Pediatric Isolated Skull Fractures May Not Require Overnight Hospitalization

Research from the Ann & Robert H. Lurie Children’s Hospital challenges the longstanding practice of keeping all children with head injuries in the hospital overnight for observation, finding that patients with isolated skull fractures could be sent home safely if they had no evidence of brain injury and no neurological symptoms. The findings were published in the Journal of Pediatric Surgery.

If confirmed in larger studies, these findings could pave the way toward ending what the researchers call an unnecessary and costly practice.

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“These ‘just in case’ overnight stays appear to be not only unwarranted and wasteful, but can be disruptive for the family and traumatic for the child,” lead investigator Catherine Hunter, MD,  pediatric surgeon at Lurie Children’s and assistant professor of surgery at Northwestern University Feinberg School of Medicine, said in a statement. “Reducing the number of unnecessary hospitalizations can help generate substantial savings to individual patients and the healthcare system as a whole.”

Trauma is the leading cause of morbidity and mortality in pediatrics, with an estimated 500 000 pediatric patients seen in US emergency rooms and trauma bays every year for concerns of traumatic brain injury. Pediatric traumatic brain injury is one of the most expensive diagnoses, accounting for more than $1 billion annually in total hospital charges in the United States.

“Despite data supporting discharge from the hospital for isolated skull fractures, there is reluctance to adhere to this recommendation by health care providers because of a relative [scarcity] of data specific to pediatric populations,” the researchers wrote.

To examine their hypothesis that children with isolated skull fractures did not require overnight observation, the researchers retrospectively analyzed data from 71 children (56% boys, 44% girls, with ages ranging from 1 week to 12.4 years old) treated at Lurie Children’s over 10 years for head trauma with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma.

For each patient, the researchers analyzed their age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention.

The researchers found that of the 71 patients, only 22.5% were discharged from the ED following evaluation, while 77.5% were admitted for overnight neurological observation. None of the children required surgery, and no patients underwent repeat head imaging during their index admission. Repeat imaging was conducted on 3 previously admitted patients who returned to the ED.

There was also a significant difference in hospital costs between the discharged and admitted patients, with an average increase in $4291.50 for admitted patients (p<0.0001).

While the researchers emphasized that their analysis purposefully excluded children with serious head traumas, loss of consciousness, or brain bleeding — those who are at high risk and must be kept in the hospital for further testing and observation — Rashmi Kabre, MD, co-author on the paper and director of pediatric trauma at Lurie Children’s, noted that their findings “underscore the notion that not all head injuries are the same, and that kids with isolated skull fractures and no other symptoms may be perfectly safe going home.” This could generate substantial savings both to consumers and the healthcare system.

The researchers, however, caution that isolated fractures suggesting non-accidental trauma or intentional injury such as child abuse require further evaluation and overnight observation, even if no neurological symptoms are found.

Reference

Blackwood BP, Bean JF, Sadecki-Lund C, Helenowski IB, Kabre R, Hunter CJ. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. J Pediatr Surg. 2015; doi:10.1016/j.jpedsurg.2015.08.064.