Background: There is an estimated $760 to $935 billion in annual cost of waste in the United States healthcare system. $12.8 to $28.6 billion is attributed to wasteful studies/treatments. In an effort to examine current waste in our institution, we examined the use of radiographs in orthopedic patients evaluated in our pediatric emergency department (ED). The pediatric population is largely unable to make decisions for themselves and thus are susceptible to unneeded studies.
Hypothesis/Purpose: We propose that there is a significant amount of waste, in regard to: time, cost, and resources in the ED. Additionally, we believe that unnecessary studies result in excess radiation exposure. Our objective is to create guidelines for emergency department practitioners to use while taking care of pediatric patients in order to decrease waste and minimize radiation exposure.
Methods: This study was a retrospective chart view focusing on patients who were seen in the Pediatric Emergency Department at Stony Brook University Hospital during the 2020 calendar year and subsequently followed up in the office with one of the pediatric orthopedic attendings. The charts of all patients who were evaluated in the ED for possible fracture were reviewed, including the documented history/exam and radiographs. Patient age, mechanism, presentation, whether the patient was initially evaluated by orthopedics and treatment were recorded. Ability to comply with examination due to baseline cognitive ability and mental status at time of presentation was also noted. Additionally, we recorded the total number of radiographs, the number that contributed to treatment and the number that may have been unnecessary based on criteria determined by the senior author . Patients excluded were those greater than 18 years of age, those not initially evaluated in Stony Brook Emergency room, and patients that were lost to follow up and did not present to the clinic following their emergency room visit. All data were recorded and analyzed by the senior author and our statistician.
Results: 406 patient charts were included for patients who were evaluated in the ED and subsequently seen in the office. We determined that 2807 radiographs were unnecessary, with an average of 6.9 per patient. $454,734 were spent on radiographs that ultimately did not change management. 216 hours, 43 minutes, 41 seconds were spent in the ED x-ray suite alone, an average of 32 minutes and 1 second per patient. The estimated radiation exposure from x-rays that did not change management was 28,070 mrem in total, an average of 69 mrem per patient. These radiation totals do not take into account radiation exposure accrued from studies outside the Stony Brook network or computed tomography. Total numbers of each of these values per year are higher as we excluded transferred patients and those that did not follow up with one of our attendings.
Conclusions: There is an excessive amount of monetary waste, radiation, and time associated with radiography in pediatric orthopedic patients in the emergency department. We propose a new set of guidelines as a potential solution to provide better, more efficient care to our pediatric patients.
