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Improving Time to Antibiotics in Patients With Long Bone Open Fractures Presenting to the Pediatric Emergency
Kaitlin Keenan1, Deepa Patel2, Ronak Patel2
1NYU Langone, Mineola, NY.
Insights
A new pediatric emergency department triage workflow significantly improved timely administration of intravenous antibiotics for open fractures, reducing wait times to under 60 minutes. This quality improvement initiative enhanced patient care for pediatric trauma cases.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Quality Improvement Science
Background:
- Open fractures in pediatric patients require prompt antibiotic administration to minimize infection risk.
- Current triage protocols may delay the delivery of critical intravenous antibiotics.
Purpose of the Study:
- To evaluate a novel triage workflow designed to decrease the time to intravenous antibiotic administration for pediatric open fractures to less than 60 minutes.
- To assess the impact of a multidisciplinary quality improvement project on antibiotic delivery times.
Main Methods:
- A prospective, multidisciplinary quality improvement project was conducted at a Level 1 pediatric trauma center.
- The new workflow included splint removal and skin assessment during triage to identify open fractures.
- Plan-Do-Study-Act cycles were utilized to refine the workflow and reduce antibiotic administration time.
Main Results:
- The percentage of patients receiving intravenous antibiotics within 60 minutes increased from 36% to 87.5% post-implementation.
- Median time from arrival to antibiotic administration decreased from 86 minutes to 34 minutes.
- Continuous improvement efforts focused on education, reinforcement, and barrier identification.
Conclusions:
- The implemented triage workflow effectively improved the timeliness of intravenous antibiotic administration for pediatric open fractures.
- This initiative successfully achieved the goal of delivering antibiotics within 60 minutes in 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.
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