Substantial improvement in prophylactic antibiotic administration for open fracture patients: results of a performance improvement program.

OBJECTIVES: Administration of early and appropriate antibiotic in treating patients with open fractures is an important early factor in preventing infection and optimizing outcomes. The purpose of this study is to evaluate the effects of an orthopaedic trauma performance improvement program directed at early antibiotic administration for open fracture patients at our trauma center.
DESIGN: Retrospective comparative cohort study of patients treated for an open fracture by before and after implementation of our performance improvement program specifically designed to address early open fracture care.
SETTING: Single metropolitan level 2 regional trauma center. PATIENTS: Patients with open fractures treated by orthopaedic surgery (hand and spine excluded) at our institution between January 2012 and December 2013 were included. Patients transferred from another facility were excluded. INTERVENTION: Patients were divided into one of the following 2 groups. Group 1 included patients treated before our open fracture performance improvement program (January 2012-December 2012) and group 2 comprised those treated after the program was instituted (January 2013-December 2013). MAIN OUTCOME MEASUREMENTS: Patient demographics, injury factors, and performance measures relating to early open fracture care [eg, the characteristics of early antibiotic administration in their treatment course, including timeliness of prophylactic intravenous (IV) antibiotic therapy and reasons for delay or omission of these treatments] were evaluated.
RESULTS: Group 1 was comprised of 127 patients with a total of 142 open fractures, whereas group 2 included 132 patients with a total of 156 open fractures. Patient and injury factors were not significantly different between the 2 groups. Group 1 received IV antibiotics at an average of 70.5 minutes after arrival at our institution compared with group 2 who received antibiotics at an average of 32.4 minutes (P < 0.001). The average times from emergency department arrival to physician evaluation improved from 6.5 to 4.5 minutes (P = 0.02) and antibiotic order to antibiotic delivery improved from 37 to 13 minutes (P < 0.001) for group 1 compared with group 2, respectively. The average time between physician evaluation and antibiotic showed a trend toward improvement (12.7-8.0 minutes, P = 0.57). Fifty percent of patients in group 1 (63/127) had antibiotics initiated within 1 hour of hospital arrival, whereas 78% (100/132) in group 2 had antibiotics initiated within 1 hour (P < 0.001). Eighty-five percent (112/127) of patients in group 1 had antibiotics initiated within 3 hours of hospital arrival, whereas 95% (125/132) in group 2 had antibiotics initiated within 3 hours (P = 0.03). Of those patients receiving standard antibiotics (cephalosporin), 79% (85/107) in group 1 and 91% (104/114) in group 2 received the recommended dose of IV antibiotic for their body weight (e.g., 2 g cefazolin for patients of >80 kg) (P < 0.006).
CONCLUSIONS: Optimal treatment of open fracture patients with early and appropriate antibiotic prophylaxis was lacking for many patients at our trauma center. A multifaceted performance improvement program specifically concentrating on education, accountability, and antibiotic availability aimed at this aspect of orthopaedic trauma care was very effective in improving our early treatment of these patients. LEVEL OF EVIDENCE: Therapeutic level III. See instructions for authors for a complete description of levels of evidence.