Clinical Practice Guidelines for Osteomyelitis in Children

You may have heard (or even used) the expression: easier said than done. That phrase is never truer than when changing the way complex health problems are addressed in a hospital setting. Take for example, osteomyelitis (deep infection of bone and/or muscle) in children.

This is a condition that requires close communication and coordination of many hospital services (e.g., admission department, medical staff, laboratory and imaging studies, surgical staff, and discharge processing). A common sense approach is always welcomed. But evidence-based guidelines for evaluation, diagnosis, and treatment are needed to ensure optimal treatment and results.

That’s why the staff at Children’s Medical Center of Dallas Texas created their own evidence-based clinical practice guidelines (CPGs) and then tested the impact of following these CPGs. They worked together as a multidisciplinary team to develop and put into practice a method for dealing with children admitted to their hospital with possible musculoskeletal infections. The group included staff members from admissions, orthopedics, pediatrics, anesthesiology, hematology, radiology, emergency department, infectious disease, nursing, and social work.

First, they developed a flow-chart (algorithm) to use when evaluating children with suspicious signs of osteomyelitis. The report they published of their results includes a printed copy of this chart from initial admission to final discharge. They used this method with 61 children admitted over a period of one year.

The results of treatment were then compared with 210 children who were treated for the same problem before the clinical practice guidelines (CPGs) were developed. The two groups were carefully matched so they were similar in ages, sex (boys and girls), and diagnosis. Areas of study to evaluate outcomes included length of hospital stay, rates of positive cultures for bacteria causing the infection, timing of MRI studies (from admission to MRI), type of antibiotic used, and rate of readmission to the hospital.

One of the reasons the group put together their own clinical practice guidelines (CPGs) is because they observed wide variations in how children were evaluated, diagnosed, and treated for this condition in their own hospital. For example, there were 33 different antibiotics used in Group I (the 210 children with osteomyelitis treated before the CPGs were developed).

There were four areas where differences were noted between the two groups after treatment: 1) causative organism (specific bacteria responsible for the infection), 2) antibiotic selection, duration, and changes, 3) orders for advanced imaging such as MRI and time from admission to MRI, and 4) surgical intervention, length of hospital stay, and readmission rate.

The results were so dramatic (significantly improved outcomes in group II) that the following recommendations were made and started at this hospital:

  • Tissue cultures and blood work were ordered immediately.
  • A special time slot was saved each day in the radiology department for any child suspected of osteomyelitis needing an MRI; this greatly decreased the time between admission and proper diagnosis and treatment.
  • All children suspected of osteomyelitis were placed in the same hospital unit (rather than being spread out in different units around the hospital). This allowed for improvements in communication and coordination of care.
  • Daily meetings (called “rounds”) were held by the core medical staff regarding each child in the unit. This constant monitoring of each child’s response to treatment made it possible to discharge them sooner with fewer complications. Information about treatment decisions made during this meeting was relayed to the families each day.
  • The primary pediatric attending physician was recognized as the final decision-maker with authority to make decisions when disagreements among the team occurred.

    These new guidelines made it possible to quickly and positively identify the bacteria causing the problem and then choose the best antibiotic to combat the infection. The majority of children in group II had excellent results with full and quick recovery. They returned to normal function and did not have chronic or returning infections.

    These results speak for themselves as to the value and importance of an evidence-based team approach. A short (five to 10-minute) meeting at the beginning of the day improved coordinated communication among the many departments involved in the care of these children. The trend toward shorter hospital stays means lower costs and less suffering for the child.