176 - Reducing Unplanned Postoperative Emergency Department Visits in Pediatric Orthopedic Surgery: A Quality Improvement Study

Publication Number: 3169.176

Eddie Geagea, Nemours Children's Hospital, Orlando, FL, United States; Kathryn Farrell, Nemours Children's Hospital, Orlando, FL, United States; Mona Doshi, Nemours Children's Hospital, Orlando, FL, United States; John F. Lovejoy, Nemours Children's Hospital, Orlando, FL, United States

Background: Orthopedic postoperative concerns are a common reason for pediatric visits to the emergency department (ED),leading to increased healthcare costs, overutilization of limited resources, and unnecessary family expenses. Yet, limited data exist on the incidence, causes, costs, and effectiveness of quality improvement interventions to reduce unplanned postoperative return visits (UPRVs).

Objective: We aimed to determine the incidence, drivers, reasons, time patterns, and associated charges of UPRVs after pediatric orthopedic surgery, and evaluate the effectiveness of targeted quality improvement interventions in reducing them.

Design/Methods: We conducted a quality improvement project utilizing the Model for Improvement with statistical process control (SPC) encompassing all pediatric patients undergoing orthopedic surgery, totaling 6,733, between2020 and 2024. Implementing a five Plan-Do-Study-Act (PDSA) cycle focused on patient and staff education, standardized discharge instructions, enhanced communication, improved pain management, standardized pre-and postoperative instruction packets and implementation of video instructions, and Spanish. The primary outcome was the monthly rate of UPRVs to the ED within 30 days of surgery. Secondary outcomes included reasons for UPRVs, timing of presentation, the proportion considered potentially manageable through telehealth, and return rates stratified by orthopedic surgical category with associated charges.

Results: Among 6,733 procedures, the annual return rate declined from 3.98% in 2020 to 1.51% in 2024, representing a 62.1%relative reduction and $76,128 in cost savings compared with the baseline. Pain was the leading reason, wound concerns became more prominent in 2023-2024, while medication-related returns decreased from 9.4% in 2023 to 0% in 2024. In 2020, 74% of returns occurred after clinic hours, of which 52% were potentially manageable via telehealth. Between 2021 and 2024, the proportion of UPRVs after clinic hours declined to 54.6%. By surgical category (2021-2024), UPRVs were most frequent after spine procedures (20.4%; $52,338 in ED charges), followed by foot/ankle (13.9%; $35,685) and sports/arthroscopy (13.9%).

Conclusion(s): This quality improvement initiative substantially reduced UPRVs to the ED, improving access, streamlining orthopedic care, and reducing financial burden for families and the health system. By shifting more visits into regular clinic hours, interventions enhanced efficiency, facilitated timely management of urgent needs, and improved both the patient experience and the overall value of orthopedic care delivery.

CV Eddie Geagea 2025 (2) (1) (2).pdf

Key driver diagram for reducing Unplanned Postoperative Return Visits (UPRVs) to the Emergency Department (ED).


Run chart of the monthly rate of unplanned postoperative return visits (UPRVs) to the emergency department (ED) within 30 days of surgery.
(A) The monthly UPRV rate is shown for the years 2020-2024 (grey line). The median rate is shown for each year (gradient red line). Green boxes depict the interventions that started in July-2021 and continue each year. By the end of 2024, the median rate of UPRVs can be seen to have decreased considerably. (B) From 2020 to 2024, the monthly UPRV rate showed sustained median reduction after the mid-2021 PDSA initiation; yearly medians gradually decreased from 3.77 in 2020 to 1.06 by 2024.