Maximizing Adherence and Minimizing Time to Antibiotics: A Multidisciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures.

OBJECTIVES: To determine if a multidisciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation. DESIGN: Retrospective pre-post study design. SETTING: Single Level II Trauma Center. PATIENT SELECTION CRITERIA: All patients who triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated before implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (January 2021-October 2022) were defined as the "pre" group and those treated following implementation the "post" group. OUTCOME MEASURES AND COMPARISONS: The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between preprotocol and postprotocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx <60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug-resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days. RESULTS: Twenty-four patients (mean age 39.5 ± 16.3 years) met the criteria after protocol implementation compared with 72 patients (mean age 34.3 ± 14.8 years) before implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9 ± 104.6 minutes to 22.2 ± 12.8 minutes in the postprotocol group ( P < 0.001). In addition, only 53% in the preprotocol group received Abx within 60 minutes compared with 96% in postprotocol group ( P < 0.001). Post hoc power analysis revealed that the study was powered at 92% (effect size = 0.72) to detect a significant difference between the preprotocol and postprotocol groups. CONCLUSION: This study provides evidence that a multidisciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patterns and predictors of oral antipsychotic prescribing in adult patients with schizophrenia.

Background: Evidence increasingly suggests minimal differences in efficacy between oral antipsychotics for the pharmacologic treatment of schizophrenia. As a result, newer treatment guidelines avoid an algorithmic approach to antipsychotic selection and recommend treatment be determined on a case-by-case basis. Objective: To determine patterns and predictors of oral antipsychotic prescribing for adults diagnosed with schizophrenia. Methods: This is a retrospective, cross-sectional study using data from the National Ambulatory Medical Survey (NAMCS) from 2005 to 2016 and 2018. Treatment options were defined as a first-generation antipsychotic (FGA), second-generation antipsychotic (SGA), or no antipsychotic. Multivariable logistic regression analysis was conducted to identify predictors of antipsychotic treatment, adjusting for predisposing, enabling, and need factors. Results: The final study sample consisted of visits by 38,403 adults (unweighted n = 1932; age ≥ 18) diagnosed with schizophrenia in the United States. Risperidone, olanzapine, and quetiapine were the most prescribed antipsychotics. Patients ≥65 years old were half as likely to be prescribed an SGA versus no antipsychotic (OR 0.44, 95% CI [0.31, 0.61]). Patients with a higher number of chronic conditions also had lower odds of being prescribed an SGA or FGA versus no antipsychotic (OR 0.98 [0.97, 0.99]; OR [0.96 [0.96, 0.99]), while patients prescribed a higher number of medications had higher odds of being prescribed an SGA versus no antipsychotic (OR 1.2, 95% CI [1.1, 1.4]). Conclusions: Multiple factors were associated with prescribing an SGA or FGA versus no antipsychotic, but no factors were associated with prescribing an SGA versus FGA. Future studies are needed to determine the reasoning behind differences in antipsychotic prescribing.