IMPLEMENTATION OF A MULTIDISCIPLINARY CARE PATHWAY FOR PAEDIATRIC BONE AND JOINT INFECTIONS TO PREVENT UNPLANNED EMERGENCY DEPARTMENT VISITS AFTER HOSPITAL DISCHARGE: A QUALITY IMPROVEMENT STUDY

Management of pediatric bone and joint (B&J) infections typically entails inpatient admission for appropriate workup, antibiotic therapy, and in some cases, surgical debridement. Re-admission and re-operation are reported in up to 26% of children. A recent retrospective review of our institutional data revealed 29% of patients with septic arthritis (SA) or osteomyelitis (OM) had unplanned returns to the emergency department (ED) after discharge from hospital. Unplanned ED visits pose significant costs and additional burden to the healthcare system and affected families. In order to improve the quality and efficiency of care for children with B&J infections at our institution, a quality improvement (QI) initiative was implemented to eliminate unplanned ED visits that included routine C-Reactive Protein (CRP) monitoring and scheduled follow-up appointments. A multidisciplinary care pathway for children with B&J infections was implemented in September 2021 and patients admitted with SA, OM, subperiosteal or intraosseous abscess were prospectively followed until June 2022. Specialists in pediatric orthopedics, infectious diseases (ID) and pediatric medicine were involved in pathway development and patient care. The QI pathway comprised routine CRP measurements on admission and every 3 days throughout their stay, and a standardized outpatient follow-up schedule including telephone, virtual and in-person visits with orthopedics and ID (Figure 1). The primary outcome measures were unplanned ED visits after discharge, re-admission, and re-operation rates. These results were compared to a retrospective cohort of children with B&J infections treated between June 2018 and August 2021. Forty-five children aged 3 weeks to 17.9 years (mean 6.8 years) were treated and followed according to the pathway. Mean CRP at admission was 65.8 mg/L (range 1.5–224.7). Twenty-three had OM (51.1%), 2 OM with intraosseous abscess (4.4%), 5 OM with subperiosteal abscess (11.1%), and 17 SA (37.7%). Twenty-two children (48.9%) were treated with antibiotics, 22 (48.9%) had surgical and antibiotic management, and one (2.2%) underwent interventional radiology biopsy and antibiotics. Adherence to CRP monitoring after admission occurred in 93.3%, with 42 patients having at least one CRP result immediately prior to discharge. Mean follow-up was 16.4 weeks (range 2.4–52.1). Eight patients (17.7%) had unplanned returns to the ED. The most common reasons were fever and pain. Of these, 4 patients (8.9%) were re-admitted and one patient (2.2%) was re-admitted twice. Three (13.6%) of the 22 surgically treated patients underwent re-operation, two during their initial hospital admission, and one a month later on re-admission. Re-operation and re-admission rates in the retrospective cohort were similar at 15% and 8%, respectively. By implementing a multidisciplinary approach for the treatment and follow-up of children with B&J infections, unplanned ED visits were reduced from 29% to 18% within 10 months. While re-operation and re-admission rates did not change from the preceding years, by reducing the number of unplanned ED visits, the pathway significantly lessened the burden and costs to the health care system, patients and their families. For any figures or tables, please contact the authors directly.