O2153: Enhancing X-Ray Orders by Utilizing Proper Physical Exam and Applying Clinical Guidelines

Background: Many pediatric injuries can be diagnosed with one radiograph. Because of healthcare costs and radiation risks, provider prudence while ordering radiographs is crucial. Although clinical guidelines like the pediatric Ottawa rules exist, the decision to order radiographs often bypasses clinical judgment. The purpose of this study was to conduct a review of the radiographic practices of providers.

Methods: This was a retrospective cohort of 179 pediatric patients between the ages of one and eighteen years old with an extremity injury. Detailed chart review was performed on patients regarding demographics, HPI, physical exam, radiographs, and follow up. Primary outcomes included radiographs, time to radiograph from triage, and the radiographs’ relationship to the physical exam. Specifically, knee, ankle, and foot complaints were examined in relation to pediatric Ottawa rules. Predictor variables included age, sex, ordering provider, and location of presentation.

Results: The average patient age was 5.02 years old, with a range from 1.01 years to 17.61 years. The average patient received 0.127 millisieverts of radiation at an average cost of $749.03. Measured from the time of triage note creation, the average time from arrival to placement of radiograph orders was 41 minutes. At least one set of unnecessary radiographs was performed in 139 (86.3%) of 161 patients with documentation of physical exam. Of those 161 patients, there were 51 (31.7%) that should have received zero radiographs based on the provider’s physical exam. Radiographs were ordered prior to encounter provider’s note creation in 21 (15.9%) of 139 patients with sufficient documentation. Of the 19 patients that received a knee radiograph, only 4 (21.1%) were indicated by physical exam. Of the 24 patients that received ankle radiographs, 13 (54.2%) were indicated by physical exam. Of the 61 patients that received foot radiographs, only 16 (26.2%) were indicated by physical exam. Younger age significantly correlated with unnecessary knee and foot radiographs per Ottawa ankle and knee rules, having completely negative radiographs, and having zero radiographs indicated. Older age was correlated with an increase in unnecessary radiographs ordered. Males were more likely than females to have a physical exam that indicated zero radiographs. Neither provider type nor location of triage showed significant outcomes.

Conclusion: Many patients are not receiving a proper screening prior to radiographic orders. On both ends of the pediatric spectrum, age is a factor that contributes to a poor correlation between physical exam and radiographic outcomes. Advanced practice providers should continue to be used in the clinical orthopedic setting, as they are non-inferior to physicians regarding radiographic habits. All providers need to revert to a basic physical exam and to apply recognized and respected clinical guidelines to best serve their patients, their families, and the overall healthcare system.