Are radiographs overutilized in pediatric orthopaedic emergency room care?

Background: It is estimated that $12.8 billion to $28.6 billion is wasted annually on unnecessary imaging studies and treatment in the United States. This is especially important to the pediatric population, which is unable to make decisions for themselves and vulnerable to radiation exposure. We hypothesized that a significant number of unnecessary radiographs are performed in the pediatric emergency department (ED), leading to excessive time, cost, and radiation exposure to pediatric patients. Methods: We retrospectively reviewed 406 patients who were evaluated in a pediatric ED for possible fractures at a single institution during the 2020 calendar year. Records were reviewed for demographics, history, and physical exams, as well as the sequential order which radiographs were performed. All radiographs were evaluated by the senior author to determine if they resulted in a change in management. All data were recorded and analyzed by the senior author and our statistician using Student's t-test. Results: 406 patient encounters were included. 2,807 radiographs were deemed unnecessary, with an average of 6.9 radiographs per patient. $454,734 was spent on radiographs that ultimately did not change management. A total of 216 hours and 43 minutes was spent in the X-ray suite alone, for an average of 32 minutes per patient. The estimated amount of radiation exposure that did not change management was potentially as high as 69 millirem per patient. Conclusions: There is an excessive amount of monetary waste, radiation exposure, and encounter time spent with pediatric Orthopaedic patients in the ED. There are several potential strategies to alleviate this problem, which we hope can be taken into consideration to help address this widespread health care issue. Key Concepts: (1)There are a substantial number of unnecessary radiographs performed in the pediatric ED both during diagnosis and treatment of fractures.(2)This unnecessarily increases the time, cost, and radiation exposure that pediatric patients experience.(3)Several possible strategies exist to reduce this waste including obtaining films after a careful physical exam, consider which views would be most beneficial, whether the joint above and below would truly be needed, using fluoroscopy in the ED during reduction and casting and limiting post splinting or casting imaging if there was no or minimal formal reduction. Level of Evidence: III.