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Case Study

Improving Antibiotic Time for Open Fracture

Henry Ford Health

General Information

Institution Name: Henry Ford Health

Primary Author Name and Title: Sarah Capizzo, BSN, RN

Co-Authors and Titles: Brooke Jamison, BSN, RN

Name of Case Study: Improving Antibiotic Time for Open Fracture

What Was Done:

Identification of Local Problem

During our Level 1 Reverification in March 2023, reviewers identified an opportunity for improvement related to persistently prolonged antibiotic administration time for open fractures. They also pointed out that these delays were identified as a weakness during the previous review and had not yet been addressed. The problem affects trauma patients with open fractures, identified during both TQIP data review and the March 2023 Level 1 reverification survey. While the TQIP metric specifically tracks blunt open tibia fractures, our institution 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 Score (AIS), and not limited to blunt mechanisms.

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 exceed the MTQIP benchmark of 90 minutes. Notably, similar delays were cited in the previous TQIP review and remained unaddressed, highlighting a persistent system-level gap in care. Delayed antibiotics increase risk of infection, which can prolong hospital stays, complicate recoveries, and worsen patient outcomes.

How Was the Quality Improvement (QI) Activity Put in Place

Context of the QI Activity

Henry Ford Hospital is a not-for-profit, urban, designated Level I trauma center with helicopter service, tertiary quaternary care hospital located in Detroit, MI. With 877 licensed beds, Henry Ford has 646 inpatient beds, 39 Level III Neonatal ICU beds, 54 Observation beds, and 165 Adult ICU beds; the largest in Michigan.

The goal of this project was to increase the percentage of open fracture patients receiving antibiotics within 90 minutes to >90%. Through collaboration in MTQIP, we are able to see that other Level 1 and 2 hospitals in the area are able to give timely antibiotics for open fractures. Achieving this goal improves infection prevention and aligns with national and state benchmarks, impacting quality metrics and institutional standing. Initial implementation and data collection spanned 2022 to mid-2024, with ongoing monitoring into 2025.

Project Timeline

  • 2022: Case reviews began
  • March 2023: Specific guidelines developed
  • May–Sept 2023: Guideline revisions approved
  • Nov 2023: Nurse competencies updated
  • 2024: Audit filters added, real-time tracking enabled

Planning and Development Process

The intervention was collaboratively implemented by a multidisciplinary team, including:

  • Emergency Department (ED) Liaison – Provides clinical leadership and insight into ED workflows.
  • Orthopedic Liaison – Ensures alignment with ortho-specific fracture management practices.
  • Trauma Medical Director (TMD) and Trauma Program Manager (TPM) – Guide strategic direction and protocol development.
  • Trauma Quality Team – Coordinates data review, implementation, and education efforts.
  • Pharmacy Team – Supports antibiotic selection, availability, and workflow optimization.

Intervention Modes of Delivery

  • Face-to-face stakeholder meetings (Monthly Resus meetings)
  • Internal workgroup meetings for guideline development
  • EMR-based changes (Quick Links order sets)
  • In-person nursing education and competencies

Location of Intervention

  • Interventions occurred primarily in the Emergency Department

Frequency

  • Monthly case review meetings (Resus)
  • Guideline and protocol updates implemented on a rolling basis
  • Education refreshers as needed

Intervention Timeline

  • Intervention planning began in late 2022
  • Active implementation from early 2023 to present
  • Ongoing review and improvement continued through 2024

Resources Used and Skills Needed

  • Improvement Team
  • Trauma Quality: Sarah Capizzo (PI Coordinator), Brooke Jamison (MTQIP RN Coordinator), Sherri Minchella (Trauma Program Manager)
  • Acute Care Surgery: Dr. Johnson (Trauma Program Manager)
  • Ortho: Dr. Hakeos (Ortho Liaison)
  • ED: Dr. Krupp (ED Liaison), ED Nurse Manager
  • Pharmacy
  • IT

Costs and Funding Sources

No added FTEs. Used existing meetings and internal resources. Minor Epic customization.

What Were the Results?

Overall Results and Analysis

While our guideline changes were geared toward our penetrating trauma, the overall education of this benchmark helped improve our blunt mechanism cohort.

2022: Average time to antibiotics was 76 minutes.

2023: Marked improvement to an average of 16 minutes.

2024: Average rose to 91 minutes due to a single significant outlier, though >90% of patients still received antibiotics within 30 minutes.

Measures met: 90% <30 min in 2023; maintained in 2024

Setbacks

Our ED has a relatively high nursing turnover (which is not unique to our institution). We had to ensure all new RNs/ED staff members were aware of the new policy so that we could maintain progress in giving timely antibiotics. We did this by reviewing outlier cases with ED monthly at our Resus Meeting.

Data lag due to coding delays, small numbers of open tibia fractures per cycle.

Tips for Others

Key Takeaways

A key lesson from this project is that sustainable change in trauma care takes time, collaboration, and ongoing education. Our success wasn’t immediate—it unfolded over several years and required input from multiple stakeholders to find solutions that worked for both trauma and the ED. Breaking down silos and building partnerships, especially with ED leadership and staff, was critical to moving the mark.

We met our goal of administering antibiotics within 90 minutes, but we’re aware that just one or two missed cases could have tipped us in the other direction. This reinforces the need for continuous education, especially for new staff, and for always connecting our teams to the “why.” When staff understand the impact—reduced infections, better outcomes, meeting national benchmarks—it creates buy-in beyond just checking a box.

This project reminded us that improvement is not just about protocols—it’s about creating a culture of shared responsibility and accountability.

Future Plans

This project will continue with targeted revisions and process enhancements based on ongoing performance monitoring and identified outliers. While our overall compliance has improved significantly, we continue to observe occasional delays—particularly in blunt mechanism cases—highlighting the need for sustained vigilance and frontline engagement.

We recognize that even a small number of delayed cases can affect our benchmark performance. In response, we've prioritized real-time case review, incorporating injury photos when available, which provide visual context and enhance the quality of our case discussions. These reviews are paired with continuous feedback loops to the ED team to reinforce learning and accountability. Our team continues to explore opportunities for improvement, with the next goal being to develop a nurse-driven protocol for timely antibiotic administration. We’ve observed that tetanus is often administered promptly—interestingly, the antibiotics are stored in the same refrigerator. By linking these two actions in the care workflow, we hope to reinforce early antibiotic administration as a natural part of the trauma response process.

This small but practical change reflects our larger aim: making best practice easier to do in real time.

Our team is committed to sustaining this project through continuous data monitoring and adaptation. As benchmarks evolve, so do our strategies. In Fall 2024, the TQIP “Open Long Bone” cohort expanded to include additional fracture types—humerus, radius, ulna, femur, tibia, and fibula. In response, we updated our internal review processes to reflect the expanded inclusion criteria. Our current median time to antibiotic administration is 48 minutes, based on the most recent Fall 2024 TQIP benchmark report—a reflection of ongoing improvement and multidisciplinary effort. Results will be shared with ED leadership, trauma team members, and quality stakeholders through regular Resus meetings, scorecard updates, and real-time case reviews when benchmarks are missed. We are also working to identify a nurse champion within the ED to support sustainability, peer education, and continued frontline awareness. This project is a model for how our team adapts to national changes while keeping patient care at the center of every improvement effort.