Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis

Abstract

Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children 1 -3 and often requires prolonged and costly treatment. 1, 3 -6 A recent large study from Spain revealed that children with osteomyelitis were hospitalized for an average of 13.5 days, that 20% required surgery, and that 2.3% developed longterm sequelae, such as leg-length discrepancy. 3 Early transition to oral therapy has been shown to be an effective and less costly approach compared with prolonged parenteral therapy. 5 -13 Despite efforts at our institution to reduce costs through early transition to oral therapy, 14 our inpatient costs remained high. In preliminary discussions among specialties involved in caring for children with AHO at our institution, substantial variation in practices from 1 patient to another was identified. We hypothesized that standardizing our practice in all areas would lead to an overall cost reduction and improved care. on behalf of the AHO Care Algorithm Team BACKGROUND AND OBJECTIVES: Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs. METHODS:We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm. RESULTS:Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward. CONCLUSIONS: A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization. abstract To cite: Robinette ED, Brower L, Schaffzin JK, et al. Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis.

Delayed diagnosis and treatment of pediatric calcaneal acute hematogenous osteomyelitis: A case report

“…Surgical debridement has historically been controversial. While some recent evidence has emerged demonstrating that early aggressive surgical source control may be beneficial, other authors have shown higher rates of chronic osteomyelitis following aggressive primary surgery (5,9,10). Various surgical techniques have been described in the literature including abscess drainage and debridement, osseous drilling and the spilt-heel technique (7,8).…”

Osteomielitis aguda: clasificación, fisiopatología y diagnóstico

“…Hasta en un 30% de niños (sobre todo neonatos [70% de los casos] y menores de 18 meses) coexisten con osteomielitis aguda y artritis séptica, especialmente en hombro y cadera por la existencia de metáfisis intraarticular (8). Un estudio reciente realizado en España reveló que los niños con osteomielitis e554 fueron hospitalizados por un promedio de 13.5 días, que el 20% requirió cirugía y que el 2.3% desarrolló secuelas a largo plazo, como la discrepancia en la longitud de las piernas (12). Se ha descrito un aumento del número de casos de osteomielitis aguda de hasta 2,8 veces en los últimos 20 años lo que podría deberse a la mejora de las técnicas diagnósticas (11).…”

Improving Care and Outcomes for Pediatric Musculoskeletal Infections

“…[15][16][17] Previous quality improvement (QI) studies have revealed improved patient outcomes or process measures through clinical algorithms for osteomyelitis and/or septic arthritis. [18][19][20][21][22] These studies may have been limited by small sample sizes and/or use of pre-post analysis without additional methods to account for temporal trends. 23,24 We aimed to improve the care of patients with MSKI at our organization through 4 QI interventions: (1) infectious disease (ID) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) application of a MSKI algorithm and order set.…”