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

Prehospital Antibiotic Administration for Suspected Open Fractures: Joint COT/OTA/ACEP/NAEMSP/NAEMT Position Statement

One of the primary concerns associated with open fractures is the development of a fracture-related infection (FRI). To minimize the risk of developing an FRI and subsequent morbidity, prophylactic antibiotics should be administered to patients with open fractures as soon as possible. While the antibiotic recommendations for severe open fractures are somewhat debatable, the use of a cephalosporin remains a mainstay of prophylactic treatment. Though administration of prehospital antibiotics does represent an expansion of EMS responsibilities, there have been several other treatment expansions in the prehospital setting, such as the administration of tranexamic acid and the application of pelvic binders. The administration of antibiotics, specifically cefazolin, is inexpensive, technically simple, and does not require special storage. The following recommendations are supported by and represent consensus of the COT, OTA, ACEP, NAEMSP and NAEMT with regards to prehospital antibiotic prophylaxis for suspected fractures:In a responsive patient with no history of penicillin or cephalosporin allergy, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life threats. This intervention should not delay transport.In an obtunded patient, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life-threats. This intervention should not delay transport.In a responsive patient with a documented penicillin allergy, the administration by EMS of a 1st generation cephalosporin should be performed with close monitoring after the management of life-threats. This intervention should not delay transport.

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.

Adherence to Antibiotic Recommendations and Infection Among Patients With Open Long-Bone Fractures: An Examination of Antibiotic Prioritization in Fracture Management

Open fractures are at high risk of infection because of exposure of bone and tissue to the environment. Initiation of intravenous antibiotics is recommended within 1 hour of hospital arrival, although the presence of other severe injuries may lead to delays in fracture management. This retrospective study of adult patients with open long-bone fractures admitted to six level 1 trauma centers between January 1, 2018, and December 31, 2019, aimed to examine adherence to antibiotic recommendations. Associations between receiving recommendation-adherent antibiotics and patient and injury characteristics were investigated univariately and in adjusted regression analyses. The most common fracture locations among the 404 patients included were the tibia (43%) and fibula (26%). Fifty-eight percent of patients received recommendation-adherent antibiotics. After adjustment, patient demographics, comorbidities, cause of injury, and overall injury severity did not show significant associations with adherence to recommendations. Concomitant serious abdominal (adjusted odds ratio [AOR]=0.44) and spinal injuries (AOR=0.23) were associated with lower odds of receiving recommendation-adherent antibiotics. Additionally, fractures of certain locations were associated with increased odds of adherence (humerus: AOR=2.78; fibula: AOR=1.64), as were type 3 fractures (AOR=1.55). The overall infection rate was 4%, and adherence to antibiotic recommendations was not associated with infection (3% vs 5% for nonadherent, P=.34). Results suggest that although full recommendation adherence was somewhat low among this patient population, certain injury characteristics were predictive of adherence rates. Current antibiotic recommendations may benefit from consideration of how antibiotic initiation may fit into the prioritization of injury management, especially in patients with polytrauma with other severe injuries. [Orthopedics. 2023;46(1):54-58.].

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.

Prehospital Administration of Cefazolin in Trauma Patients

OBJECTIVE

A lack of research has become a barrier to the common use of prehospital antibiotics. The objective of this study is to further the limited research of prehospital antibiotics through evaluating the clinical impact, safety, and reliability of prehospital cefazolin administration in trauma patients.

METHODS

We completed a retrospective evaluation of adult trauma patients who were transported by a single air and ground critical care transport program between January 1, 2014, and June 30 2017. Two hundred eighty-two patients received prehospital cefazolin for deep wounds or open fractures before their arrival at a single level 2 trauma center during the study period. Patient demographics, mechanism of injury, injury type, infection rate, and identification of allergic reactions to cefazolin were also collected.

RESULTS

Of 278 patients in the final analysis, 35.3% (n = 98) were diagnosed with an open fracture and 58.6% (n = 163) had a deep tissue injury. Eighty-two percent of prehospital open fracture diagnoses were confirmed in the emergency department. The overall infection rate was 6%; 31.3% of patients received a second dose of cefazolin in the emergency department during the study period. No patients receiving prehospital cefazolin had allergic or anaphylactic reactions. The overadministration rate was 5% (n = 14).

CONCLUSION

Prehospital providers reliably identified open fractures, and prehospital cefazolin administration was not associated with anaphylactic reactions. This study population's infection rate of open fractures caused by traumatic injury was found to be 6%, and there was a low inappropriate administration rate.

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.