Henry Ford Hospital (HFH)—located in Detroit, Michigan—is a nonprofit, urban, tertiary quaternary care hospital that is designated as a Level I trauma center with helicopter service.
With 877 licensed beds, HFH has 646 inpatient beds, 39 Level III neonatal ICU beds, 54 observation beds, and 165 adult ICU beds—the largest licensed bed facility in Michigan. HFH has participated in the ACS Trauma Quality Improvement Program (TQIP) for more than 12 years and was successfully reverified as a Level I trauma center in 2023.
Identifying the Local Problem
During its trauma reverification process, an opportunity for improvement was identified related to persistently prolonged antibiotic administration time for open fractures. Delayed antibiotic administration increases risk of infection, which can prolong hospital stays, complicate recoveries, and worsen patient outcomes. The problem affects trauma patients with open fractures, identified during both TQIP data review and the March 2023 Level I reverification survey.
While the TQIP metric specifically tracks blunt open tibia fractures, HFH also participates in the Michigan Trauma Quality Improvement Program (MTQIP), which monitors a broader cohort: patients with acute open femur or tibia fractures, as defined by the Abbreviated Injury Scale, and not limited to blunt mechanisms. MTQIP is a collaborative funded by Blue Cross Blue Shield and has approximately 30 participating hospitals within the state. The benchmarks are tracked and relayed to the team at HFH by Brooke Jamison, BSN, RN, MTQIP RN coordinator. Jamison has been in this role for 4 years.
The delayed antibiotic administration also was noted during a previous review but had not yet been addressed. Sarah Capizzo, BSN, RN, who has worked at HFH for almost 6 years and has been the performance improvement coordinator for the past year, noted when the delay was first identified, it was handled in a track-and-trend method.
“This (method) doesn’t work. We need specific interventions,” she said.
Capizzo explained her role as someone who “oversees the data and puts all the pieces together.” Both Capizzo and Jamison agreed that it is an important position, one that became a standard of care in the TQIP guidelines in 2022.
“Having this guidance in the standards helps to push the quality of care,” Capizzo said.
With the opportunity for improvement pointed out again during the 2023 reverification, the quality improvement project began.
A focused internal review revealed that open fracture patients—particularly those with firearm-related injuries—experience consistent delays in antibiotic administration. These delays predominantly occur in the emergency department (ED), where time to antibiotics frequently exceeds the MTQIP benchmark of 90 minutes.
Developing QI Activity
The goal of the project was to increase the percentage of open fracture patients receiving antibiotics within 90 minutes to more than 90%. Through collaboration with MTQIP, HFH staff realized that other Level I and II hospitals in the area can administer timely antibiotics for open fractures. Achieving this goal by developing specific protocols improves infection prevention and aligns with national and state benchmarks, affecting quality metrics and influencing institutional standing. Initial implementation and data collection spanned 2022 to mid-2024, with ongoing monitoring into 2025.
During meetings, including the monthly Resus meeting and the Institutional Trauma Committee meeting at HFH (which includes many departments such as pharmacy, orthopaedic, trauma quality, and liaisons from the ED), specific guidelines for the QI project were developed. One guideline revision that was put into place was related to clarifying the verbiage stating that antibiotics were to be given before x-rays were taken. According to Capizzo, it was found that waiting for an x-ray caused delays in antibiotic administration.
Adding Quick Links order sets was another intervention that was part of the QI project. Having an antibiotic order automatically in the order set was a strategy to help achieve the goal of prompt antibiotic administration.
To educate nurses and staff on these interventions, the ED education staff took the lead and developed a PowerPoint presentation that was part of competency training.
Results and Next Steps
Active implementation of the guideline changes began in early 2023. Guideline revision happened mid-2023, and nurse competencies were updated toward the end of that year. Case reviews of 2022 showed the average time to antibiotics was 76 minutes.
While the guideline changes were geared toward penetrating trauma, the overall education of this benchmark helped improve the blunt mechanism cohort. With guidelines in place, 2023 had a marked improvement to an average of 16 minutes. In 2024, more than 90% of patients received antibiotics within 30 minutes.
Jamison explained that one of the next steps is finding a way to remind staff to pull the tetanus vaccine and antibiotic at the same time. Both of these items are kept in the same Pyxis, so pulling them at the same time makes sense. However, looking back through charting, it became clear that the tetanus vaccine often was pulled first, and the antibiotic was pulled later—sometimes even hours later.
This project was submitted during the call for abstracts for the TQIP Annual Conference in November 2024 and was accepted for the poster session. A total of 11 posters from HFH were accepted for the TQIP conference last year. Both Capizzo and Jamison attended the TQIP conference and noted that participating in TQIP and attending the conference enhance networking opportunities.
Read the full case study, “Improving Antibiotic Time for Open Fracture,” in the ACS Case Study Repository. For more information regarding TQIP, contact tqip@facs.org.
Samantha Kipley is a Quality Resource Specialist in the ACS Division of Research and Optimal Patient Care in Chicago, IL.
