Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department

McCanny, Peter J; McCoy, S; Grant, Tim; Walsh, Simon J.; O’Sullivan, Ronan

doi:10.1136/emermed-2011-200604

Cited by 10 publications

(6 citation statements)

References 20 publications

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“…It is uncertain if more comprehensive laboratory (or routine testing), validation and implementation of a clinical decision rule, or more advanced imaging (eg, POCUS) would improve diagnostic accuracy. Overall, the low proportion of paediatric ED presentations with acute non-traumatic limp, common diagnosis of transient synovitis and infrequent diagnosis of septic arthritis is consistent with international literature 2 14 15…”

Section: Discussionsupporting

confidence: 81%

“…Ultrasound is more sensitive than X-ray at detecting joint effusions 2 5 18. Ultrasound has been suggested as a primary imaging modality in the workup of a non-traumatic limp,14 19 reserving X-rays for cases of suspected fractures, SUFE and Perthes disease. Ultrasound was used in 15.6% of our cohort, and the most common findings were unilateral joint effusion (51%) and a normal study (36%).…”

Section: Discussionmentioning

confidence: 99%

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Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study

Haines

Gowdie

et al. 2022

Emerg Med J

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BackgroundAcute non-traumatic limp in children has many causes, ranging from common benign and self-limiting disease to serious time-sensitive emergencies such as septic arthritis. We aimed to (1) describe the epidemiology and workup of paediatric acute non-traumatic limp presentation in three Australian EDs and (2) compare investigations and treatment between a tertiary paediatric centre and two non-tertiary centres.MethodsA retrospective chart review of children aged 0–16 years, with an initial presentation of non-traumatic limp to three EDs in Melbourne, Australia. Data on presentation, management and outcomes was systematically collected on all eligible patients.ResultsOf 63 941 presentations over a 12-month period, 475 (0.7%) met inclusion criteria. The median (IQR) age of presentation was 5 (3–8) years, with a male predominance (61%). Blood tests and imaging were performed in 39% and 51%, respectively. 34% of presentations had no investigations. The most frequent ED diagnoses were transient synovitis (37%) and viral myositis (16%). 84% were discharged home after ED evaluation. Compared with the two non-tertiary hospitals, children who presented to the tertiary centre were less likely to have any investigation performed (OR=0.41, 95% CI: 0.27 to 0.62, p<0.001) and more likely to be discharged home after evaluation (OR=4.67, 95% CI: 2.79 to 7.81, p<0.001).ConclusionAlthough mostly due to benign disorders, an important number of limping children who presented to the ED had serious disease, with approximately one-third of these not diagnosed at the initial ED visit. There is large variation in workup including blood test, imaging and decisions regarding ED disposition.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study

Haines

Gowdie

et al. 2022

Emerg Med J

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“…This practice reduced the number of unnecessary tests, and the length of ED stay of these patients decreased. [22] Our study implies the improvement of turnaround time of laboratory blood tests and CT and the reduction of unnecessary testing might be effective solutions for ED crowding.…”

Section: Discussionmentioning

confidence: 76%

Execution of Diagnostic Testing Has a Stronger Effect on Emergency Department Crowding than Other Common Factors: A Cross-Sectional Study

2014

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Study ObjectiveWe compared the effects of execution of diagnostic tests in the emergency department (ED) and other common factors on the length of ED stay to identify those with the greatest impacts on ED crowding.MethodsBetween February 2010 and January 2012, we conducted a cross-sectional, single-center study in the ED of a large, urban, teaching hospital in Japan. Patients who visited the ED during the study period were enrolled. We excluded (1) patients scheduled for admission or pharmaceutical prescription, and (2) neonates requiring intensive care transferred from other hospitals. Multivariate linear regression was performed on log-transformed length of ED stay in admitted and discharged patients to compare influence of diagnostic tests and other common predictors. To quantify the range of change in length of ED stay given a unit change of the predictor, a generalized linear model was used for each group.ResultsDuring the study period, 55,285 patients were enrolled. In discharged patients, laboratory blood tests had the highest standardized β coefficient (0.44) among common predictors, and increased length of ED stay by 72.5 minutes (95% CI, 72.8–76.1 minutes). In admitted patients, computed tomography (CT) had the highest standardized β coefficient (0.17), and increased length of ED stay by 32.7 minutes (95% CI, 40.0–49.9 minutes). Although other common input and output factors were significant contributors, they had smaller standardized β coefficients in both groups.ConclusionsExecution of laboratory blood tests and CT had a stronger influence on length of ED stay than other common input and output factors.

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“…Due to broad spectrum of underlying causes, facing a limping child can be a challenge for physicians. Although the vast majority of final diagnoses were transient synovitis, by the concern about missing out more serious disorders such as septic arthritis and malignancies physicians usually appeal to laboratory tests or imaging methods despite their mostly worthless effects (1,(4)(5)(6) . But the key part of diagnosis is detailed history combined with a systematic examination, even for uncommon conditions.…”

Section: Introductionmentioning

confidence: 99%

Kohler's Disease: Acute Foot Pain and Limping in Pediatric Emergency Department

Er¹,

Sözbılen²,

Kantas³

et al. 2020

Trends in Pediatrics

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Kohler's disease is a rare cause of limping in children which is hypothetically related with impaired blood supply of navicular bone by the compression of other tarsal bones. The clinical manifestations are pain and swelling in the midfoot and limping with typical steps on the lateral aspect of affected foot. As it is an elusive entity for physicians, the lack of clinical suspicion leads to utilization of advanced diagnostic tools and delayed diagnosis. Here we present a case of Kohler's disease as a 5 years-old girl with acute foot pain and limping.

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Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department

Cited by 10 publications

References 20 publications

Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study

Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study

Execution of Diagnostic Testing Has a Stronger Effect on Emergency Department Crowding than Other Common Factors: A Cross-Sectional Study

Kohler's Disease: Acute Foot Pain and Limping in Pediatric Emergency Department

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