Medical Professional Publications

How to Reduce Cast Complications in Orthopedics

Columbus, OH — March 2018

In early 2015, the Department of Orthopaedics at Nationwide Children’s Hospital was seeing 5.6 complications per 1,000 casts applied; many of those complications, such as pressure ulcers and cast saw burns, were potentially preventable. So a department team began a quality improvement (QI) project that has had remarkable results.

A new report of that project, published in the Journal of Pediatric Orthopedics, shows the cast complication rate declined by 97 percent to 0.15 per 1,000 in less than a year, and that low rate has been sustained.

“We implemented a number of interventions, but the introduction of a formalized monthly resident casting education program with a competency checklist made the quickest, most notable difference,” says Julie Balch Samora, MD, PhD, orthopedic surgeon at Nationwide Children’s, director of Quality Improvement for the hospital’s Department of Orthopaedics and lead author of the study.

Over the course of a two year period documented in the research, a total of 40 people were involved in cast application, bivalving or cast removal. More than half were rotating residents. While efforts were made to train them in casting before the project began, there was no formal program, says Dr. Samora.

So the QI team created one. Education sessions were held at the beginning of every rotation, and residents were required to participate even if they had completed a prior rotation. A “lead cast technician” was designated to teach each resident. Residents had to demonstrate competency in applying and removing casts using a key component checklist, including attention to water temperature, cast padding and cast saw technique.   

Among the other QI interventions in the project were:

  • Creation of a robust complication reporting system, after it became clear that not all incidents were documented
  • Education for cast technicians, allied health professionals and physicians
  • Requirement that AquaCast® Saw Stop Protective Strips be applied as an extra barrier between cast saws and skin
  • A daily audit of casting inventory and a daily status check of casting saws

The complication rate dropped by almost half after just the first month of interventions and continued to decline as the interventions were refined.

“Nationwide Children’s has a focus on QI, and these projects are the right things to do,” says Dr. Samora. “We can have better outcomes, improve patient care, save stress and expense for families and save money. In this case, we could do all of those simultaneously.”


Balch Samora J, Samora WP, Dolan K, Klingele KE. A quality improvement initiative reduces cast complications in a pediatric hospital. Journal of Pediatric Orthopedics. 2018 Feb; 38(2):e43-e49.

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