Emergency room visits by pediatric fracture patients treated with cast immobilization.

BACKGROUND: The purpose of this review was to determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care.

METHODS: Retrospective chart review of patients initially seen in a busy urban pediatric orthopaedic clinic identified those who had an ER visit because of a cast-related problem over a 5-year period. Patients were included only if they were seen for their initial visit and cast application in our fracture clinic.

RESULTS: Of 168 ER visits made by 155 children treated with cast immobilization, 29% were because of a wet cast; 10%, a damaged cast; 23%, a tight cast; 13%, a loose cast; and 10%, pain. In addition to wet and damaged casts, compliance issues included a missed clinic appointment (5%) and being told by medical personnel to return to the ER for a cast check (8%). Several groups with a high risk for return to the ER were identified: the younger the patient, the more likely that the cast was too loose or wet, and the older the patient, the more likely the cast was too tight. Cast type also played a role: a significantly higher rate of return to the ER was found with long arm, long leg, and hand casts. There were no major complications and no child required hospitalization.

CONCLUSIONS: All 168 ER visits required only a cast change or reassurance, which could have been done during regular fracture clinic hours; no child required hospitalization or surgery. From these results, a program has been instituted that includes patient education, triage, and follow-up in our fracture clinics to not only improve the quality of patient care but to decrease the financial burden on physicians and the healthcare system.

LEVEL OF EVIDENCE: Economic and decision analysis, Level III.