The atraumatic limping child – does a pathway improve assessment of limping children seen in a DGH acute paediatric assessment unit PAU?

Abstract

<h3>Aims</h3> A new pathway for assessing limping children was introduced and audited in a DGH PAU. It offers a decision making tree for investigations based on “red flags” and systemic illness features. The intention was to assess pathway suitability and management choices and make comparisons to previous local audits. <h3>Method</h3> After the pathway was advertised and introduced, a retrospective case note review was conducted. Children logged in the attendance diary as limp/non weight bearing/leg pain were analysed for 6 months following pathway introduction. Their notes were retrieved and assessed alongside a standardised data collection form. The audited standard was 100% use of the limping child pathway. <h3>Results</h3> 29 relevant children aged 8 months to 13 years were identified. Fewer blood tests and xrays performed, fewer children required orthopaedic opinions and follow up was consistently earlier (48-72 hrs, better safety-netting) compared to pre-pathway audits. Pathway was used in 32%. Clerkings reconsidered during audit to decide which investigations the auditor would have requested; actual investigations done were thus labelled “good” or “bad” decisions. Pathway use improved decision making – good decisions increased from 73% to 86%; bad decisions decreased from 27% to 14%. <h3>Conclusion</h3> Improvements following previous audits attributed both to direct pathway use and raised awareness of limping assessment in other cases. Based on this small audit, the pathway lead to a more standardised assessment and streamlining of visits. The 100% target for pathway uptake was not met but based on this audit, it helped practitioners rationalise investigation choices safely and improved confidence in reviewing and discharging children. Ongoing local work has produced a policy for limping children, which will be accessible to related users (Paediatrics, A&amp;E, Orthopaedics) and aims to improve local cross departmental practise. National practice remains variable and we believe there is a need for national evidence based guidance.