P0517 - Reducing Orthopedic Consults in the Pediatric Emergency Department

Background: Orthopedic injuries are among the most common complaints that present to the pediatric emergency department (ED). Many orthopedic injuries can be safely managed by emergency providers initially with outpatient orthopedic or primary care follow-up. At our institution, we identified an excess of non-emergent orthopedic consults and sought to reduce these consults in order to expedite the care of emergent orthopedic conditions. Our aim was to reduce the proportion of orthopedic encounters with orthopedic consult from 26% to 17%, a 33% reduction, within 6 months.

Methods: We utilized the Model for Improvement with collaboration between the emergency and orthopedic departments. Our multidisciplinary team reviewed baseline orthopedic consult data and developed a Pareto chart (Figure 1) of ED diagnoses not requiring emergent orthopedic consultation and a Key Driver Diagram. Plan-Do-Study-Act (PDSA) cycle #1 interventions were the development and dissemination of orthopedic consult guidelines to ED and orthopedic providers and ED nurse training on splint placement. PDSA cycle #2 interventions were guideline optimization, continued provider and nursing education, and a splint order set in the electronic medical record. Primary measure was the proportion of orthopedic encounters with orthopedic consult measured weekly. Secondary measures were the proportion of encounters with orthopedic consult deemed non-emergent per our guidelines and ED length of stay (LOS) for orthopedic consult patients. Balancing measure was return visits for ED sedation and reduction or operative management (OR). Pre and post intervention measures were analyzed using statistical process control.

Results: From May 2019 to March 2020, the proportion of orthopedic encounters with orthopedic consult decreased from 26% to 19% (Figure 2). Encounters with non-emergent consult decreased from 4% (UCL 8, LCL 0) to 2% (UCL 5, LCL 0). Mean LOS for orthopedic consult patients did not decrease. There were no reports of return visits for ED sedation and reduction or OR post-intervention.

Conclusion: Using QI methodology, we successfully decreased the proportion of orthopedic encounters with orthopedic consult in the pediatric ED by 27% while minimizing return visits. This project is ongoing with the aim to reach a 33% reduction by further incorporating quantitative and qualitative feedback.