Improving Time to Antibiotics in Patients With Long Bone Open Fractures Presenting to the Pediatric Emergency Department

Objectives: To evaluate a new triage workflow aimed at improving time to intravenous antibiotics in open fractures to under less than 60 minutes of arrival to the Pediatric Emergency Department.

Design: A prospective, multidisciplinary, quality improvement project.

Setting: A tertiary care, Level 1 pediatric trauma hospital in New York.

Patient selection criteria: Patients ages 17 years and younger with long bone open fractures between June 1, 2020, and May 31, 2021, excluding those transferred from an outside hospital, with nonlong bone fractures and nonfractured, injured extremities.

Outcome measures and comparisons: The new workflow involved splint removal and skin assessment during triage to identify open fractures. The aim of serial Plan-Do-Study-Act cycles was to refine this workflow and reduce antibiotic administration time. Primary outcome: percentage of patients with open fracture receiving intravenous antibiotics within 60 minutes. Secondary outcome: assessment of triage documentation regarding splint presence and removal. An exact Wilcoxon two-sample test compared time from patient arrival (quick registration) with antibiotic administration before, during, and after workflow implementation on June 1, 2020.

Results: A total of 51 patients (33 male) ages 17 years and younger, with open fractures, were reviewed: 25 during the preintervention phase January 1, 2018 to May 31, 2020; 14 during the intervention phase June 1, 2020 to May 31, 2021; and 12 during the postintervention phase June 1, 2021 to November 30, 2021. Continuous improvement efforts through Plan-Do-Study-Act cycles focusing on education, reinforcement, recognition, and barrier identification increased the percentage of patients receiving antibiotics within 60 minutes from 36% to 87.5%. The median time and interquartile range (interquartile range: 25th percentile-75th percentile) from quick registration to administration was 86 minutes (interquartile range: 51-147) before June 1, 2020, and 34 minutes (interquartile range: 16-42) thereafter.

Conclusion: The implemented triage workflow led to improved time to antibiotics to within 60 minutes for patients with long bone open fractures in the pediatric emergency department.

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