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045. New skull fracture protocol at Oklahoma Children's Hospital reduces admissions and transfers

Authors: Lacey Carter, MD

Introduction:
Children presenting with mild head trauma make up 1-2% of emergency department (ED) visits each year and < 1% require neurosurgical intervention. In an effort to reduce admissions for minor pediatric head trauma, we created and implemented a protocol for isolated skull fracture management in children.Methods: Retrospective review of all patients < 18-years-old was performed, to analyze injury mechanisms and outcomes from June 2016 to May 2017. From this data, a skull fracture protocol was developed and implemented on July 1, 2018 to determine which patients could be discharged from the ED. We analyzed the post-protocol data from September 2018 to December 2020. Penetrating injuries, other injuries requiring admission, surgical intervention, or presenting GCS < 14 were excluded.
Results:
In the pre-protocol analysis, 150 patients were reviewed (mean age 4.5y, range 7d-16y, 61% male). 148 were admitted, of which 81% were discharged within 24 hours. In the 27 months after protocol implementation, 242 patients met criteria (mean age 3.8y, range 5d-17y, 60% male). The protocol was adhered to in 223 patients (92%). 171 were admitted per the protocol and three returned after discharge due to vomiting. Seventeen were admitted although they met discharge criteria. Seventy-one patients were discharged from the ED and two returned with vomiting. None required neurosurgical intervention. Two were inappropriately discharged without neurosurgery consult, but did not return after discharge. No morbidity or mortality was identified post-protocol implementation, and the number of transfers from outside hospitals reduced by 10%. The 71 discharges from the ED, which would have been admitted before the protocol, saved approximately $167,489.
Conclusion:
Children with isolated non-depressed skull fractures without intracranial hemorrhage can be safely discharged from the ED after a short period of observation and PO challenging. This can be done at outside hospitals or at pediatric medical centers to save transfer and admission costs.