Tracking the prehospital time course of open fracture patients.

OBJECTIVES

A tenet of open fracture management is timely administration of antibiotics to reduce risk of fracture-related infection (FRI). Trauma centers strive to administer intravenous antibiotics within one hour of patient arrival. The foundation for this recommendation is based on relatively few studies, which base their findings on time from hospital arrival to antibiotic administration. Little attention has been paid to the prehospital time course of open fracture patients. We hypothesized that a significant portion of open fracture patients arrive at the hospital greater than one hour after their injury, which would represent an opportunity for improved care.

METHODS

Design: Retrospective Case Series Setting: Urban/Suburban Academic Level I Trauma Center Patient Selection Criteria: Subjects were identified using a retrospective search for open fracture patients arriving via emergency medical services (EMS). Patients were included if they were age 18 or greater, presented with an open fracture, and had complete pre-hospital documentation, in-hospital documentation, and radiographs. Outcome Measures and Comparisons: Data collected included patient demographics, fracture location, Gustilo-Anderson classification, dispatch time, on scene time, enroute to hospital time, arrival at hospital time, transfer of care time, modality of transport, whether intravenous antibiotics were administered prior to arrival at the hospital, and development of FRI. Descriptive statistics were used to analyze the findings.

RESULTS

454 patients met the inclusion criteria. Mean time from dispatch to transfer of care was 66.8 ± 26.9 min in all transports; 84.1 ± 25.6 min with helicopter EMS; and 64.8 ± 26.4 min with ground EMS. 239 patients (52.6 %) had transfer of care time greater than one hour after dispatch time. Only 3.7 % of open fracture patients received antibiotics prior to hospital arrival. There was a positive correlation with the development of FRI and prolonged pre-hospital time.

CONCLUSIONS

Many patients with open fractures had transfer of care more than one hour after dispatch. FRI was associated with increased prehospital time. These results suggest an opportunity for prehospital antibiotic administration to mitigate the risk of infection in patients with open fractures.

LEVEL OF EVIDENCE

Level IV.