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Transfer of children with isolated linear skull fractures: is it worth the cost?
Ian K White1, Ecaterina Pestereva1, Kashif A Shaikh1
1Department of Neurological Surgery, Indiana University School of Medicine; and.
Insights
Most pediatric patients with isolated linear skull fractures do not require transfer to a Level 1 trauma center, saving millions in transport costs. This study highlights the need to refine transfer protocols for these low-risk head injuries.
Area of Science:
- Pediatric Traumatology
- Neurosurgery
- Health Economics
Background:
- Children with skull fractures are often transferred to specialized pediatric neurosurgical centers.
- Historical data and recent studies suggest varying risks of clinical decline in pediatric skull fracture patients.
- Limited data exists on the financial implications of transferring low-risk pediatric patients with isolated skull fractures.
Purpose of the Study:
- To analyze the clinical outcomes of pediatric patients transferred with isolated skull fractures.
- To determine the financial costs associated with transferring these patients to a Level 1 pediatric trauma center.
- To evaluate the necessity of such transfers for low-risk pediatric skull fracture cases.
Main Methods:
- Retrospective review of pediatric head injury patients at Riley Hospital for Children (2005-2013).
- Identification of patients with isolated skull fractures (excluding intracranial hematoma, brain injury, or multisystem trauma).
- Analysis of clinical outcomes, transfer methods (ambulance/helicopter), and associated costs for isolated linear, nondisplaced skull fractures.
Main Results:
- 438 pediatric patients with isolated linear, nondisplaced skull fractures were transferred, incurring $1.83 million in transfer fees alone.
- No transferred patient required neurosurgical intervention, and all recovered with symptomatic treatment.
- No late decline or epilepsy was observed in the study cohort.
Conclusions:
- The high cost of transfers for low-risk pediatric skull fractures ($1.83M over 9 years) contrasts with uniformly good clinical outcomes.
- Most children with isolated, linear, nondisplaced skull fractures do not necessitate transfer to a Level 1 pediatric trauma center, barring concerns of abuse.
- Further research is recommended to refine protocols for identifying pediatric patients who truly require specialized transfer for isolated skull fractures.
Abstract:
OBJECTIVE Children with skull fractures are often transferred to hospitals with pediatric neurosurgical capabilities. Historical data suggest that a small percentage of patients with an isolated skull fracture will clinically decline. However, recent papers have suggested that the risk of decline in certain patients is low. There are few data regarding the financial costs associated with transporting patients at low risk for requiring specialty care. In this study, the clinical outcomes and financial costs of transferring of a population of children with isolated skull fractures to a Level 1 pediatric trauma center over a 9-year period were analyzed. METHODS A retrospective review of all children treated for head injury at Riley Hospital for Children (Indianapolis, Indiana) between 2005 and 2013 was performed. Patients with a skull fracture were identified based on ICD-9 codes. Patients with intracranial hematoma, brain parenchymal injury, or multisystem trauma were excluded. Children transferred to Riley Hospital from an outside facility were identified. The clinical and radiographic outcomes were recorded. A cost analysis was performed on patients who were transferred with an isolated, linear, nondisplaced skull fracture. RESULTS Between 2005 and 2013, a total of 619 pediatric patients with isolated skull fractures were transferred. Of these, 438 (70.8%) patients had a linear, nondisplaced skull fracture. Of these 438 patients, 399 (91.1%) were transferred by ambulance and 39 (8.9%) by helicopter. Based on the current ambulance and helicopter fees, a total of $1,834,727 (an average of $4188.90 per patient) was spent on transfer fees alone. No patient required neurosurgical intervention. All patients recovered with symptomatic treatment; no patient suffered late decline or epilepsy. CONCLUSIONS This study found that nearly $2 million was spent solely on transfer fees for 438 pediatric patients with isolated linear skull fractures over a 9-year period. All patients in this study had good clinical outcomes, and none required neurosurgical intervention. Based on these findings, the authors suggest that, in the absence of abuse, most children with isolated, linear, nondisplaced skull fractures do not require transfer to a Level 1 pediatric trauma center. The authors suggest ideas for further study to refine the protocols for determining which patients require transport.
