556 - Improving Time to Antibiotic Administration in Open Fractures

Publication Number: 556.5288

Vincent R.. Alexander, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Fiona Fimmel, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Emily Rheaume, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Kelly S. Falcone, CCHMC, Cincinnati, OH, United States; Adam A.. Vukovic, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Sean Bartlett, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, United States; Laurie H. Johnson, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Background: Delayed antibiotic treatment for pediatric open long-bone fractures is associated with increased risk of infection. National guidelines recommend the administration of intravenous (IV) antibiotics within 60 minutes of an open fracture patient presenting to the Emergency Department (ED). Our level 1 pediatric trauma center has historically not met this benchmark.

Objective: To improve time to antibiotic administration in pediatric open long-bone fractures in a level I pediatric ED from a baseline of 114 minutes to 60 minutes or less over a 9 month intervention.

Design/Methods: A multidisciplinary team used serial Plan-Do-Study-Act cycles to implement new programs and refine existing ED policies, operationalizing prompt administration of antibiotics for patients with open fractures. We solicited information from ED stakeholders about barriers to antibiotic administration and provided education about guidelines to key members of the ED team. We revised existing criteria for evaluation of long-bone fractures and also introduced a fracture order set with standardized recommendations for antibiotic administration based on fracture grade and information about practice guidelines. Cases of open fractures were evaluated on a biweekly basis, and members of the treating ED team were emailed to solicit their feedback. Data were analyzed using X-MR control charts, with standards for interpretation of control charts employed to identify any signals of change (See Key Driver Diagram).
Our primary endpoint was time to appropriate antibiotic administration after arrival to the ED. As a process measure, we tracked utilization of the new order set. As a balancing measure we also tracked time to fracture reduction.

Results: Data collected from 9/2020 to 10/2024 included 97 patients, 21 of whom were seen in the 10 months after the intervention began. We note an improvement in time to antibiotic administration from a baseline of 114 minutes to 36 minutes (Figure 1). Time to fracture reduction was not negatively impacted by the study intervention. There was a modest improvement in the antibiotic order set usage to 29%.

Conclusion(s): Use of an iterative multimodal quality improvement package can improve adherence to evidence-based protocols for the initial treatment of pediatric open long-bone fractures. This improvement is sustained, and further work remains to be done to assess secondary outcomes and to sustain improvement.

Key Driver Diagram


Figure 1