The Adequacy of Emergency Room (ER) and Urgent Care Center (UCC) Radiographs for Pediatric Upper Extremity Injuries
Karan Dua, MD1; Eric Margulies, BS2; Nathan N. O'Hara, MHA2; Joshua M. Abzug, MD3
1State University of New York, Downstate Medical Center, Brooklyn, NY; 2University of Maryland School of Medicine, Baltimore, MD; 3Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
Introduction Emergency room (ER) and urgent care center (UCC) providers are most commonly the first evaluators of acute pediatric upper extremity injuries, including obtaining radiographs. After evaluation of these patients in the ER/UCC, they are referred to hand surgeons for further evaluation, who sometimes need to obtain additional radiographs. Additional radiographs increase the length of the visit, the healthcare costs associated with the injury, and the radiation exposure to the patient. The purpose of this study was to determine the adequacy of the initial radiographs obtained by ER and UCC providers for pediatric upper extremity injuries.
Materials and Methods A prospective study was performed of patients who presented to the pediatric upper extremity office for injury evaluation after being seen at an outside ER/UCC, during which radiographs were obtained. The adequacy of the initial radiographs was determined in a binary fashion with images deemed 'adequate' if no additional radiographs were obtained, and considered 'inadequate' if the senior resident or attending physician ordered new radiographs. Patients who required additional radiographs to assess a potential loss of reduction were excluded from the study. The duration of the office visit was recorded for all patients.
Results 51 patients were enrolled of in the study. The average number of radiographs obtained by an outside ER/UCC was 2.9 (SD=0.87). Fifty-three percent (n=27) of ER/UCC radiographs were deemed adequate and 47% (n=24) were considered inadequate. Patients with inadequate radiographs required an average of 3.4 (95% CI: 2.7-4.0) additional images. The most common reasons for repeat radiographs were missing views (n=8, 33.3%), an inadequate lateral view (n=7, 29.2%), and poor image quality (n=4, 16.7%). Patients with adequate images had a significantly shorter clinic visit time (p <0.0001) compared to patients with inadequate radiographs, with a mean difference of 32.0 minutes (95% CI: 22.4-41.6). Preliminary analysis showed physician assistants took a lower proportion of inadequate images compared to physicians and nurse practitioners. There was a trend in hand/finger radiographs being more adequate.
Conclusion ER/UCC pediatric upper extremity injury radiographs are often insufficient to permit the adequate diagnosis and treatment by surgeons. Repeat injury radiographs require longer clinic visits for the patient and family, increase the financial cost to the overall healthcare system, and increases radiation exposure to the patient.
ER/UCC providers would benefit from better education regarding how to optimize the radiographs obtained during acute pediatric upper extremity injury evaluations, which would lower patient morbidity and healthcare costs.
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