Implementation of an Antibiotic Therapy Protocol for Open Fractures in the Emergency Department

Well established in the Emergency Department (ED) literature is that the most important factor in decreasing subsequent infection rate in open fractures is the time to first administration of antibiotics. As such, the authors developed a new ED open fracture antibiotic protocol to facilitate more expeditious antibiotic administration and appropriate choice of antibiotics.

During Phase 1 of this project, the authors identified the 2012 - 2016 historical length of time from presentation of an open fracture to the possible initiation of antibiotic therapy at their institution. Results demonstrated critical areas for improvement in both timing and types of antibiotics administered. Phase 2 of the study evaluated the effect of the new open fracture antibiotic protocol. Sample cases from both phases were then further identified based on type of open fracture, time to initiation of antibiotics from ED presentation, type of antibiotics, and time to definitive treatment. Analyses were performed using GraphPad proprietary software.

A random sample of 110 patients were included from Phase 1 and 27 patients from Phase 2. A total of 43 Phase 1 patients were administered cefazolin (Kefzol, Ancef); the remainder of the patients received a number of different antibiotics. During Phase 2, all 27 patients received cefazolin and Gentamycin if necessary per the new protocol. The average time to initiation of antibiotics was 0.907 hours during Phase 1 compared to 0.568 hours in Phase 2. The new protocol also significantly decreased the average time to antibiotics in ED from 2.17 hours to 1.82 hours when including EMS transfer time. Average time to definitive treatment in the operating room was 6.63 hours during Phase 1 and was significantly lowered to 3.97 hours during Phase 2.

Timing to initiation of antibiotics after open fractures is the most important aspect to decrease infection rates. In order to decrease these times, the authors implemented a new ED protocol that specifically stated the type of antibiotic to be given based on the open fracture without orthopedics needing to be notified before administration. Ideally, the use of such protocols in ED settings will serve to greatly decrease infection risks after open fracture.