A resuscitation order that reduces the chance of a comfort procedure

Design

Cross-sectional study of the National Inpatient Sample, 2016-2022, with adjusted and frailty-stratified analyses

Population

298,343 rib fracture and 462,796 hip fracture hospitalisations in adults

Primary outcome

Receipt of regional analgesia by do-not-resuscitate status

Effect

Rib fractures OR 0.76 (95% CI 0.69-0.83); hip fractures OR 1.00 (0.94-1.06); least frail rib fracture patients OR 0.34 (0.25-0.48)

Regional analgesia is recommended for rib and hip fractures and is given to hardly anyone: across 298,343 rib fracture and 462,796 hip fracture admissions in the National Inpatient Sample between 2016 and 2022, it reached 2.9% and 3.0% respectively. This study asked whether do-not-resuscitate status - present in 10.7% of rib fracture and 16.7% of hip fracture admissions - changed those odds.

For rib fractures it did. After adjustment, do-not-resuscitate status was associated with lower odds of receiving regional analgesia (OR 0.76, 95% CI 0.69-0.83). For hip fractures there was no association at all (OR 1.00, 95% CI 0.94-1.06). The frailty-stratified analysis sharpens the finding uncomfortably: the effect was strongest among the least frail rib fracture patients (OR 0.34, 95% CI 0.25-0.48), which is precisely the group in whom a resuscitation preference says least about how much intervention is appropriate.

A do-not-resuscitate order is a statement about cardiopulmonary resuscitation. It is not a statement about analgesia, and a paravertebral or erector spinae block for rib fractures is a comfort intervention - arguably more indicated when the goal of care is comfort, not less. The divergence between rib and hip fractures suggests this is not a general reluctance to do procedures but something specific to how an elective-feeling regional technique gets weighed when a resuscitation order is on the chart.

• Treat a do-not-resuscitate order as a reason to consider a block, not a reason to skip one
• Write the analgesic plan separately from the resuscitation status in the notes
• Rib fracture blocks are comfort interventions - align them with the goals of care rather than against them
• Only about 3% of these fractures received any regional analgesia; the baseline is the bigger problem
• Ask explicitly at handover whether a block was considered and declined, or simply never raised

Why it matters

An order meant to protect comfort appears to be reducing access to one of the few interventions that provides it.

Don't overread it

Cross-sectional administrative data - it cannot show whether blocks were declined by patients or never offered.

The statistics, in plain English

The contrast between the two fracture types is what makes this credible. If do-not-resuscitate patients were simply receiving fewer procedures across the board, hip fractures would show the same pattern, and they show none at all (OR 1.00, interval 0.94 to 1.06 - as flat as administrative data get). The frailty stratification matters because frailty is the obvious confounder: a frail patient might reasonably receive fewer interventions. The effect being strongest in the least frail patients, at OR 0.34, points away from that explanation. This is cross-sectional administrative data, so it shows an association in coded records and cannot capture what was discussed at the bedside.

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