Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wound to the left great toe and redness of the toe
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male child that was taken to the ED with two-day history of left foot redness and one-day history of swelling after stubbing it on the bed. The redness was spreading up his foot. He reportedly had fevers, and vomited after being given acetaminophen. He was seen by his pediatrician and referred to the ED. 

The patient's vital signs included temperature 36.1, heart rate 148, respiratory rate 22, and blood pressure 124/77. Examination was significant for no acute distress, normal oropharynx, normal capillary refill, benign abdomen, clear lungs, and a small open wound to the left great toe medially with significant streaking up to the ankle. He had one episode of vomiting in the ED. Laboratory evaluation revealed mild anemia and mild ketonuria. X-rays were unremarkable. Cultures were obtained, and he was treated with a normal saline bolus and vancomycin. 

The patient was admitted for further management of cellulitis of the left great toe. By the next day, his was doing well, with improved intake, no fevers, decreased tenderness and swelling, and ongoing tachycardia responsive to a normal saline bolus. He was transitioned to enteral clindamycin and deemed stable for discharge home. Blood culture was ultimately negative and wound culture was positive for Staphylococcus aureus with resistance to clindamycin (no mention of MSSA (methicillin-sensitive Staphylococcus aureus) vs MRSA (methicillin-resistant Staphylococcus aureus), although it was sensitive to oxacillin). 


Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient.

This male child injured his left great toe and subsequently developed a wound infection with surrounding and rapidly progressive cellulitis. No abscess was identified, and he was able to ambulate. He was reportedly febrile at home and had two episodes of emesis. He had not received any outpatient intervention; his primary care practitioner referred him to the ED. While it was not unreasonable to monitor him in the hospital overnight with parenteral antibiotics, he was overall hemodynamically stable, and he did not require acute inpatient admission. He could have been safely and effectively managed at a lower level of care such as observation.