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 60 minutes of arrival to the Pediatric Emergency Department.

Methods: Design: A prospective, multi-disciplinary, quality improvement project.

Setting: A tertiary care, Level 1 Pediatric Trauma hospital in New York.

Patient selection criteria: Patients aged 17 and under with long bone open fractures between June 1, 2020 and May 31, 2021, excluding those transferred from an outside hospital, with non-long bone fractures and non-fractured, injured extremities.Outcome Measures and Comparisons: The new workflow involved splint removal and skin assessment during triage to identify open fractures. Serial Plan-Do-Study-Act (PDSA) cycles aimed to refine this workflow and reduce antibiotic administration time. Primary outcome: Percentage of open fracture patients receiving intravenous (IV) 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) to antibiotic administration before, during and after workflow implementation on 6/1/2020.

Results: A total of 51 patients (33 male) aged 17 and under, with open fractures were reviewed: 25 during the pre-intervention phase 1/1/18-5/31/20, 14 during the intervention phase 6/1/20-5/31/21, and 12 during the post-intervention phase 6/1/21-11/30/21. Continuous improvement efforts via PDSA cycles focusing on education, reinforcement, recognition, and barrier identification increased the percentage of patients receiving antibiotics within 60 minutes from 36% to 87.5%. Median time and Interquartile range (IQR: 25th percentile-75th percentile) from quick-registration to administration was 86 minutes (IQR: 51-147) before 6/1/2020, and 34 minutes (IQR: 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: Level III. See Instructions for Authors for a complete description of levels of evidence.