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Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study
Faisal Al-Sani1, Soni Prasad2, Jyoti Panwar3
1Division of Pediatric Emergency Medicine, Department of Pediatrics, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Objectives:
We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome.
Methods:
This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow-up and had institutional medical records reviewed in 3 weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation.
Results:
We enrolled 2,302 children (mean [±SD] age = 9.0 [4.4] years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval = 6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician's pretest probability of a fracture was ≤ 20% versus> 20% (adjusted odds ratio [aOR] = 1.6), patient's pain score was ≤ 2 versus> 2 (aOR = 1.6), and injury was located in a joint versus other location (aOR = 1.7).
Conclusions:
Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.
Insights
Emergency physician interpretations of pediatric musculoskeletal radiographs often differed from radiologists, leading to increased healthcare visits. Low suspicion for fracture and joint injuries were key risk factors for these discrepancies.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Musculoskeletal Imaging
Background:
- Accurate interpretation of pediatric musculoskeletal (MSK) radiographs in the emergency department (ED) is crucial for timely and appropriate patient management.
- Discrepancies between emergency physician (EP) and radiologist interpretations can potentially lead to adverse events (AEs).
Purpose of the Study:
- To determine the frequency of discordant pediatric MSK radiograph interpretations by EPs compared to radiologists.
- To identify if these discordant interpretations led to adverse events (AEs).
- To establish variables independently associated with discordant interpretations and AEs.
Main Methods:
- A prospective cohort study was conducted in a tertiary care children's ED.
- Children presenting with extremity injuries requiring radiographs were enrolled.
- EP interpretations were compared to a radiology reference standard, with follow-up to assess for AEs defined as clinical sequelae or repeat healthcare visits due to interpretation delay.
Main Results:
- Of 2,302 children, 7.8% had discordant EP interpretations leading to AEs.
- No negative clinical outcomes were reported, but discordant interpretations resulted in significantly more subsequent ED visits (77.2%) or orthopedic clinic visits (41.5%).
- Factors associated with discordant interpretations included low pretest probability of fracture (≤20%), low pain score (≤2), and injury location in a joint.
Conclusions:
- Discordant pediatric MSK radiograph interpretations by EPs occur with notable frequency in the ED setting.
- The primary adverse events observed were increased healthcare utilization, specifically more frequent subsequent ED and clinic visits.
- Low clinical suspicion for fracture and injuries located in a joint are significant risk factors for discordant interpretations by emergency physicians.
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