by Elizabeth Hofheinz, M.P.H., M.Ed.
Few surgical situations are as complex as a child with a musculoskeletal infection. Recognizing this, a team of researchers from the University of Texas Southwestern and the Children’s Health System of Texas in Dallas have outlined the optimal way to treat these patients: with a multidisciplinary team. Their work, “Team Approach: Pediatric Musculoskeletal Infection,” was published in the March 8, 2020 edition of JBJS Reviews.
Lawson A. B. Copley, M.D., M.B.A. is professor of Orthopaedic Surgery and Pediatrics at the University of Texas Southwestern. Dr. Lawson, who also works at the Texas Scottish Rite Hospital for Children and the Children’s Medical Center of Dallas, commented to OTW, “We have seen disorganized processes of care and poor communication between the stakeholders of care. This led to prolonged evaluations, delay in diagnosis and intervention, inconsistency of treatment methods, and frustration of providers and families.” 
The authors highlight and advocate strongly for a team approach involving emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology. They wrote, “The emergency department is where initial clinical assessment of children with suspected musculoskeletal infection often starts. This evaluation can be expedited by pattern recognition, which can lead to expeditious prioritization of specific ancillary testing, which in turn may be supplemented by laboratory findings to guide resuscitation.”
The authors cited prior work outlining that ED “priorities included establishing rapid intravascular access, initiating fluid resuscitation, obtaining blood cultures, initiating antibiotics, and monitoring the response to fluid boluses.”1 They also mention three studies that found, “Early recognition of septic shock is crucial because pathogens can double in number every 28 minutes in untreated bacterial infections.”2,3,4
The authors wrote, “If intubation and mechanical ventilation are needed, it is important to ensure adequate volume resuscitation because increased intrathoracic pressure can reduce venous return and lead to worsening shock.”
“A child with catecholamine- and hydrocortisone-resistant septic shock may not be able to survive in settings that are not equipped to deal with this situation. Early recognition and expeditious transfer using an efficient form of transportation, such as fixed-wing air- craft with a critical care team, might be effective. Whether the communication with the tertiary care center is done by telemedicine or standard telephone communication, the ability to recognize and escalate this type of referral is within the scope of providers within a network of care. There are a variety of surgical intervention methods that might be considered to decompress infections of this nature. Similarly, there are a variety of antibiotic selections that might be alternatives in these cases.”
Dr. Copley told OSN, “[Using a team approach] We have seen improved processes of care and better communication among stakeholders and with families. This has led to improved efficiency and accuracy of the diagnostic process. Treatment became more effective and consistent. Patient and family satisfaction markedly improved. Historically, children with severe illness in the ICU would be taken down to MRI, undergo sedation for a lengthy MRI with and without contrast and then return to the ICU after the MRI. The surgical team would then later review the findings of the MRI and decide that surgery was necessary. The child would then be taken to the operating room at a separate time, possibly even the next day, and undergo another sedation. Their recovery would accelerate after the procedure.”
“Now, the child is taken to the MRI with the expectation that they will be transferred immediately following the MRI to the operating room, under continued anesthesia. The scans are of short duration, typically less than 20 minutes, and no contrast is administered. Everyone involved with the child’s care, including the intensivist, ICU nurse, radiologist reading MRIs, MRI technician, anesthesiologist sedating for MRI, anesthesiologist in the operating room, operating room nurse, orthopaedic surgeon, MRI scheduler, and operating room scheduler are all on the same page and know the plan from the outset of the day until the case is complete. It is a well-oiled machine.”
“Don’t wait on a hospital administrator to create a system like this,” urges Dr. Copley. “If you see a need to improve care, take the time to engage with all of the stakeholders and keep the most important thing at the forefront of the dialogue: better patient care. Everyone who has an ounce of self-respect will be on board and join the effort to improve a suboptimal system.”
“Quality improvement begins with the recognition of a tangible need, and proceeds through sustained determination and active, engaged dialogue with key stakeholders. The improvement may not happen overnight, but it will never happen without a champion.”
- Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2): 580-637.
- Forsyth VS, Armbruster CE, Smith SN, Pirani A, Springman AC, Walters MS, Nielubowicz GR, Himpsl SD, Snitkin ES, Mobley HLT. Rapid growth of uropathogenic Escherichia coli during human urinary tract infection. MBio. 2018 Mar 6;9(2):1-13.
- Ames SG, Horvat CM, Zaritsky A, Carcillo JA. The path to great pediatric septic shock outcomes. Crit Care. 2018 Sep 22;22(1): 224-7.
- Gibson B, Wilson DJ, Feil E, Eyre-Walker A. The distribution of bacterial doubling times in the wild. Proc Biol Sci. 2018 Jun 13;285(1880): 1-9.