Pediatric Emergency Medicine Fellow Children's Hospital of the King's Daughters (CHKD) Children's Hospital of The King's Daughters Norfolk, Virginia, United States
Background: Pediatric Urgent Care (PUC) centers provide an evolving method of care for children. Many PUC centers do not have 24/7 Pediatric Radiologist coverage and rely on PUC provider interpretation. Radiograph discrepancy rates have been reported in prior Emergency Department (ED) studies, but rates have not been evaluated and reported for PUC centers, which could represent a patient safety concern.
Objective: Our aim was to determine the radiographic discrepancy rates in a PUC center network.
Design/Methods: This observational, retrospective study evaluated radiographs (chest, clavicle, lower extremity, and upper extremity) ordered and interpreted by PUC advanced practice providers (APP) and physicians from 1/1/2016 to 12/31/2018 at one hospital’s four affiliated PUC centers. During the times of 1700-2300, Pediatric Radiologists were unavailable to provide readings until the next day when they designated interpretations (i.e., gold standard) as accurate or discrepant. The overall discrepancy rates (false positive and false negative) and clinically significant discrepancy (CSD) rates (i.e., required a change in management) for PUC providers was determined by chart review and compared (considered significant at p<0.05). Chart review inter-rater reliability was confirmed using a 10% sample of charts (kappa=0.77). Patients were excluded if they were transferred directly from the PUC center to the ED.
Results: 17,260 radiographs were included: 4712 chest, 203 clavicle, 6270 lower extremity, and 6072 upper extremity. Radiographs had a 9.4% (n=1619) overall discrepancy rate, with a 5.2% (n=902) false positive and 4.2% (n=717) false negative rate. The CSD rate was 5.4% (n=932). Highest CSD rates were noted in upper extremity (7.3%), followed by lower extremity (5.7%), chest (2.7%), and clavicle (1.0%) radiographs. Changes in management included 4.5% (n=770) change in follow-up, 2.4% (n=412) change in therapy, and 0.4% (n=68) return for evaluation. No discrepancy resulted in mortality. No significant differences in any rates were seen between physicians and APPs. Conclusion(s): Overall discrepancy and CSD rates were comparable to similarly designed ED studies (ranging from 1-28% and 0.41-6.3%, respectively), with no differences noted between physicians and APPs. These findings suggest that a PUC center, without 24/7 radiologist coverage, can provide relatively low discrepancy rates for patients requiring radiographs.
Authors/Institutions: Allison Wood, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Anne O. McEvoy, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Lauren Paluch, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Brynn Sheehan, Eastern Virginia Medical School, Norfolk, Virginia, United States; Jiangtao Luo, Eastern Virginia Medical School, Norfolk, Virginia, United States; Paul C. Mullan, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Turaj Vazifedan, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Theresa E. Guins, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Jeffrey Bobrowitz, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States; Joel Clingenpeel, Children's Hospital of The King's Daughters, Norfolk, Virginia, United States
