, including acute respiratory distress syndrome (ARDS), pulmonary embolism, and ventilator-associated pneumonia (VAP) [17,18].\u003c/p\u003e \u003cp\u003eGiven the potential of SRF to enhance chest wall stability and respiratory function, investigating whether it reduces mortality and long-term disability in functionally dependent patients is essential. This study addresses that gap by comparing outcomes between functionally dependent patients who underwent SRF and those who received conservative treatment. We hypothesized that SRF would lead to improved survival and better clinical outcomes compared to non-surgical management. To test this, we conducted a retrospective cohort analysis comparing mortality, pulmonary complications, and hospital course between patients who underwent SRF and those managed conservatively.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study utilized the ACS-TQIP dataset from 2020 to 2022. Owing to its retrospective design, a pre-study sample size calculation was not applicable. The diagnosis and severity of injuries were determined using Abbreviated Injury Scale (AIS) diagnostic codes. The AIS codes used by the ACS-TQIP included versions from 1998, 2005, and 2015, with the 2005 version used for the majority of patients (2020 ACS-TQIP: 99.45% of patients and 99.47% of diagnoses; 2021 ACS-TQIP: 95.53% of patients and 95.64% of diagnoses; 2022 ACS-TQIP: 91.86% of patients and 92.12% of diagnoses). The ACS-TQIP also provides a conversion table to map 2015 diagnoses to the 2005 version. Consequently, we excluded patients with AIS diagnosis codes from 1998 and converted all diagnosis codes from the 2015 version to the 2005 version. AIS code 9, indicating \u0026ldquo;not possible to assign,\u0026rdquo; was treated as a missing value.\u003c/p\u003e \u003cp\u003eAfter confirming the versions of the diagnosis codes, we included all patients with three or more rib fractures and a functionally dependent health status. Exclusion criteria included the following: (1) severe head injury (AIS\u0026thinsp;\u0026ge;\u0026thinsp;4) or injury severity \u0026ldquo;not possible to assign\u0026rdquo; (AIS\u0026thinsp;=\u0026thinsp;9; Supplementary Table\u0026nbsp;1); (2) non-binary or unknown gender (3); age under 18 years or unknown (4); trauma mechanisms other than blunt trauma or unknown mechanisms; (5) data not from ACS verification level I, II, or III facilities or unknown the facility level; (6) prehospital cardiac arrest or unknown status; (7) transfer to another hospital from the emergency department (ED) or lack of discharge information; (8) death in the ED; and (9) in-hospital death within 24 hours or unknown length of stay (LOS). (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe main outcomes of interest in this study included mortality and the incidence of ARDS, unplanned intensive care unit (ICU) admission, unplanned intubation, and VAP. Secondary outcomes included total ventilator days, whether intubation was performed, total ICU LOS, whether the patient was admitted to the ICU, and overall hospital LOS. The follow-up period was limited to the index hospitalization. Discharge dispositions labeled as \u0026ldquo;not known/not recorded\u0026rdquo; were treated as missing values, whereas \u0026ldquo;mortality\u0026rdquo; and \u0026ldquo;transfer to hospice\u0026rdquo; were categorized as mortality, following practical guidance for the National Trauma Data Bank. [19]\u003c/p\u003e \u003cp\u003e \u003cb\u003eCovariate selection\u003c/b\u003e included patient demographics such as age, sex, and whether they underwent SRF (Supplementary Table\u0026nbsp;2). Data on patients\u0026rsquo; vital signs and consciousness in the ED were collected, including systolic blood pressure, body temperature, pulse rate, respiratory rate, pulse oximetry, and Glasgow Coma Scale score. Injury-related data, such as Injury Severity Score (ISS), cause of injury, and ACS facility level, were also recorded. Early SRF was defined as surgery performed within 72 hours of hospital admission, whereas SRF performed after 72 hours was considered late.\u003c/p\u003e \u003cp\u003eRelevant injuries included internal organ injuries of the head (Supplementary Table\u0026nbsp;1); thoracic injuries (4XXXXX), excluding superficial ones such as skin, subcutaneous tissue, pectoral muscle, and breast (Supplementary Table\u0026nbsp;3); and abdominal injuries (5XXXXX), excluding superficial ones such as skin, subcutaneous tissue, rectus abdominis, and vulva (Supplementary Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003eComorbidities included congestive heart failure, current smoking, chronic renal failure, cerebrovascular accidents, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, liver cirrhosis, and myocardial infarction. The primary and secondary outcomes were collected as described above (see \u003cb\u003eStudy population\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analyses\u003c/b\u003e were conducted by reporting continuous variables as medians with interquartile ranges, whereas categorical variables were presented as counts and percentages. The Mann\u0026ndash;Whitney U test was used to compare continuous variables, and categorical variables were analyzed using the chi-square test with continuity correction. When expected values under the null hypothesis were less than five, Fisher\u0026rsquo;s exact test was used instead of the chi-square test. An initial comparison of variables between patients who underwent rib fixation surgery and those who did not revealed several significant differences in pre-treatment factors. To minimize potential bias, a 3:1 propensity score matching (PSM) approach was applied to balance these pretreatment factors. A standardized mean difference (SMD)\u0026thinsp;\u0026gt;\u0026thinsp;0.1 was considered statistically significant. Following PSM, all target outcomes were compared. Additionally, a subgroup analysis was conducted to assess whether the timing of intervention affected outcomes. Statistical significance was defined as a \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and all analyses were performed using R (version 2024.12.0\u0026thinsp;+\u0026thinsp;467).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e lists the demographic characteristics of the patients. A total of 18,639 patients with rib fractures were included in this study, of whom 359 (1.9%) underwent SRF, whereas 18,280 (98.1%) received conservative treatment. The SRF group was significantly younger than the conservative treatment group (median age: 73.0 vs. 78.0 years, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and had a higher proportion of males (54.6% vs. 48.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023). Patients in the SRF group also presented with a higher respiratory rate (median: 20.0 vs. 18.0 breaths/min, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower pulse oximetry (median: 96.0% [93.0, 98.0] vs. 96.0% [94.0, 98.0], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and higher ISS (median: 14.0 vs. 10.0, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to those receiving conservative treatment. Fall were notably less frequent in the conservative treatment group (64.1% vs. 82.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although most comorbidities were comparable between the two groups, current smoking (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and COPD (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.048) were significantly more prevalent in the SRF group. The median time to surgery among patients receiving SRF was 67.2 hours (IQR: 41.3\u0026ndash;108.4). Compared to the conservative group, the SRF group had higher ICU admission rates (76.6% vs. 42.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), greater ventilator use (34.3% vs. 7.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), longer ICU LOS (median: 5.0 vs. 0.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and extended total hospital LOS (median: 13.0 vs. 6.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They also experienced significantly higher rates of complications, including ARDS (2.2% vs. 0.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), unplanned ICU admissions (12.6% vs. 4.6%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), unplanned intubations (10.9% vs. 3.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and VAP (3.4% vs. 0.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Despite these indicators of more severe illness and resource utilization, mortality rates were not significantly different between the two groups (6.1% vs. 7.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.410).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of All Patients With Rib Fractures and Received Either SRF or Conservative Treatments\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;18,280)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eSRF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;359)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[70.0, 84.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[65.5, 81.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.023\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9434\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSystolic blood pressure (mmHg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[123.0, 160.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e138.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[122.0, 160.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.129 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody temperature (degree)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[36.4, 36.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[36.4, 36.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.263 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulse rate (/min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[71.0, 95.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[76.0, 101.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespiratory rate (/min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[16.0, 20.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[18.0, 22.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulse oximetry (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[94.0, 98.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[93.0, 98.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.00\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlasgow Coma Scale score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[15.0, 15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[15.0, 15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.601\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury Severity Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[9.0, 14.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[10.0, 20.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInternal organ injuries of the Head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.815\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(93.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThoracic injuries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;≦\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(87.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;≧\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e398\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbdominal injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(85.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;≦\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e837\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;≧\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eACS verification facility level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11,084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(73.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury mechanism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(82.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor vehicle accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2592\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongestive heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.074\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e807\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.033\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.392\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5537\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(71.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(70.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.791\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.048\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver Cirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e548\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.054\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.602\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute respiratory distress syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned ICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e849\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilator-associated pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVentilator use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU_admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(76.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal ventilator day\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.0, 0.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.0, 3.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal ICU LOS (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.0, 3.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[1.5, 10.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal hospital LOS (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[4.0, 10.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[9.0, 19.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.410\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eContinuous variables: median [interquartile range]; Categorical variables: numbers (percentages)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eACS\u003c/em\u003e, American College of Surgeons, \u003cem\u003eAIS\u003c/em\u003e abbreviated injury scale, \u003cem\u003eICU\u003c/em\u003e intensive care unit, \u003cem\u003eLOS\u003c/em\u003e length of stay, \u003cem\u003eSRF\u003c/em\u003e surgical rib fixation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Mann\u0026ndash;Whitney U test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e Fisher\u0026rsquo;s exact test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFollowing 1:3 propensity score matching, 294 patients in the SRF group were matched with 883 patients who received conservative treatment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Even after matching, SRF patients exhibited higher rates of ARDS (2.0% vs. 0.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019), unplanned ICU admissions (11.2% vs. 6.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009), unplanned intubations (10.2% vs. 3.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and VAP (3.1% vs. 0.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). ICU LOS (5.0 vs. 1.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and total hospital LOS (12.0 vs. 8.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were also longer in the SRF group. Notably, mortality was significantly lower in the SRF group after matching (4.8% vs. 9.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes of Patients Received Either SRF Or Conservative Treatment in 1:3 Propensity Score Matching Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;882)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eSRF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;294)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute respiratory distress syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003csup\u003ec\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned ICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilator-associated pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.007\u003csup\u003ec\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilator use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal ventilation day (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.0, 0.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.0, 3.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal ICU LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.0, 4.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[1.0, 9.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hospital LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[5.0, 12.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[9.0, 19.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.017\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eContinuous variables: median [interquartile range]; Categorical variables: numbers (percentages)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eICU\u003c/em\u003e intensive care unit, \u003cem\u003eLOS\u003c/em\u003e length of stay, \u003cem\u003eSRF\u003c/em\u003e surgical rib fixation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Mann\u0026ndash;Whitney U test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e Fisher\u0026rsquo;s exact test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSubgroup analysis of the 359 patients who underwent SRF revealed that 196 (54.6%) received early SRF and 163 (45.4%) received late SRF (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Age, sex, initial vital signs, or most comorbidities had no significant differences, except for a higher prevalence of COPD in the late SRF group (31.9% vs. 21.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033). Early SRF was associated with better outcomes, including lower rates of unplanned ICU admissions (8.7% vs. 17.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022), fewer ventilator days (0.0 [0.0\u0026ndash;2.0] vs. 0.0 [0.0\u0026ndash;7.0], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013), shorter ICU LOS (4.0 vs. 7.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and reduced total hospital LOS (11.0 vs. 16.0 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mortality rates were comparable between the early and late SRF groups (5.6% vs. 6.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.821).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Patients Who Received Either Early SRF or Late SRF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEarly SRF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;196)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eLate SRF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;163)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[64.8, 82.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[66.0, 80.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.274\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(52.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.457\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(43.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(47.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[122.0, 164.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e136.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[121.5, 154.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.303\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody temperature (degree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[36.4, 36.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[36.4, 36.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.562\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse rate (/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[76.0, 101.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[76.0, 100.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.669\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate (/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[17.0, 22.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[18.0, 23.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.393\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse oximetry (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[94.0, 98.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[93.0, 98.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.120\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlasgow Coma Scale score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[15.0, 15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[15.0, 15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury severity score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[9.0, 18.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[10.0, 20.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.092\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal organ injuries of the head\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.238\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(95.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(91.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASI\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(87.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.472\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(83.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIS\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACS verification facility level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.674\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury mechanism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.571\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor vehicle accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(33.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongestive heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.868\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.907\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.463\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.181\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(68.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.657\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.033\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver Cirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute respiratory distress syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned ICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.098\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilator-associated pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.967\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilator use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.087\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(79.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.245\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal ventilator day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.0, 2.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.0, 7.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.013\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal ICU LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.0, 8.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[2.0, 12.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hospital LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[8.0, 15.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[11.0, 21.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.821\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration between admission and SRF (hrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[26.5, 56.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[89.7, 143.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eContinuous variables: median [interquartile range]; Categorical variables: numbers (percentages)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eACS\u003c/em\u003e, American College of Surgeons, \u003cem\u003eAIS\u003c/em\u003e abbreviated injury scale, \u003cem\u003eICU\u003c/em\u003e intensive care unit, \u003cem\u003eLOS\u003c/em\u003e length of stay, \u003cem\u003eSRF\u003c/em\u003e surgical rib fixation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Mann\u0026ndash;Whitney U test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e Fisher\u0026rsquo;s exact test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study evaluated the impact of SRF on clinical outcomes in functionally dependent patients with rib fractures. The findings revealed that patients who underwent SRF experienced higher rates of complications, including ARDS, VAP, unplanned intubation, and unplanned ICU admission. They also required longer ICU and hospital LOS. Despite these adverse events, SRF was associated with a significant survival benefit after propensity score matching. In functionally dependent patients with three or more rib fractures, SRF appears to offer the best chance of survival. However, clinicians should be aware that this population may face a heightened risk of postoperative complications. Performing early surgery once the patient's condition stabilizes may reduce the risk of complications. Careful perioperative management and tailored support are essential to minimize these risks.\u003c/p\u003e \u003cp\u003eRib fractures are known to be associated with significant morbidity and mortality, especially in older adults and individuals with comorbidities. The mortality burden is even more pronounced in elderly or frail populations. Bulger et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) reported that elderly patients with rib fractures had double the mortality rate of younger patients with similar injuries (22% vs. 10%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [21]. Shibahashi et al. (2019) demonstrated that SRF significantly reduced in-hospital mortality in patients with multiple rib fractures compared with non-operative management (95% CI [confidence interval], -14.8% to -8.0%), particularly in those with flail chest. [20] A meta-analysis by Sawyer et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) further supported the mortality benefit of SRF (OR:0.63 (0.44, 0.03)) [21]. A systematic review also found that SRF reduced mortality in elderly patients, with a mortality rate of 4% in the surgical group compared to 8% in the conservative treatment group. [14] Our study contributes to the growing body of literature by focusing specifically on functionally dependent individuals\u0026mdash;a group defined not solely by age but by baseline disability and dependence in activities of daily living. In our cohort, SRF was associated with significantly lower in-hospital mortality compared to conservative treatment, even after adjusting for age, comorbidities, and injury severity. This underscores the importance of considering functional status\u0026mdash;beyond chronological age or frailty indices\u0026mdash;when evaluating patients for surgical intervention.\u003c/p\u003e \u003cp\u003eSRF was associated with increased ventilator use, longer ICU and hospital LOS, and higher rate of ARDS, unplanned ICU admission, unplanned intubation, and VAP in the current study. Feng et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) reported that among trauma patients with rib fractures, adverse outcomes, including respiratory complications and mortality, increased with the number of fractured ribs, particularly in older and frail individuals. [22] Similarly, Zhao at al (2025) found that SRF was not superior to conservative treatment in terms of ICU (MD [mean difference]1.01, 95% CI 0.08 to 1.94, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03) and hospital LOS (MD 1.92, 95% CI 0.82 to 3.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0006). [23] Conversely, a meta-analysis by Long et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) concluded that SRF was associated with significant reduced ICU (WMD [weighted mean difference] -5.72, 95% CI -7.31 to -4.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and hospital LOS (WMD \u0026minus;\u0026thinsp;8.48, 95% CI -11.34 to -5.63, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), duration of mechanical ventilation (WMD \u0026minus;\u0026thinsp;4.93, 95% -8.79 to -1.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), and risk of pneumonia (RR [relative risk] 0.4, 95% CI 0.3 to 0.53, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). [24] Hisamune et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) found that, SRF reduced duration of mechanical ventilation (MD -4.62, 95% CI -7.64 to -1.60, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.00001), ICU LOS (MD -3.05, 95% CI -5.87 to -0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001), and incidence of pneumonia (RR\u0026thinsp;=\u0026thinsp;0.57, 95% CI 0.35 to 0.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). These discrepancies suggest that complications are highly influenced by patient selection and perioperative care. [25]\u003c/p\u003e \u003cp\u003eWe also analyzed the effect of SRF timing and found that early intervention led to significantly fewer ventilator days, fewer unplanned ICU admissions, and shorter ICU and hospital LOS\u0026mdash;without increasing mortality. These findings are consistent with previous reports. Wang et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) observed that early SRF led to shorter ICU and hospital LOS and fewer ventilator days. [26] Similarly, Simmonds (2022), using data from the ACS TQIP database, found that early SRF resulted in shorter ICU LOS, reduced ventilation days, and fewer complications such as tracheostomy, VAP, and unplanned intubation. [27] Although mortality rates did not differ significantly between early and late SRF groups in our cohort, the functional and resource-related advantages of early SRF are clinically meaningful. These benefits are especially important for functionally dependent patients, who are particularly vulnerable to prolonged immobility and respiratory compromise. Therefore, the timing of SRF should be a key consideration in clinical decision-making. Early intervention, when feasible, may enhance recovery and reduce complications in high-risk populations.\u003c/p\u003e \u003cp\u003eThe survival benefit observed in our study may be attributed to several factors. SRF improves chest wall stability, respiratory mechanics, and pain control, thereby enabling better pulmonary hygiene and earlier mobilization. [28, 29] These advantages are particularly important in functionally dependent patients with limited physiologic reserves. Although the SRF group experienced higher complication rates, these may reflect more intensive monitoring rather than the direct effects of surgery. In high-risk patients, even modest improvements in respiratory function and stability can translate to significant mortality reductions. Our findings support the selective use of SRF in this population. Given the complex interaction of injury severity, frailty, and comorbidities, a multidisciplinary approach to patient selection and perioperative management is critical.\u003c/p\u003e \u003cp\u003eFuture studies should aim to validate these findings through prospective, multicenter trials assessing short- and long-term outcomes, including post-discharge quality of life and functional status. Additionally, investigations into the cost-effectiveness of SRF and the development of standardized protocols for patient selection and perioperative care are warranted to better define its role in functionally dependent patients.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. First, its retrospective design introduces potential selection bias and unmeasured confounding, even after propensity score matching. Second, the ACS-TQIP database consists data from participating hospitals, which may not be representative of the entire healthcare system. Lastly, although we focused on in-hospital mortality and complications, long-term outcomes and quality-of-life measures were not assessed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, our study demonstrates that SRF in functionally dependent patients with rib fractures is associated with a significant reduction in in-hospital mortality compared to conservative management. Although patients in the SRF group experienced higher rates of certain in-hospital complications, the overall survival benefit supports the selective use of SRF in this high-risk population. These findings, in alignment with previous literature [14], highlight the potential of surgical intervention to improve outcomes in functionally dependent patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSRF: surgical rib fixation\u003c/p\u003e\n\u003cp\u003eACS-TQIP: American College of Surgeons Trauma Quality Improvement Program\u003c/p\u003e\n\u003cp\u003eARDS: acute respiratory distress syndrome\u003c/p\u003e\n\u003cp\u003eVAP: ventilator-associated pneumonia\u003c/p\u003e\n\u003cp\u003eICU: intensive care unit\u003c/p\u003e\n\u003cp\u003eAIS: abbreviated injury scale\u003c/p\u003e\n\u003cp\u003eISS: injury severity score\u003c/p\u003e\n\u003cp\u003eMVA: motor vehicle accident\u003c/p\u003e\n\u003cp\u003eCOPD: chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003ePSM: propensity score matching\u003c/p\u003e\n\u003cp\u003eLOS: length of stay\u003c/p\u003e\n\u003cp\u003eCI: confidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical approval for this study was obtained from Jen-Ai Hospital Institutional Review Board (IRB 202500042B0) on 04.14.2025.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the ACS-TQIP but restrictions apply to the availability of these data, which were use d under license for the currently study and are not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthor Contribution\u003c/p\u003e\u003cp\u003eYi Jung Chen, Chih Po Hsu, and Jen-Fu Huang conceived and designed the study. Yi Jung Chen, Chih Po Hsu, and Ya Chiao Lin collected and curated the dataset, and performed the statistical analysis. Yi Yu Lin prepared the visualizations, and drafted the manuscript. Jen-Fu Huang provided supervision and project administration. All authors contributed to interpretation of the data, critically revised the manuscript for important intellectual content, and approved the final version of the manuscript. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZiegler DW, Agarwal NN. The morbidity and mortality of rib fractures. \u003cem\u003eJ Trauma\u003c/em\u003e. 1994;37(6): 975-979.\u003c/li\u003e\n \u003cli\u003eBulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. \u003cem\u003eJ Trauma\u003c/em\u003e. 2000;48(6):1040-46.\u003c/li\u003e\n \u003cli\u003eMarini CP, Petrone P, Soto-S\u0026aacute;nchez A, Garcia-Santos E, Stoller C, Verde J. Predictors of mortality in patients with rib fractures. \u003cem\u003eEur.\u0026nbsp;J.\u003c/em\u003e\u003cem\u003e\u0026nbsp;Trauma Emerg.\u0026nbsp;Surg.\u003c/em\u003e 2021;47:1527-1534.\u003c/li\u003e\n \u003cli\u003eKerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? \u003cem\u003eJ. Trauma.\u0026nbsp;\u003c/em\u003e2003;54:1058\u0026ndash;63.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFlagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half-a-dozen ribs: The breakpoint for mortality. \u003cem\u003eSurgery\u003c/em\u003e. 2005;138(4):717\u0026ndash;723.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBulger E, Arneson M, Mock C, Jurkovich GJ. Rib. Fractures in the elderly. \u003cem\u003eJ Trauma\u003c/em\u003e. 2000;48:1040-6.\u003c/li\u003e\n \u003cli\u003eBergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, Lemaire J, Martin M. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. \u003cem\u003eJ Trauma\u003c/em\u003e. 2003;54:478-485.\u003c/li\u003e\n \u003cli\u003eCooper E, Wake E, Cho C, Wullschleger M, Patel B. Outcomes of rib fractures in the geriatric populations: a 5-year retrospective, single-institution, Australia study. \u003cem\u003eANZ J Surg\u003c/em\u003e. 2021;91(9):1886-1892.\u003c/li\u003e\n \u003cli\u003eParis F, Tarazona V, Blasco E, Canto A, Casillas M, Pastor J, Paris M, Montero R. Surgical stabilization of traumatic flail chest. \u003cem\u003eThorax\u003c/em\u003e. 1975;30:521-7.\u003c/li\u003e\n \u003cli\u003eSlobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 2013;216(2):302\u0026ndash;311 e1.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGranetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. \u003cem\u003eInteract Cardiovasc Thorac Surg\u003c/em\u003e. 2005;4(6):583\u0026ndash;587.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMarasco SF, Nguyen Khuong J, Fitzgerald M, Summerhayes R, Sekandarzad MW, Varley V, Campbell RJ, Bailey M. Flail chest injury\u0026ndash;changing management and outcomes. \u003cem\u003eEur J Trauma Emerg Surg\u003c/em\u003e. 2023;49(2):1047\u0026ndash;55.\u003c/li\u003e\n \u003cli\u003e\u003ca href=\"http://cwisociety.org/\"\u003ehttp://cwisociety.org/\u003c/a\u003e (Accessed on Apr., 2025)\u003c/li\u003e\n \u003cli\u003eHoepelman RJ, Beeres FJP, Heng M, Knobe M, Link BC, Minervini F, Babst R, Houwert RM, van de Wall BJM. Rib fractures in the elderly population: a systemic review. \u003cem\u003eArchives of Orthopaedic and Trauma Surgery\u003c/em\u003e. 2023;143:887-893.\u003c/li\u003e\n \u003cli\u003ePieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, French B, Gasparri M, Marasco S, Minshall C, Sarani B, Tisol W, VanBoerum DH, White TW. Consensus statement: surgical stabilization of rib fractures solloquium clinical practice guidelines. \u003cem\u003eInjury\u003c/em\u003e. 2017; 48(2):307-321.\u003c/li\u003e\n \u003cli\u003eDuong W, Grigorian A, Nahmias J, Farzaneh C, Christian A, Dolich M, Lekawa M, Schubl S. An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures. \u003cem\u003eEur J Trauma Emerg Surg\u003c/em\u003e. 2020;48:205-210.\u003c/li\u003e\n \u003cli\u003eAlvarado F, Kaban J, Chao E, Meltzer JA. Surgical stabilization of rib fractures in patients with pulmonary comorbidities. \u003cem\u003eInjury\u003c/em\u003e. 2023;54:1287-1291.\u003c/li\u003e\n \u003cli\u003eCheng R, Yang M, Zhang Y, Cho WC, Ma D, Chen D, Zhu Y, Shen J. Risk factors affecting pulmonary complications in elderly patients with isolated rib fractures. \u003cem\u003eJ Thorac Dis\u003c/em\u003e. 2025;17(2):542-550.\u003c/li\u003e\n \u003cli\u003eZain G. Hashmi, Amy H. Kaji, Avery B. Nathens. Practical Guide to Surgical Data Sets: National Trauma Data Bank (NTDB). \u003cem\u003eJAMA Srug\u003c/em\u003e. 2018;153(9):852-853.\u003c/li\u003e\n \u003cli\u003eShibahashi K, Sugiyama K, Okura Y, Hamabe Y. Effect of surgical rib fixation for rib fracture on mortality: A multicenter, propensity score matching analysis. \u003cem\u003eJ Trauma Acute Care Surg.\u003c/em\u003e 2022;87(3):599-605.\u003c/li\u003e\n \u003cli\u003eSawyer E, Wullschleger M, Muller N, Muller M. Surgical rib fixation of multiple rib fractures and flail chest: a systemic review and meta-analysis. \u003cem\u003eJ Surgical Research\u003c/em\u003e. 2022;276:221-234.\u003c/li\u003e\n \u003cli\u003eFeng LR, Lilienthal M, Galet C, Skeete DA. Frailty as a predictor of negative outcomes in trauma patients with rib fractures. \u003cem\u003eSurgery\u003c/em\u003e. 2023;173:812-820.\u003c/li\u003e\n \u003cli\u003eZhao P, Ge Q, Zheng H, Luo J, Song X, Hu L. Clinical outcome analysis for surgical fixation versus conservative treatment on rib fractures: a systemic evaluation and meta-analysis. \u003cem\u003eWorld J Emer Surg\u003c/em\u003e. 2025;20:10.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLong R, Tian J, Wu S, Li Y, Yang X, Fei J. Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: A meta-analysis of randomized controlled trials. \u003cem\u003eInternational J Surg\u003c/em\u003e. 2020;83:79-88.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHisamune R, Kobayashi M, Nakasato K, Yamazaki T, Ushio N, Mochizuki K, Takasu A, Yamakawa K. A meta-analysis and trial sequential analysis of randomized controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures. \u003cem\u003eWorld J Emerg Surg.\u003c/em\u003e 2024;19(11).\u003c/li\u003e\n \u003cli\u003eWang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. \u003cem\u003eJ. Cardiothorac.\u0026nbsp;Surg.\u003c/em\u003e 2023;18:118.\u003c/li\u003e\n \u003cli\u003eSimmonds A, Smolen J, Ciurash M, Alexander K, Alwatari Y, Wolfe L, Whelan JF, Bennett J, Leichtle SW, Aboutanos MB, Rodas EB. Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. 2022;94(4):532-37.\u003c/li\u003e\n \u003cli\u003eGranetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. \u003cem\u003eInteractive Cardiovascular and Thoracic Surgery\u003c/em\u003e. 2005;4:583-87.\u003c/li\u003e\n \u003cli\u003eMarasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, Fitzgerald M. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. \u003cem\u003eJournal of the American College of Surgeons.\u003c/em\u003e 2013;216(5):924-32.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"surgical rib fixation, trauma surgery, functionally dependent patients","lastPublishedDoi":"10.21203/rs.3.rs-6639870/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6639870/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRib fractures are frequently encountered in trauma care and are particularly hazardous for functionally dependent patients, leading to increased morbidity and mortality rates. Surgical rib fixation (SRF) improves outcomes in selected populations; however, its role in functionally dependent individuals remains underexplored.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort analysis was conducted using the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) dataset from 2020 to 2022. Patients with three or more rib fractures and documented functional dependency were included. Propensity score matching (3:1) was applied to reduce the selection bias between patients receiving SRF and those managed conservatively. The main outcomes of interest were in-hospital mortality, acute respiratory distress syndrome (ARDS), unplanned intensive care unit (ICU) admission, unplanned intubation, and ventilator-associated pneumonia (VAP). A subgroup analysis compared early (\u0026le;\u0026thinsp;72 hours) versus late SRF.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 18,639 eligible patients, 359 (1.9%) underwent SRF. Before matching, patients with SRF had higher injury severity scores (ISS), ICU admissions, and complication rates. After matching (294 SRF vs. 883 conservative patients), SRF was associated with significantly lower mortality (4.8% vs. 9.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017) despite higher rates of ARDS (2.0% vs. 0.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019), unplanned ICU admission (11.2% vs. 6.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009), unplanned intubation (10.2% vs. 3.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and VAP (3.1% vs. 0.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). In the subgroup analysis, early SRF led to fewer ventilator days (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013), and shorter ICU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and hospital length of stays (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with no difference in mortality compared with late SRF.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSRF in functionally dependent patients with rib fractures significantly reduces in-hospital mortality, despite a higher incidence of complications and prolonged ICU length of stays. Early SRF further improves clinical outcomes by decreasing ventilator duration and overall hospital length of stay. These findings support the consideration of SRF\u0026mdash;particularly when performed early\u0026mdash;as a beneficial strategy for managing rib fractures in functionally dependent patients. Future prospective studies are warranted to validate these results and establish clear patient selection criteria.\u003c/p\u003e","manuscriptTitle":"Surgical Rib Fixation Improves Survival in Functionally Dependent Trauma Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 07:56:20","doi":"10.21203/rs.3.rs-6639870/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-30T08:06:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T09:26:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-24T11:18:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324349342130944930831687078892920565210","date":"2025-05-16T11:31:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57784882159371915739913877048574946115","date":"2025-05-15T00:06:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-14T10:42:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-13T02:55:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-13T02:53:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Emergency Surgery","date":"2025-05-11T13:25:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bed7cf64-176a-4417-b2c0-cd860d02c862","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T16:05:36+00:00","versionOfRecord":{"articleIdentity":"rs-6639870","link":"https://doi.org/10.1186/s13017-025-00634-2","journal":{"identity":"world-journal-of-emergency-surgery","isVorOnly":false,"title":"World Journal of Emergency Surgery"},"publishedOn":"2025-07-10 15:57:33","publishedOnDateReadable":"July 10th, 2025"},"versionCreatedAt":"2025-05-19 07:56:20","video":"","vorDoi":"10.1186/s13017-025-00634-2","vorDoiUrl":"https://doi.org/10.1186/s13017-025-00634-2","workflowStages":[]},"version":"v1","identity":"rs-6639870","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6639870","identity":"rs-6639870","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}