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Isolated skull fractures: trends in management in US pediatric emergency departments
Rebekah Mannix1, Michael C Monuteaux, Sara A Schutzman
1Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Harvard University, Boston, MA.
Insights
Most children hospitalized for isolated skull fractures do not require neurosurgery. This study questions the necessity of hospital admission for pediatric skull fractures, highlighting low intervention rates and high costs.
Area of Science:
- Pediatric Emergency Medicine
- Neurosurgery
- Health Services Research
Background:
- Previous research indicates a low risk of neurosurgical intervention for pediatric isolated skull fractures.
- Hospital admission for these cases may not always be necessary.
Purpose of the Study:
- To evaluate current practices for managing children with isolated skull fractures in US emergency departments (EDs).
- To assess the rate of hospital admission and neurosurgical intervention for these patients.
Main Methods:
- Retrospective multicenter cross-sectional study.
- Utilized the Pediatric Health Information System database for children (under 19) with isolated skull fractures from 2005-2011.
- Primary outcome: hospital admission rate; Secondary outcomes: neurosurgical procedures, repeated imaging, hospitalization duration, and cost.
Main Results:
- 3,915 patients with isolated skull fractures were identified; 78% were hospitalized.
- Most hospitalized children (85%) were discharged within 1 day.
- Only 1 child required neurosurgery, while 47 had repeated CT scans. Hospital costs were significantly higher for admitted patients.
Conclusions:
- The majority of children with isolated skull fractures in US children's hospitals are hospitalized.
- Neurosurgical intervention rates are very low.
- Further assessment is needed to determine the appropriateness of current admission practices.
Study Objective:
Previous studies have suggested that children with isolated skull fractures are at low risk of requiring neurosurgical intervention, suggesting that admission to the hospital may not be necessary in many instances. We seek to evaluate current practice for children presenting to the emergency department (ED) for isolated skull fractures in US children's hospitals.
Methods:
We conducted a retrospective multicenter cross-sectional study of children younger 19 years with a diagnosis of isolated skull fracture who were evaluated in the ED from 2005 to 2011, using the Pediatric Health Information System database. The primary outcome measure was the rate of hospital admission. Secondary outcomes were any neurosurgical procedure during hospitalization, repeated neuroimaging, duration of hospitalization, and cost of care.
Results:
We identified 3,915 patients with isolated skull fractures, of whom 60% were male patients; 78% were hospitalized. Of hospitalized children, 85% were discharged within 1 day and 95% were discharged within 2 days. During hospitalization, 47 patients received repeated computed tomography imaging and 1 child required a neurosurgical procedure. Hospital costs were more than triple for hospitalized patients compared with patients discharged from the ED ($2,064 versus $619).
Conclusion:
Most children treated in EDs of US children's hospitals with isolated skull fractures are hospitalized. The rate of neurosurgical intervention is very low. A better understanding of current practice is necessary to assess whether these admissions are warranted or not.
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