Purpose <p>Open pelvis fractures are associated with a high rate of mortality and require a multidisciplinary approach to resuscitation, hemorrhage control, and fracture stabilization. The patients presenting with these injuries, practice guidelines, and use early of interventions including angioembolization (AE), exploratory laparotomy (EL), and preperitoneal pelvic packing (PPP) have changed over time. It is not known if these changes are associated with mortality.</p> Methods <p>Adults presenting with an open pelvis fracture between 2017 and 2022 were retrospectively identified from the American College of Surgeons Trauma Quality Improvement Program. The primary outcome was in-hospital mortality identified by “deceased” or “expired” emergency department or hospital discharge disposition. Patient-level adjusted risk of mortality was calculated by multivariable logistic regression considering patient comorbid conditions, injury characteristics, interventions, and facility characteristics across observed years. Adjusted mortality risk relative to AE, EL, and PPP interventions was assessed per year by Chi-square and Kruskal–Wallis tests.</p> Results <p>Of 10,172 eligible patients identified, 81.44% were male. The mean adjusted mortality was 10.78% and significantly decreased by 0.43% per year (<i>p</i> = 0.001). AE was performed for 4.42% of patients and did not significantly change per year. EL was performed for 8.03% of patients and decreased by 0.60%/year (<i>p</i> &lt; 0.001). PPP was performed for 7.56% of patients and increased by 0.76%/year (<i>p</i> &lt; 0.001). Trauma centers of mid-tier size (400–600 beds) reported increasing admissions of open pelvis fractures.</p> Conclusion <p>In-hospital mortality after open pelvis fracture declined 2017–2022 as practice patterns evolved for the acute management of associated hypotension, including increased use of PPP and decreased use of EL.</p> Level of evidence <p>Prognostic Level III.</p>