Open Fractures in Pediatric Orthopaedics-Can Pathways Improve Care? A 1-Year Pre and Postimplementation Analysis
Christopher A Makarewich1, Lia W McNeely2, Shivani Gohel2
1Department of Orthopaedics, University of Utah and Primary Children's Hospital, Salt Lake City, UT.
Insights
Implementing an open fracture pathway significantly reduced the time to antibiotic administration in pediatric patients. This critical intervention helps prevent infection following open fractures.
Area of Science:
- Orthopedic Surgery
- Emergency Medicine
- Infectious Disease Prevention
Background:
- Timely antibiotic administration is crucial for preventing infection in open fractures.
- An open fracture pathway was implemented to decrease the time from emergency department (ED) arrival to antibiotic administration.
- This study evaluates the pathway's effectiveness and suggests improvements.
Purpose of the Study:
- To assess the impact of an open fracture pathway on antibiotic administration time.
- To identify areas for protocol improvement.
- To provide a framework for implementing similar pathways at other institutions.
Main Methods:
- A retrospective pre-pathway cohort was compared with a prospective post-pathway cohort.
- Key metrics included time from ED arrival to antibiotic order and administration, antibiotic choice, and time to surgical debridement.
- Patients receiving antibiotics prior to transfer were also analyzed.
Main Results:
- The pathway significantly increased the proportion of transferred patients receiving antibiotics before arrival (60.5% vs. 90.0%).
- For patients not pre-treated, time from ED arrival to antibiotic order decreased significantly (115.3 to 63.5 minutes).
- Overall time from ED arrival to antibiotic administration decreased from 163.3 to 99.2 minutes.
Conclusions:
- An open fracture care pathway effectively reduces the time to antibiotic administration in pediatric patients.
- This intervention is vital for improving outcomes and preventing infections in open fractures.
- The study supports the adoption of such pathways in clinical practice.
Background:
In the care of open fractures, time to antibiotic administration has been shown to be a critical factor in preventing infection. To help improve outcomes at our institution we designed and implemented an open fracture pathway with the goal of reducing the time from emergency department (ED) arrival to antibiotic administration. Here we evaluate the success of this pathway, propose improvements in the protocol, and provide a framework for initiation at other institutions.
Methods:
We compared a retrospective prepathway cohort with a prospective postpathway cohort for 1-year pre and postpathway implementation. First, we analyzed the number of patients from outside facilities who had received antibiotics before transfer. For patients who had not received antibiotics before arriving at our institution, we reviewed pathway metrics including time from ED arrival to the ordering and administration of antibiotics, whether the correct antibiotic type was selected, and time to surgical debridement.
Results:
There were 50 patients in the prepathway cohort and 29 in the postpathway cohort. Prepathway 60.5% of transfers (23 of 38) received antibiotics before transfer, whereas post-pathway 90.0% of transfers (18 of 20) received antibiotics ( P =0.032). For patients who had not received antibiotics before arriving at our institution and were included in pathway metric analysis, there were no differences in demographics or fracture characteristics. Time from ED arrival to antibiotic order decreased from 115.3 to 63.5 minutes ( P =0.016). Time from antibiotic order to administration was similar between groups (48.0 vs. 35.7 min, P =0.191), but the overall time from ED arrival to antibiotic administration decreased from 163.3 to 99.2 minutes ( P =0.004). There were no significant differences in whether the correct antibiotic type was chosen ( P =0.354) or time from ED arrival to surgery ( P =0.783).
Conclusions:
This study provides evidence that for pediatric patients presenting with open fractures, a care pathway can successfully decrease the time from ED arrival to antibiotic administration.
Level Of Evidence:
Therapeutic level III-retrospective comparative study.
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