Cast Problems in Children Can Strain ED Resources

ACEP News 
June 2009

By Diana Mahoney
Elsevier Global Medical News


BOSTON -- Unplanned, nonemergent visits to the emergency department for cast-related concerns following treatment in an orthopedic fracture clinic are common and place an unnecessary burden on the health care system, results of a 5-year retrospective study demonstrate.

The increased training demands of competitive youth sports have resulted in more pediatric fractures. "We need to develop strategies to reduce these [nonemergent] visits," Dr. Jeffrey R. Sawyer said at the annual meeting of the Pediatric Orthopaedic Society of North America.

While nonemergent use of the emergency department (ED) has been well studied in primary care, there are no studies in the orthopedic literature regarding the use of the ED for cast-related problems, according to Dr. Sawyer of the University of Tennessee Campbell Clinic in Germantown. Therefore, he and his colleagues retrospectively reviewed all patients who sought care in the ED following treatment in Campbell's pediatric fracture clinic over a 5-year period.

Of 644 children who used the ED for problems related to casts and fracture treatment, 155 met the study criteria, which included having complete records and having been treated with casts by clinicians at Campbell exclusively. "The other 489 kids who came to the [emergency department] were treated either with splints or braces, or were cased at other institutions," Dr. Sawyer explained.

A total of 168 primarily nonemergent ED visits were recorded for the 155 patients (mean age 9 years), most of which were linked to cast/fracture problems (46%) or compliance problems (44%), Dr. Sawyer reported. The percentages of patients in casts by fracture type were as follows: forearm, 38%; tibia, 21%; hand, 12%; elbow, 8%; and ankle and femur, 5% each. Wrist, humerus, and foot fractures were each noted in fewer than 5% of the patient visits, he said.

Based on a review of the evaluation and management codes for the ED visits, the most prevalent cast/fracture problems cited were a too-tight cast in 23% of patients, followed by a too-loose cast in 13%, and pain control in 10%, according to Dr. Sawyer. The primary noncompliance-related problem was a wet cast in 29% of the patients.

When looking at trends by age, the investigators found that the likelihood of returning to the ED for a wet or too-loose cast was significantly higher among younger patients, while older children were significantly more likely to return for a too-tight cast, Dr. Sawyer noted. When assessed by reason for return, "33% of the visits required immediate evaluation, as when the cast was too tight or for pain control, while 52% of the visits--including those for damaged, wet, or loose casts--had low potential for serious injury," he said. The remaining 15% of the visits were attributed to patients who had missed clinic appointments or had been advised to have a follow-up in the ED.

In 74% of the visits, management included cast adjustment or removal, while education and follow-up, pain control, and local skin care were addressed in 20%, 5%, and 1% of the visits, respectively, Dr. Sawyer said.

The mean ED visit length was 171 minutes, and orthopedic consultation was obtained in 48% of the visits. Total hospital charges were $126,324, not including professional fees, and total orthopedic charges were $17,578, Dr. Sawyer said.

"This is big, not only in terms of cost to the hospital/health care system, but also in resource diversion from children who have more emergent problems in the emergency department," he said.

To reduce nonemergent ED visits, Dr. Sawyer and his colleagues have implemented the following changes:


  • Children with cast problems are seen daily at a nurse practitioner clinic.
  • Residents and cast technicians are educated about high-risk cast types and patients at risk of return.
  • Waterproof liners are used in casts of younger patients.
  • Bilingual instructions are given to improve cast compliance.
  • In addition, an after-hours cast phone triage protocol is being developed to provide hospital phone operators with a surgeon-approved decision tree to help keep nonemergent kids out of the ED.

Dr. Sawyer had no financial disclosures related to his presentation.

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