Navigating Safe Transportation for Children in Spica Casts

Patricia Bonatakis PT, DPT
Christine Frugard, MSN, RN, PNP-AC

A spica cast is a type of orthopedic cast used to immobilize the hip, pelvis, and one or both legs, which is essential for proper healing following pediatric hip surgery. This procedure is most often required for children with developmental hip dysplasia or those who have sustained traumatic femur fractures. A significant challenge arises during patient discharge: the fixed, wide-angle position of the spica cast makes it incompatible with standard car seats. The variability in cast angles, dependent on the child's specific needs, further complicates safe transportation. Historically, our hospital has relied on ambulance services for these discharges. However, this solution is neither practical nor cost-effective, as the high costs are often not covered by insurance, placing a substantial financial burden on families. More importantly, this approach fails to address the family's long-term need for safe transportation to crucial follow-up appointments and any subsequent emergency visits, leaving them without a viable or sustainable solution.

To establish a safe and approved transportation protocol for pediatric patients in spica casts, a multi-step approach was implemented.

1. Manufacturer Consultation and Equipment Selection: All major U.S. car seat manufacturers were contacted to determine their policies regarding the use of their products for children in spica casts. Of those contacted, only Evenflo provided a solution. Evenflo issued a formal medical letter to our institution, authorizing the use of their car seats on the condition that the child fits correctly and securely while in the cast.

To accommodate children who cannot fit into a conventional car seat due to cast width or because they exceed the seat's height and weight limits, the hospital also procured EZ-ON 503 lay-down vests as an alternative restraint system.

2. Addressing Liability and Procurement: The hospital's Risk Management department initially advised against the direct purchase of car seats due to liability concerns. To overcome this barrier, a partnership was established with the New Jersey State Police, who agreed to provide Evenflo car seats through an in-kind donation.

In collaboration with Risk Management, a network-wide liability waiver was developed. This form must be signed by the parent or caregiver before receiving a car seat. The waiver explicitly transfers the responsibility for the proper installation and use of the car seat to the family, thereby mitigating hospital liability. Upon discharge, the family retains ownership of the car seat, ensuring they have a consistent and safe transportation solution for follow-up appointments and other travel needs.

3. Evaluation of Alternatives: Specialized car seats designed for spica casts, such as the Merritt Wallenberg seat, were evaluated but deemed unfeasible for our operational model. The significant financial cost, the logistical complexities of implementing a loaner program (including tracking, cleaning, and maintenance across multiple orthopedic groups), and challenges related to ownership made this option impractical for widespread implementation.

Since the program's inception in 2025, five pediatric patients in spica casts have been successfully discharged using the new protocol. In all five cases, the children were properly fitted into a donated Evenflo car seat. Key outcomes include: Patient Impact: All five families were provided with a permanent, safe transportation solution at no cost, eliminating their need for ambulance services. Compliance: 100% of parents/caregivers successfully executed the liability waiver prior to receiving the car seat. Financial: The program operated at zero cost to both the families and the hospital, as all car seats were secured through an in-kind donation. The non-return policy provides a sustainable long-term solution for families.

The safe and cost-effective transportation of pediatric patients in spica casts presents a significant logistical and financial challenge for both healthcare institutions and families. This initiative successfully addressed this critical gap in care by developing a multi-faceted program built on manufacturer collaboration, strategic partnerships, and proactive risk mitigation.

The initial implementation has demonstrated unqualified success, providing a safe, no-cost transportation solution for all participating families while simultaneously eliminating hospital liability and procurement costs. By creating a standardized protocol that is both sustainable and replicable, we have established a new standard of care for this patient population. This program serves as a model for how innovative, inter-departmental problem-solving can enhance patient safety, improve family satisfaction, and optimize resource management.

Identify the transportation safety challenges for pediatric patients in spica casts and recognize the approved car seat and alternative restraint solutions implemented to address this gap.

Describe the process for overcoming institutional barriers, such as liability concerns and procurement costs, through the implementation of a liability waiver and a strategic community partnership.

Explain the benefits of a standardized spica cast car seat program, including enhanced patient safety, reduced financial burden on families, and mitigated liability for the hospital