Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The authors reviewed the transfer requests for isolated pediatric traumatic brain injuries (TBIs) at a Level I/II facility with the goal of identifying clinical and radiographic traits associated with potentially avoidable transfers that could be safely managed in a non–tertiary care setting.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors conducted a retrospective study of patients &lt; 18 years of age classified as having TBI and transferred to their Level I tertiary care center over a 12-year period. The primary outcome of interest was identifying potentially avoidable transfers, defined as transfers of patients not requiring any neurosurgical intervention and discharged 1 hospital day after admission.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Overall, 70.8% of pediatric patients with isolated TBI did not require neurosurgical intervention or monitoring, indicating an avoidable transfer. Potentially avoidable transfers were associated with outside hospital imaging that was negative (86%) or showed isolated, nondisplaced skull fractures (86%) compared to patients with cranial pathology (53.8%, p &lt; 0.001) as well as age ≤ 6 years (81% [negative imaging/isolated, nondisplaced fractures] vs 54% [positive cranial pathology], p &lt; 0.001). The presence of headaches, nonfocal deficits, and loss of consciousness were associated with necessary transfer (p &lt; 0.05). Patients with potentially avoidable transfers underwent frequent repeat CT studies (19.1%) and admissions to the pediatric intensive care unit (55.9%) but at a lower rate than those whose transfers were necessary (p &lt; 0.001). Neurosurgical interventions occurred in 11% of patients with cranial pathology, which accounted for 17.9% of necessary transfers and 5.2% of all transfers.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>In the authors’ region, potentially up to 70% of interfacility transfers for pediatric brain trauma in the absence of other systemic injuries warranting surgical intervention may not require neurosurgical intervention and could be managed locally. No patients transferred with isolated, nondisplaced skull fractures or negative CT scans required neurosurgical intervention, and 86% were discharged the day after admission. In contrast, 11% of patients with CT scans indicative of cranial pathology required neurosurgical intervention. Age &gt; 6 years, loss of consciousness, and nonfocal deficits were associated with a greater likelihood of needing a transfer. Further studies are required to clarify which patients can be managed at local institutions, but referring centers should practice overcaution given the potential risks.</jats:p></jats:sec>

Evaluating the Role of a Neurosurgery Consultation in Management of Pediatric Isolated Linear Skull Fractures

“…Our data answers a specific question that previous papers have alluded to, but not emphasized, in their results [6, 7, 10, 12, 14, 15]. To briefly summarize, Arrey et al [6] determined that there was no need to hospitalize 326 patients with ILSF with a median age of 19 months unless there was a pending nonaccidental trauma workup.…”

“…Interestingly, Tavor et al [17] retrospectively demonstrated that severe mechanism of injury (running, biking, fall onto protruding instrument) combined with clinically evident skull fracture, neurological deficit, and severe headache identified almost all 182 patients who required intervention in their study. Similarly, Mackel et al [12] found that an intracranial finding or altered mental status may be predictive for future intervention. These studies taken together suggest that the typical fracture requiring neurosurgical intervention results from a severe mechanism of injury, is associated with some symptoms at the time of presentation, has additional intracranial pathology, and typically involves the frontal or temporal bone.…”

“…Thankfully, the incidence of any neurosurgery intervention in the general pediatric trauma population is small, ranging roughly from 0 to 8% [12-19]. Bonfield et al [13] demonstrated that among 897 pediatric skull fracture patients, only 6.5% underwent surgical repair for fracture elevation, frontal sinus repair, or open fracture debridement for cosmetic reasons.…”

“…Study exclusion criteria were age > 18 years, open or depressed fractures, skull base fractures, pneumocephalus, poly-trauma, intraparenchymal hemorrhage, epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, cervical spine fractures, penetrating head trauma, and initial GCS scores < 13. The literature suggests an increase in surgical management in patients with these features [12-14]. Neurosurgical intervention included recommendations to change acuity of care, to obtain additional imaging, or to undertake invasive procedures not limited to placement of external ventricular drain, fiberoptic intracranial pressure monitor, craniotomy, and/or angiography.…”

“…Isolated linear skull fractures (ILSF) are the most common type of pediatric skull fracture accounting for 85% of all skull fractures [5]. Despite numerous studies with large patient populations demonstrating that ILSF with Glasgow Coma Scale (GCS) scores of ≥14 have little risk for severe complications [3, 6-12], management of pediatric ILSF commonly includes admission and routine pediatric neurosurgical consultation. Our objective was to examine changes in management that arose from a pediatric neurosurgery consultation in pediatric patients with ILSF and GCS scores ≥14.…”