Protocol aims to clarify when hospital stays are needed with ISFs.

Researchers at Monroe Carell Jr. Children’s Hospital at Vanderbilt, a level 1 pediatric trauma center, have developed and tested a multidisciplinary skull fracture management protocol to guide more targeted treatment decisions for affected patients.

Isolated, nondisplaced skull fractures (ISFs) are a common result of pediatric head trauma. Most pediatric ISF patients treated in EDs are hospitalized, but few require neurosurgical intervention. Efforts have been underway for over a decade to reduce ISF patient transfers to trauma centers when most can be treated locally.

“In the past, any child with this type of skull fracture would be transferred to us for observation from outside facilities, some coming from long distances away,” said Christopher Bonfield, M.D., an assistant professor of neurological surgery at Vanderbilt. “Most of these patients don’t require admission.”

“There has been a significant increase in ISFs across the U.S. because of improved imaging capabilities,” added Rebecca Reynolds, M.D., a neurosurgery resident at Vanderbilt. “We’re trying to parse out what is essential care for these patients; specifically, what is safe as well as cost effective.”

Protocolizing Admission

Wide variability in ISF treatment exists across pediatric trauma centers, with around 78 percent resulting in admissions. Several studies have tried to protocolize admission using the Glasgow coma score and factors such as neurological deficits, recurrent symptoms or suspected nonaccidental trauma. Despite these efforts, “nationally, there isn’t any standard regarding who gets admitted and who doesn’t,” Bonfield said.

“We’re trying to parse out what is essential care for these patients; specifically, what is safe as well as cost-effective.”

Based on anecdotal evidence at Vanderbilt and earlier studies, the researchers hypothesized that fracture location as well as vomiting and ondansetron (Zofran®) use following pediatric ISFs play a role in the need for admission and ED revisits.

Retrospective Look at ISFs

In a study published in the Journal of Neurosurgery: Pediatrics, the research team – including pediatric trauma, pediatric emergency medicine, and neurosurgery – looked at 518 Vanderbilt ISF patients between 2008 and 2018 to see which patients were discharged from the hospital and then returned a day or two later.

They found that older patients and those with occipital fractures were more likely to present with vomiting and to be treated with ondansetron. Additionally, ondansetron use at initial presentation was found to be a significant predictor of revisits following ED discharge.

The team then incorporated these factors into a fracture management protocol based on antiemetic usage. “If they meet certain criteria, we should watch them overnight; if not, we can probably send them home,” Bonfield said.

Testing the Protocol

The researchers have begun to test the tool in pre- and post-protocol cohorts comprised of 162 and 90 children, respectively. Preliminary data show that in the post-protocol cohort, admission rates declined 11 percent and neurosurgery consultations were reduced by nearly half. There was also a trend toward fewer 72-hour ED revisits.

There were no mortalities and no inpatient neurosurgical procedures were performed.

Although overall trauma consultations did not change significantly, consults for abusive head trauma increased. “It’s critical that we identify nonaccidental trauma and make sure those patients get the necessary [child protective services] evaluations to assess the home safety situation,” Reynolds said.

“If they meet certain criteria, we should watch them overnight; if not, we can probably send them home.”

Reducing the Burden of Care

While the new protocol can help lessen the cost burden for both patients and the health system, the goal, Bonfield stresses, is to ensure safety. The team is planning to test the protocol in some of Vanderbilt’s community partner hospitals, where many ISF transfers originate.

“Reducing costs is always important, and reducing admissions has become even more essential during COVID, where hospital capacity can be an issue. Streamlining decision-making is key. However, safety remains paramount,” Bonfield said.

About the Expert

Christopher Bonfield, M.D.

Christopher Bonfield, M.D., is director of the adult and pediatric neurosurgery scoliosis and spine deformity program and the pediatric neurospine program, as well as neurosurgery director of the pediatric craniofacial program at Monroe Carell Jr. Children’s Hospital at Vanderbilt. He is an associate professor of neurological surgery at Vanderbilt University Medical Center, with clinical interests that include general pediatric neurosurgery with an emphasis on craniofacial surgery and spinal deformity/scoliosis correction.

Rebecca Reynolds, M.D.

Rebecca Reynolds, M.D., is a neurosurgery resident at Vanderbilt University Medical Center. She is interested in pediatric neurosurgery and global health, serving as an NIH Fogarty Global Health Fellow in 2019-2020 in Lusaka, Zambia, where she studied pediatric hydrocephalus and spina bifida. She has been involved in several neurotrauma quality improvement initiatives for adults and children.