UNM Medical Leadership Academy, Cohort 1
Group 9
Stephen W. Lu, MD
A. Robb McLean, MD
Daniel Waldman, MD
“Management of Lower Extremity Osteomyelitis/High Risk infections at UNM
Hospital”
Hypothesis:
Lower extremity osteomyelitis represents a significant burden on the UNM Health System with both
long Emergency Department and inpatient lengths-of-stay. There are multiple bottlenecks in care
provision and a lack of standardized approach to this patient population. Creating evidence-based
clinical pathways for the admission and inpatient care of this patient population, inter-service
agreements describing roles and responsibilities for the care of these patients, and using best evidence
from peer organizations will help standardize patient care, reduce inpatient average length of stay
(ALOS), and improve outcomes, consistent with the first and second pillars of the Joint Operating Plan.
Findings may be applicable more broadly to the treatment of all osteomyelitis at our institution.
This project has 3 identified phases of which phase 1 and 2 are complete.
Phase 1 – Form a multidisciplinary group to study the issue using institutional and national peer data.
Define issues and create an appropriate scope of the project that 1) will not require significant
additional resources (human, financial or IT), and 2) can be implemented in the relatively short term.
Phase 2 – Issue recommendations to address the identified issues within the scope of the project as well
as identify longer term goals.
Phase 3 – Implement the recommendations and perform a follow-up study of results.
Phase 1. Issues in the care of lower extremity osteomyelitis patients:
A multidisciplinary group of participants was identified for this project. Regular meetings were
scheduled and held. Representatives included Dr. Waldman (Family Medicine), Dr. Stephen Lu
(Surgery), Dr. Rich Miller (Orthopedics), Dr. Sheila Modi (Internal Medicine), Dr. Perryman Collins
(Internal Medicine), Dr. Sarah Allen (Infectious Disease), Dr. Robb McLean (Emergency Medicine) and Dr.
Nathan Whitfield (resident, Emergency Medicine). This project coincided with work undertaken
independently by Dr. Collins of Internal Medicine/Utilization Review who was subsequently engaged.
Numerous potential issues were identified in the care of lower extremity osteomyelitis patients at
UNMH. These a priori concerns included: suspected long lengths of stay in the ED; lack of clarity over
the best admission service; long inpatient lengths of stay; concerns over the rates of and need for bone
biopsy for osteomyelitis; inefficient communication between consulting and primary teams; discharge
barriers including availability and requirement for OPAT appointments; delays in PICC line placement;
and quality concerns about outpatient facilities managing these patients. Phase 1 involved data analysis
to substantiate these suspected issues and help focus the project.
An ED analysis of patient throughput was performed looking at all ED patients who had a lower
extremity MRI performed for possible osteomyelitis. See Appendix A.
A UHC Data analysis and comparison was performed looking at inpatient metrics of osteomyelitis
patients. Specific data about inpatient length of stay (including by service), bone biopsy rates, and
amputation rates were collated among other data. See Appendix B.
Infectious Disease, surgery and orthopedics were all engaged to discuss the role of bone biopsies in the
management of these patients, challenges in timely consultation recommendations and surgery when
needed, and PICC line placement delays. Consensus recommendations were developed out of these
multidisciplinary meetings.
Findings:
1) The Emergency Department workup for suspected lower extremity osteomyelitis is variable
leading to long ED lengths of stay. Multiple consulting services are frequently engaged. Average
time from Arrival to Admission for ED patients with osteomyelitis/suspected osteomyelitis was
12 hours for patients not receiving a pre-admission MRI versus 18 hours for those who had an
MRI performed before admission. 28/28 patients in whom a lower extremity MRI was
performed were admitted during the sampling time period. Absence of osteomyelitis on MRI
altered the need for admission in only one of the patients in whom a negative MRI over-read
prompted quick discharge. It is believed that the MRI results do influence the admitting service.
2) UNMH Hospital Average Length-of-Stay (ALOS) for all diagnoses of osteomyelitis is 14.22 days
compared with AAMC Academic comparisons (11.50 days) and non-AAMC Community hospitals
(9.08), indicating significant throughput opportunities.
3) UNMH admitted 353 osteomyelitis patients between Jan-Nov, 2013 and 135 lower extremity
osteomyelitis patients.
4) Amputation rates for UNMH Lower extremity osteomyelitis admissions are 47.4% versus AAMC
academic comparison rates of 34.3%.
5) In 2013, Internal Medicine (n=158), Family Medicine (n=56), Surgery (n=67) and Orthopedics
(n=49) all admitted osteomyelitis patients. There is no formal agreement about which service(s)
is/are best suited to admit these patients, although medical co-morbidities, presence or absence
of surgical findings, primary care physician specialty and affiliation with UNM all play a role in
this decision. If a medicine service (FM/IM) admitted all suspected osteomyelitis of the lower
extremity, this would reduce delays related to the involvement of multiple services in the
admission decision and negate the need to obtain MRI results before admission for high risk
lower extremity infections. This change in process would add approximately 1 admission per
week to the Internal Medicine and Family Medicine services combined. Expediting MRI testing
for suspected osteomyelitis in those patients not otherwise meeting admission criteria for high
risk lower extremity infections would also streamline disposition decisions for admission versus
discharge.
6) Infectious Disease recommends that almost all osteomyelitis patients receive a bone biopsy. At
UNMH, the bone biopsy rate for osteomyelitis in 2013 was 8.22% versus the AAMC comparison
(6.58%) and Non-AAMC community hospitals (3.16%). Bone biopsies are associated with a
longer average length-of-stay (16.6 vs 14.0 days) at UNMH.
7) Current PICC Line Insertion practice is to wait 48 hours for negative blood cultures, even in
absence of indicators of bacteremia, prior to placement. This delays ALOS by 2 days or more for
many patients. A literature review has been performed and discussions are ongoing with
Infectious Disease about the potential for identifying a more limited subset of patients in which
to undertake this practice.
Phase II – Recommendations
1) Implement ED Clinical Pathway (see Appendix C) for workup and admission decision-making for
suspected osteomyelitis of the lower extremity
2) Negotiate inter-service agreements that medicine services (IM/FM) primarily admit all
osteomyelitis patients of the lower extremity, and also admit patient with suspected
osteomyelitis of the lower extremity who otherwise meet admission criteria, given the role of
underlying medical co-morbidities in these patients. It is critical that criteria for admission of
high risk infections (in absence of confirmed osteo) be used to drive early admission from the ED
and that waiting for the results of ED MRIs be reserved for patients who otherwise would not
meet admission criteria and may be able to be discharged if negative.
3) Inter-service communication improvements will also be required for inpatients requiring
surgery who are on a primary medical team.
4) Implement Inpatient Early Discharge to LTACH for Osteo Pathway (EDLO) (see Appendix D)
5) Establish criteria for early PICC line insertion in patients without clear risk factors for
bacteremia.
6) Future issues to be addressed:
a. Targeted bone biopsy recommendations from Infectious Disease
b. Identify an osteomyelitis/diabetic foot infection multidisciplinary team to take
leadership for moving forward with these changes and to address the link with
outpatient processes
c. OPAT access issues
d. Direct discharge from ED to LTACH process
Phase III – Implementation
- Currently Pending
Appendix A. Emergency Department Analysis of Lower Extremity Osteomyelitis
Summary of all patients who had a foot MRI ordered in the ED for possible osteomyelitis (November
2013 through early February 2014).
o
o
o
o
o
o
o
Total MRI = 28 (68% of patients receiving MRI were diabetic)
Number positive for osteo = 21 (75%)
Number admitted = 28 (100%)***
 FP = 6
 IM = 15
 Surg/ortho = 7
Number admitted after MRI result = 16
 Arrival to admission time = 18.5 hr
Number admitted before MRI result = 10
 Arrival to admission time = 12.9 hr
Time lost awaiting MRI result = 5.6 hr
Time from MRI order to first prelim = 5.3 hr
In the diabetic subset, 84% had osteo, and 100% were admitted (19/19)
In the non-diabetic subset, 56% had osteo, and 100% were admitted (9/9).
*Non-diabetic patients had osteo risk factors including IVDA, post-GSW vascular insufficiency,
HIV, alcoholism, PAD, and chronic decubitus ulcers
Conclusions:
1. The decision to order an MRI for osteo equates the need for admission.
2. The result of the MRI rarely affects the decision to admit.
3. The presence of diabetes did not affect the likelihood of admission, and for the purpose of
ED disposition could be considered another risk factor for serious infection instead of a
separate patient population.
4. Awaiting MRI results delays admissions by over 5 hours but does not change the disposition
decision.
*** A 23 yo healthy male without known osteo risk factors was admitted by IM for a prelim read
of osteo then discharged after a “short stay” when the over-read was changed to gout (the proposed
following pathway would not apply to this type of patient due to lack of osteo risk factors).
In these 28 cases, the foot x-ray was positive for osteo in 15 cases. 13 cases of osteo were
confirmed by final MRI read. Of the two false positives, both patients had a past history of osteomyelitis
and surgical intervention. One of them showed subcutaneous gas and the other showed a new abscess.
Both still required admission.
The positive predictive value for osteomyelitis of ordering the MRI was good, at 86%, but the PPV for
need admission was 96.4% after excluding the 23 year-old mentioned above. Only one of the 28 MRI’s
had a significant change from the prelim read to the final attending read.