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Management of Pediatric Isolated Skull Fractures

A Decision Tree and Cost Analysis on Emergency Department Disposition Strategies

Williams, Daniel C. MD, MSCR*; Russell, W. Scott MD*; Andrews, Annie L. MD, MSCR*; Simpson, Kit N. DrPH; Basco, William T. Jr MD, MS*; Teufel, Ronald J. II MD, MSCR*

doi: 10.1097/PEC.0000000000001324
Original Articles

Objective Pediatric isolated skull fractures (ISFs) are common injuries that represent challenging disposition decisions for clinicians. The purpose of this study is to use a decision analysis to compare the clinical and cost-effectiveness of 3 emergency department (ED)–based disposition scenarios for a pediatric patient presenting with ISF.

Methods We conducted a cost-effectiveness analysis comparing ED disposition scenarios that included current practice, increased at-home surveillance, and observation unit utilization. Current rates of admission, deterioration after initial diagnosis, and ED return after discharge, as well as cost of observation-only status, were obtained through literature review. Cost calculations using Healthcare Cost and Utilization Project data included total ED cost, admission without complication, and admission with deterioration.

Results In current practice, 76% of subjects with ISF are admitted and 2.5% of those develop persistent or new symptoms. No patient diagnosed with ISF required neurosurgical intervention. Of those discharged home from the ED, 2.8% return with a new concern with 7.4% having new findings on imaging leading to admission. Total cost per 100 patients by current practice was US $583,587. Increasing at-home surveillance by 20% resulted in a total cost saving of US $113,176 per 100 patients while increasing returns to the ED from less than 1% to 1.1%. Admitting at the current rate to an observation unit resulted in a US $205,395 cost saving per 100 patients.

Conclusions Decreased inpatient utilization through home surveillance or observation unit use reduced cost associated with pediatric ISF management without increasing clinical risk owing to the low probability of clinical deterioration after initial diagnosis.

From the Departments of *Pediatrics, and

Health Science and Research, Medical University of South Carolina, Charleston, SC.

Disclosure: The authors declare no conflict of interest.

Reprints: Daniel C. Williams, MD, MSCR, Department of Pediatrics, Medical University of South Carolina, 135 Rutledge Ave MSC 561, Charleston, SC 29425 (e-mail:

This research was supported by a National Research Service Award (HRSA T32HP10255 and HRSA D55HP23198).

Presented at the Pediatric Academic Societies Annual Meeting May 2013, Washington DC, and at the Pediatric Hospital Medicine Meeting July 2014, Orlando, FL.

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