A Performance Improvement Project in Antibiotic Administration for Open Fractures

TIME UNTIL THE START OF ANTIBIOTIC PROPHYLAXIS AND THE RISK OF OPEN FRACTURE INFECTION: A SYSTEMATIC REVIEW

Open fractures are highly incident injuries closely related to the modern life, in which accidents caused by motor vehicles or other machines impart high energy to bone tissue. Individual morbidity is represented by the functional impairment resultant of infection, nonunion, or vicious healing. In terms of public health, there are huge costs involved with the treatment of these fractures, particularly with their complications. One of the critical issues in managing open fractures is the use of antibiotics (ATB), including decisions about which specific agents to administer, duration of use, and ideal timing of the first prophylactic dose. Although recent guidelines have recommended starting antibiotic prophylaxis as soon as possible, such a recommendation appears to stem from insufficient evidence. In light of this, we conducted a systematic review, including studies that addressed the impact of the time to first antibiotic and the risk of infectious outcomes. Fourteen studies were selected, of which only four found that the early initiation of treatment with antibiotics is able to prevent infection. All studies had important risks of bias. The results indicate that this question remains open, and further prospective and methodologically sound studies are necessary in order to guide practices and health policies related to this matter. Level of Evidence II; Therapeutic Studies Investigating the Results Level of Treatment.

Maximizing Adherence and Minimizing Time to Antibiotics: A Multidisciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures

OBJECTIVES

To determine if a multidisciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation.

METHODS

DESIGN

Retrospective pre-post study design.

SETTING

Single Level II Trauma Center.

PATIENT SELECTION CRITERIA

All patients who triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated before implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (January 2021-October 2022) were defined as the "pre" group and those treated following implementation the "post" group.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between preprotocol and postprotocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx <60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug-resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days.

RESULTS

Twenty-four patients (mean age 39.5 ± 16.3 years) met the criteria after protocol implementation compared with 72 patients (mean age 34.3 ± 14.8 years) before implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9 ± 104.6 minutes to 22.2 ± 12.8 minutes in the postprotocol group ( P < 0.001). In addition, only 53% in the preprotocol group received Abx within 60 minutes compared with 96% in postprotocol group ( P < 0.001). Post hoc power analysis revealed that the study was powered at 92% (effect size = 0.72) to detect a significant difference between the preprotocol and postprotocol groups.

CONCLUSION

This study provides evidence that a multidisciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using Children's Artwork to Improve Adherence with Timely Antibiotic Administration in Open Fractures

Introduction

Antibiotics for open fractures (OFs) administered within 60 min of emergency department (ED) arrival reduce patients' infection risk. We tested a novel method of displaying children's drawings to prompt clinicians to improve adherence with early antibiotics for OFs.

Methods

Registry-based pre- (January 1, 2016-June 30, 2019) and post- (July 1, 2019-March 31, 2022) intervention at a level 1 trauma center. In July 2019, children's artwork depicting OF was displayed in the ED alongside OF guidelines and E-mailed to faculty and residents. Primary outcome: proportion of OF patients who received antibiotics within 60 min of arrival. Time to antibiotics was calculated from ED arrival to time-stamped administration in the electronic health record. We compared time to antibiotics as continuous variables between the two groups. Proportions are presented with percentages and 95% confidence interval (CI); continuous variables as median and quartiles. Chi-square or Mann-Whitney U-tests were used for group comparisons.

Results

Five hundred fifty-four total OF patients were identified (excluded: transferred = 1, ED death = 4, unclear time to antibiotics = 11); 281 pre-implementation and 257 post-implementation. The median age was 34 years (quartiles 24 and 46). Trauma mechanisms of injury included 300 blunt (56%) and 238 penetrating (44%). Gustilo OF classification by type were as follows: 71% I, 13% II, 15% III, 1% unclassified. There was a significant difference (P = 0.001) in both percentage of patients who received antibiotics within 60 min (58%, 95% CI, 52%-63% vs. 79%, 95% CI, 74%-84%) and time to antibiotics (median: 46 min vs. 25 min) between pre- and postphases, respectively.

Conclusions

Children's artwork in our ED improved adherence with OF guidelines and decreased time to antibiotics.

Type III Gustilo-Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage

Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI. However, the necessity of initial broad-spectrum coverage for Gram-positive and -negative pathogens remains unclear. The purpose of this study was to clarify the effectiveness of prophylactic broad-spectrum antibiotics in a large, national-wide sample. We reviewed an open fracture database of prospectively collected data from 111 institutions managed by our society. A retrospective cohort study was designed to compare the rates of deep SSI between narrow- and broad-spectrum antibiotics, which were initiated within three hours after injury. A total of 1041 type III fractures were evaluated at three months after injury. Overall deep SSI rates did not differ significantly between the narrow-spectrum group (43/538, 8.0%) and broad-spectrum group (49/503, 9.8%) (p = 0.320). During propensity score-matched analysis, 425 pairs were analyzed. After matching, no significant difference in the SSI rate was seen between the narrow- and broad-spectrum groups, with 42 SSIs (9.9%) and 40 SSIs (9.4%), respectively (p = 0.816). The probability of deep SSI was not reduced by broad-spectrum antibiotics compared with narrow-spectrum antibiotics in type III open long bone fractures.

Open Fractures in Pediatric Orthopaedics-Can Pathways Improve Care? A 1-Year Pre and Postimplementation Analysis

BACKGROUND

In the care of open fractures, time to antibiotic administration has been shown to be a critical factor in preventing infection. To help improve outcomes at our institution we designed and implemented an open fracture pathway with the goal of reducing the time from emergency department (ED) arrival to antibiotic administration. Here we evaluate the success of this pathway, propose improvements in the protocol, and provide a framework for initiation at other institutions.

METHODS

We compared a retrospective prepathway cohort with a prospective postpathway cohort for 1-year pre and postpathway implementation. First, we analyzed the number of patients from outside facilities who had received antibiotics before transfer. For patients who had not received antibiotics before arriving at our institution, we reviewed pathway metrics including time from ED arrival to the ordering and administration of antibiotics, whether the correct antibiotic type was selected, and time to surgical debridement.

RESULTS

There were 50 patients in the prepathway cohort and 29 in the postpathway cohort. Prepathway 60.5% of transfers (23 of 38) received antibiotics before transfer, whereas post-pathway 90.0% of transfers (18 of 20) received antibiotics ( P =0.032). For patients who had not received antibiotics before arriving at our institution and were included in pathway metric analysis, there were no differences in demographics or fracture characteristics. Time from ED arrival to antibiotic order decreased from 115.3 to 63.5 minutes ( P =0.016). Time from antibiotic order to administration was similar between groups (48.0 vs. 35.7 min, P =0.191), but the overall time from ED arrival to antibiotic administration decreased from 163.3 to 99.2 minutes ( P =0.004). There were no significant differences in whether the correct antibiotic type was chosen ( P =0.354) or time from ED arrival to surgery ( P =0.783).

CONCLUSIONS

This study provides evidence that for pediatric patients presenting with open fractures, a care pathway can successfully decrease the time from ED arrival to antibiotic administration.

LEVEL OF EVIDENCE

Therapeutic level III-retrospective comparative study.

The intersection of fracture healing and infection: Orthopaedics research society workshop 2021

Infection is a common cause of impaired fracture healing. In the clinical setting, definitive fracture treatment and infection are often treated separately and sequentially, by different clinical specialties. The ability to treat infection while promoting fracture healing will greatly reduce the cost, number of procedures, and patient morbidity associated with infected fractures. In order to develop new therapies, scientists and engineers must understand the clinical need, current standards of care, pathologic effects of infection on fractures, available preclinical models, and novel technologies. One of the main causes of poor fracture healing is infection; unfortunately, bone regeneration and infection research are typically approached independently and viewed as two separate disciplines. Here, we aim to bring these two groups together in an educational workshop to promote research into the basic and translational science that will address the clinical challenge of delayed fracture healing due to infection. Statement of clinical significance: Infection and nonunion are each feared outcomes in fracture care, and infection is a significant driver of nonunion. The impact of nonunions on patie[Q2]nt well-being is substantial. Outcome data suggests a long bone nonunion is as impactful on health-related quality of life measures as a diagnosis of type 1 diabetes and fracture-related infection has been shown to significantly l[Q3]ower a patient's quality of life for over 4 years.  Although they frequently are associated with one another, the treatment approaches for infections and nonunions are not always complimentary and cannot be performed simultaneously without accepting tradeoffs. Furthermore, different clinical specialties are often required to address the problem, the orthopedic surgeon treating the fracture and an infectious disease specialist addressing the sources of infection. A sequential approach that optimizes treatment parameters requires more time, more surgeries, and thus confers increased morbidity to the patient. The ability to solve fracture healing and infection clearance simultaneously in a contaminated defect would benefit both the patient and the health care system.

Decreasing time to antibiotic administration in open fractures of the femur and tibia through performance improvement in a statewide trauma: Collaborative quality initiative

BACKGROUND

Open long-bone fractures represent a complex injury within the trauma system. Guidelines recommend antibiotics be given within 60 minutes of patient arrival to the emergency department. We sought to measure and improve the timeliness of antibiotic administration at the patient, hospital, and population level within a collaborative quality initiative.

METHODS

Trauma collaborative quality initiative data (January 2017 to December 2020) were analyzed from 34 American College of Surgeons Committee on Trauma verified level 1 and level 2 trauma centers. Inclusion criteria were adult patients (≥16 years), injury severity score ≥5, and open tibia or femur fracture. After the baseline year, hospitals were scored annually on a pay-for-performance metric based on patients receiving antibiotics within 120 minutes of emergency department arrival. Univariate tests examined the differences between baseline and subsequent year(s) performance. A multivariable logistic regression assessed the factors associated with meeting this target time.

RESULTS

There were 2,624 patients with an open long-bone fracture. In the baseline year (2017), 76.9% of patients received antibiotics in ≤120 minutes, with a mean time of 57.9 ± 63.3 minutes. After implementing collaborative quality initiative-wide targets, performance significantly improved in subsequent years (2018, 2019, 2020). The collaborative quality initiative achieved their goal of ≥85% of patients receiving antibiotics in ≤120 minutes in 2019 (87.9%) and 2020 (88.5%), with a mean time of 43.3 ± 54.8 minutes (P < .05 vs 2017).

CONCLUSION

A pay-for-performance process measure within a statewide trauma collaborative quality initiative improved the timely administration of antibiotics to patients with open fractures. Work remains to align compliance with the guideline target of <60 minutes and to identify factors involved in the delay of administration.

A Simple Initiative to Decrease Time to Antibiotic Prophylaxis for Open Fractures Is Durable After 2 Years

INTRODUCTION

A simple antibiotic prophylaxis initiative can effectively decrease the time to antibiotic administration for patients with open fractures. We aim to determine whether adherence to the protocol decreased over time without active input from the orthopaedic trauma team.

PATIENTS AND METHODS

This retrospective cohort study included adult patients with open fractures (excluding hand) presenting directly to the emergency department at one Level I trauma center. Three separate 50-patient groups were included: a preimplementation cohort, immediately postimplementation cohort, and a retention cohort 2 years later. The primary outcome was time from emergency department presentation to antibiotic administration, and secondary outcomes were the percentage of patients receiving antibiotics within 60 minutes and incidence of infection requiring revision surgery within 90 days. The χ2 and Student t-tests evaluated between-group differences, and multivariable linear or logistic regression evaluated risk factors.

RESULTS

After implementation, the time from presentation to antibiotic administration decreased markedly from 123.1 to 35.7 minutes and remained durable (50.0 minutes) at retention. The proportion of patients receiving antibiotics within 60 minutes increased markedly from 46% preimplementation to 82% postintervention and remained similar at retention (80%). The postintervention and retention groups were markedly more likely to receive antibiotics within 60 minutes than the preintervention group (odds ratio [OR], 8.4 and 4.7, respectively), as were patients with a higher Gustilo-Anderson type (OR, 2.4/unit increase), lower extremity injury (OR, 2.8), and male sex (OR, 3.1); mechanism, age, and Injury Severity Score were not associated. No difference was observed in infection.

CONCLUSIONS

Our educational initiative showed durable results in reducing the time from presentation to antibiotic administration after 2 years.

LEVEL OF EVIDENCE

Therapeutic Level III.

National Metrics Improved Timeliness of Antibiotic Administration for Open Extremity Fractures

INTRODUCTION

Antibiotics have been shown to be an essential component in the treatment of open extremity fractures. The American College of Surgeons' Trauma Quality Improvement Program, based on a committee of physician leaders including orthopaedic trauma surgeons, publishes best-practice guidelines for the management of open fractures. Accordingly, it established the tracking of antibiotic timing as a metric with a plan to use that metric before trauma center site reviews. Our hypothesis was that this physician-led effort at the national level would provide the necessary incentive to effect change within our institution.

METHODS

A retrospective review of all patients treated at our institution for open extremity fractures was performed over 3 periods separated by 2 quality initiatives. The first initiative was an institution-driven effort to increase awareness and educate specific departments about the importance of prompt antibiotic administration. The second initiative was the tracking of antibiotic order and administration times with quarterly audits following newly published guidelines.

RESULTS

Neither antibiotic order placement within 1 hour nor administration within 1 hour improved after our first institution-specific initiative. Both outcome measures significantly improved after the second quality initiative, as did median times from arrival to antibiotic order and administration.

CONCLUSIONS

Metrics developed and measured by a physician-led national organization led to practice changes at our hospital. Tracking of antibiotic timing for open fracture treatment was more effective than institutional education of healthcare providers alone. This study suggests that nationally published guidelines, developed and measured by physician leaders, will be found to be relevant by other physicians and can be a powerful tool to drive change.

Antibiotic utilization in open fractures

Open fractures are complex presentations with elevated risks of infection and nonunion due to a multitude of factors. Along with early surgical debridement, antibiotics have been heavily utilized and have become part of standard of care to reduce the risks of fracture-related infections. Many aspects of their use have been studied and debated. The early administration of intravenous antibiotics has been shown to significantly reduce the incidence of infection. Furthermore, current standards do not recommend prolonged antibiotic administration post wound closure. Recently, an increasing number of studies have assessed the utility of locally administered antibiotics. Clinical and basic science studies have been relatively supportive of their usage, but further studies are still warranted to further delineate their effects.