Critical Care Clinical Pharmacist Boston Medical Center
Disclosure information not submitted.
Introduction: Open fractures carry a high infection risk due to skin disruption. The Gustilo Anderson classification system defines the severity of injury based on the size, degree of soft tissue injury, contamination and presence of vascular compromise. Guidelines recommend antibiotic administration within one hour of arrival. At our institution, cefazolin is standard for all open fractures, with aminoglycosides added for grade 3. A 2023 MUE showed inconsistent compliance with 40–100% correct selection and 45–100% timely administration.
Methods: This study was conducted at a 584-bed level 1 trauma center. A root cause analysis identified key areas for intervention. Outcome metrics tracked appropriate and timely regimens. Process metrics tracked accurate grade of fractures, and the primary balancing metric included antibiotic-related adverse effects (AKI or Clostridioides difficle). Patients transferred from outside hospitals were excluded. Using the IHI Model for Improvement and PDSA cycles, interventions included provider education, reference tools, and workflow enhancements. A dot-phrase was created to streamline documentation, and an antibiotic order set is currently in development in collaboration with emergency medicine, surgery, orthopedics, and infectious diseases teams.
Results: Pre-intervention (Oct–Dec 2024): 21 open fracture cases were evaluated and showed variable compliance. Correct antibiotic selection ranged from 43–100%, and timely administration ranged from 57–88%. Post-intervention (Jan–May 2025): 18 eligible cases were identified. All patients received the correct antibiotic regimen (100% compliance) each month. Timely administration improved but remained variable, with 100% compliance in January and May, 33% in February, 50% in March, and 67% in April. Delays were most common in grade III, primarily due to late administration of tobramycin. No cases of AKI or C.diff were reported.
Conclusions: This QI project assisted in improved adherence to institutional guidelines for open fractures, achieving 100% compliance in agent selection. Limitations included small sample sizes, potential ICD-10 misclassification, and implementation delays. Ongoing efforts, including an order set and streamlined documentation tool, aim to support long-term workflow integration and impact assessment.
