Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature

Abstract

Background

Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed.

Methods

A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020.

Results

Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs.

Conclusions

An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Keywords

pediatric surgery trauma trauma acute care critical care acute care

Background

Unintentional injury is the leading cause of death in children in the United States, and pediatric traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. The Centers for Disease Control and Prevention (CDC) reports that pediatric TBI affects an estimated 475 000 children annually in the United States for ages 0-14 years. Of the 475 000, 70-90% are discharged home with mild injuries, 37 000 are hospitalized, and 2,685 die from their injuries.^1,2 More than 61% of children with moderate to severe TBI and 14% of children with mild TBI experience some form of lifelong disability.² In one cohort study of pediatric TBI patients who presented with GCS score of 3-4, 56.6% died within one year.¹ While TBI constitutes a major cause of morbidity and mortality in pediatric patients, there is substantial variation in care of these patients. For instance, one study demonstrated that pediatric patients with TBI in Florida, North Carolina, and Vermont were 33% more likely to die during a hospitalization than a similar patient population in California.³ These inconsistences were evident across multiple states in terms of mortality, TBI assessment and admission rates, comprehensiveness of discharge recommendation, rates of discharge to rehabilitation facilities, and correlation with insurance status. This variation in care occurs not only across state lines but also across the types of facilities where patients are treated.^4-7

Studies from the 1990s showed increased mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC) and recommended that once stabilized, children be transferred to a PTC.^4-7 In 1996, Johnson and Krishnamurthy⁵ published their findings from Children’s Hospital in Washington, DC (a PTC), between 1985 and 1988 that showed the mortality rate of children transferred directly from the scene to be 26.8% vs 50% in those transferred from another facility. In 1997, Hulka et al⁶ reported that injured children in Oregon’s statewide trauma system had a reduced risk of death between 1987 and 1991 compared to those in Washington without a statewide trauma system. Furthermore, the retrospective Pennsylvania Trauma Outcome Study conducted by Potoka et al⁷ between 1993 and 1997 concluded that children cared for at a PTC had significantly better outcomes than those treated at an adult trauma center despite similar injury severity.

However, the data from these studies did not specifically stratify patients according to different severities of TBI. More recent studies have investigated outcomes of patients with severe TBI at trauma centers of various designations. In a study of the National Trauma Data Bank (NTDB) from 2009, no statistically significant difference in mortality was seen in patients aged 0-17 years with severe TBI treated at an adult trauma center (ATC) vs an ATC with added qualifications in pediatrics (ATC-AQ).⁸ Additionally, in 2016, Gross et al found no difference in outcomes for adolescents (aged 15-17 years) with isolated severe TBI managed at pediatric vs. adult trauma centers in Pennsylvania.⁹ However, neither of these studies examined mild pediatric TBI (defined as blunt head trauma with GCS >13).

The care of pediatric TBI patients starts in the prehospital setting and is divided into primary and secondary triage. Primary triage in the prehospital setting is determined by first responders, while secondary triage is an evaluation regarding the ultimate location of definitive care made after initial evaluation and stabilization. Overtriage occurs when patients are transported to higher level trauma centers whose injury severity does not warrant treatment at such centers. National guidelines exist for primary overtriage rates to Level I and Level II trauma centers in order to minimize missed injuries, but they may lead to unintended consequences. The American College of Surgeons Committee on Trauma (ACS COT) accepts a rate of primary overtriage rate between 25 and 35% in the adult population.^10,11 Conversely, secondary overtriage does not have a standard definition and is poorly characterized. There is a general understanding that secondary overtriage includes a rapid discharge within 24 to 48 hours of transfer without surgical intervention, but there is no acceptable or target rate of secondary overtriage in the literature.¹⁰ Adult secondary overtriage rates have ranged between 6.9-53% depending on definitions and the populations and settings examined.¹⁰ While a certain percentage of overtriage is acceptable to avoid missed injuries, secondary overtriage leads to significant cost and burden to the health care system as well as for patients and their families.¹⁰

Despite the large public health impact of pediatric TBI, there is a lack of information and protocols regarding transfer to a pediatric trauma center and hospital admission in mild TBI. Evidence-based guidelines used to identify children at very low risk of clinically significant TBI were developed and validated by the Pediatric Emergency Care Applied Research Network (PECARN) and adopted by the Choosing Wisely campaign.^12-14 When followed, these prediction rules result in a greater than 99% accuracy rate for identifying children with low-risk TBI, which would not require computed tomography (CT). Misidentifying these patients raises the possibility of primary overtriage.^12-14 Patients at low risk for TBI with no other injuries can be safely discharged home to the care of a responsible family member or guardian. However, it is the intermediate risk patient population when an observation vs. CT shared decision-making model is recommended that raises the possibility of secondary overtriage.^12-14 We therefore conducted a systematic review of the pediatric mild TBI literature to identify transfer patterns and clinical results that can help inform the development of EMS protocols, clinical guidelines, and best practices for this patient population.

Methods

A literature search of the National Library of Medicine and the National Institutes of Health database was undertaken using the Entrez PubMed (http://www.ncbi.nlm.nih.gov/pubmed/. Click or tap if you trust this link www.pubmed.gov) interface. The primary search strategy was developed to retrieve English language articles focusing on management of pediatric traumatic brain injury and transfer decisions starting in 1990 and continuing through 2020. Keywords and phrases utilized for our search include pediatric, trauma, traumatic brain injury, transfer, and mild pediatric traumatic brain injury. Letters to the editor, editorials, other items of general commentary, and case reports were excluded from the search. Database search revealed 168 results focusing on our search criteria. These articles were then reviewed for relevance by the primary investigator, and the final reference list of 27 citations was distributed to the remainder of the study group for review (Figure 1).

Results

Mode of Transport

The mode of transport of pediatric trauma patients (ground vs. air transport) varies between regions and states across the United States. Common and widely accepted indications for air transport include deteriorating children needing time-sensitive intervention when road transport distance is too prohibitive.¹⁵ When compared to ground transport for pediatric TBI, air transport has been found to be associated with increased survival when adjusted for injury severity.¹⁶ When examining the survival and mode of transport of pediatric TBI traumas to level I trauma centers in the NTDB, helicopter transport had a mortality of 7.5% (183 deaths) vs 3.8% (337 deaths) for ground.¹⁶ However, mean GCS for helicopter was 10.9 vs mean GCS of 13.4 for ground-transported patients, and when adjusted for increased severity of injury, helicopter transport was associated with increased survival. The investigators concluded that 37 patients needed to be transported via helicopter to save one life, which many would argue is worth the added cost, but it is important to define these patients as the more critically injured patients. When used appropriately, air transport of pediatric patients with TBI leads to increased survival.

Within Utah’s statewide trauma system from 2004 to 2013, 60% of pediatric trauma patients were transferred between hospitals by ground and 40% were transferred between hospitals by air transport.¹⁷ Of those transferred between hospitals by air, 12% were discharged directly from the ED and an additional 59% from the short stay unit. Of the pediatric trauma patients discharged following transfer without further intervention, 20% were transported via air transport for interfacility transfer.¹⁷ Most transfers were discharged home within a short period of time, regardless of transport method, indicating a potential overuse of air transport and the increased costs associated with it. In a study from Australia looking at pediatric mild TBI patients defined as GCS 13-15 and skull fracture or intracranial hematoma on CT head, 83% (134) of TBI patients transferred via ambulance and 65% (34) of helicopter transfers were discharged home within 3 days.¹⁵ Of those patients transferred by helicopter, 88% needed only conservative management and 12% needed surgical intervention. Of the patients transferred by ground transport, 93% were managed conservatively and 7% needed surgical intervention. While acknowledging that Utah and Australia are vast and rural and may not be reflective of the experiences in other parts of the world, these data still have larger implications for potential waste of health care resources due to improper use of air transport for pediatric trauma interfacility transfers. Pediatric patients with mild TBI do not seem to warrant the increased cost of air transfer to a PTC. The challenge is defining which patients can be observed in non-pediatric trauma centers.

Patient Outcomes

Overall, pediatric trauma patients undergo interfacility transfer to a pediatric trauma center (PTC) at very high rates.^17-19 Pediatric head trauma patients make up the largest portion of children transferred to PTCs among pediatric traumas.^17,18 However, studies have shown that pediatric blunt head trauma patients with GCS 15 and normal head CT do not even warrant hospitalization. In a study by Holmes et al¹² in 2011, out of the roughly 12 000 patients included in the study, 83% were discharged home from an ED, only 2% received repeat neuroimaging, and only .04% had any traumatic findings on repeat neuroimaging. Most significantly, none of these patients required any neurosurgical intervention. Therefore, they concluded that admission for routine neurological exams/checks was unnecessary.

Seventy-three percent of pediatric trauma patients who initially received care at a non-PTC acute care hospital were transferred to the PTC for further evaluation in Utah.¹⁸ Head traumas were five times more likely to transfer than other traumatic injuries. Interestingly, the strongest predictor of transfer was the individual hospital’s transfer practice and not injury type, severity, or distance to PTC. Of those patients transferred to the PTC, 61% were discharged within 24 hours suggesting that many of these patients were transferred unnecessarily. Another study examined “preventable transfers” to a PTC in Salt Lake City from a non-PTC facility.¹⁷ Of the pediatric trauma transfers, 27% were categorized as preventable transfers, defined as a child discharged within 36 hours of interfacility transfer without surgical intervention or additional imaging. Of these preventable transfers, 64% were classified as “head injury,” 36% of which had normal CT findings and were ultimately diagnosed with concussion requiring no intervention.¹⁷ “Head injury” also consisted of isolated skull fractures without intracranial hemorrhage (34% or 373 patients), intracranial hemorrhage (ICH) (30%), and open fracture (only 26 patients). However, none of these patients required surgical intervention. Furthermore, even those patients found to have ICH were all discharged within 36 hours of transfer.

These high numbers of preventable transfers in pediatric trauma are due to secondary overtriage at non-PTC facilities, which may be partially attributed to lack of familiarity and comfort with the management of pediatric injuries. In West Virginia, 18% of pediatric trauma patients hospitalized for less than 48 hours with no surgical intervention underwent transfer from another facility.¹⁰ Secondary overtriage was defined as any trauma patient who was discharged home within 48 hours with no surgical procedure performed. Factors associated with higher transfer rates included age 0-2 years, those needing specialty consultation (head, facial, and spine injuries), and those arriving at night (44.9% presented on night shift). This secondary overtriage rate among pediatric traumas (18%) was found to be much higher than that of adults in West Virginia (9.8%). The study concluded that the high rate of transfers of pediatric patients with minor traumatic injuries reflected a lack of familiarity with the management of pediatric trauma. In 2015, a similar study by Goldstein et al¹⁹ conducted using the NTDB from 2008 to 2011 defined overtriage as meeting the following four criteria: Injury Severity Score (ISS) less than 9, no need for surgical procedure, no critical care admission, and length of stay less than 24 hours. 22% of transferred pediatric trauma patients met this definition. Furthermore, 37.5% of secondary overtriage patients were discharged directly from the ED following interfacility transfer. Of note it was found that the patients in the overtraiged group were more likely to have an initial GCS of 15.¹⁹ In children with mild head injury classified as GCS 13-15 with skull fracture or intracranial hematoma in Sydney, Australia, from 2009 to 2014, 93% were managed conservatively. Of the patients managed non-operatively, 75% were discharged within 2 days or less.¹⁵ Only 3% of the patient cohort studied needed admission for more than 2 days. Furthermore, only 4% of patients transferred from a non-PTC hospital for head injury needed neurosurgery for epidural hematomas and only 3% needed fracture repair surgery.¹⁵ Therefore, it can be concluded that most pediatric TBI patients with GCS 13-15 and isolated skull fracture or intracranial hematoma do not warrant transfer to a pediatric trauma center and may be able to be observed at non-PTCs. Since overtriage may, in part, be due to a lack of confidence in managing pediatric traumas among providers at non-PTC hospitals, standardized guidelines defining which patients do not warrant transfer may help alleviate some of this uncertainty and decrease the rate of secondary overtriage while still acknowledging an acceptable secondary overtriage rate for injuries such as intracranial hematomas.

In addition to unnecessary transfers to a PTC, investigations into pediatric trauma Pediatric Intensive Care Unit (PICU) admission outcomes have identified unnecessary PICU stays as another area for improvement in the health care system. A separate study conducted in Salt Lake City, Utah, examined preventable PICU admissions, defined as a patient who was transferred out or discharged home from the PICU within 30 hours of admission without mechanical ventilation, blood transfusion, or surgical intervention.²⁰ The study found that most patients in the preventable PICU admissions group were admitted with a head injury.²⁰ Of the preventable PICU admissions group, 83% were admitted with a head injury, 72% of which were isolated head injuries.²⁰ The median initial GCS of these patients was 15 and median length of stay within the PICU was only 17 hours.²⁰

Pediatric TBI patients make up a great majority of preventable transfers and admissions.^{10,12,13,16-20} Most pediatric patients with mild TBI admitted to a PTC following interfacility transfer do not require ICU level care and do not undergo surgical intervention or additional imaging. Finally, pediatric patients with mild TBIs admitted to a PTC are discharged within 24-48 hours of transfer.

Healthcare Costs

Pediatric TBI patients account for 23% of trauma-related admissions with 90% of these being mild with an estimated cost burden of > 1 billion dollars per year in the United States.¹⁶ A longitudinal analysis of injured children also examined financial cost data for all children less than 14 years of age admitted for treatment of traumatic injury.²⁰ Major head injury was the second most common type of injury (27.6%) and accounted for the highest charges annually per health care system ($5,066 905). However, this cost was associated with what they classified as major head injury with an Abbreviated Injury Scale (AIS) of greater than or equal to 3 and therefore did not include cost of mild head injury.

Pediatric TBI preventable transfers and preventable PICU admissions comprise a significant portion of avoidable costs to patients and the health care system. Fenton et al¹⁷ found the total estimated transfer charges for preventable transfer patients were $8,857 246.32 (with the mean per transfer $5,204.02). While this cost estimate was for all pediatric traumas and was not specific to pediatric TBI, head injury was, nevertheless, the most common injury among preventable transfers (64%). Additionally, 20% of preventable transfers were transferred via air transport and mean patient air transport charge per transfer was $18,574 and ranged from $9,048 to $47,857. Pediatric TBI constituted 80% of preventable PICU admission charges.²¹ Pediatric TBI PICU admission costs totaled $8,076 545.43, with a median charge of $8,277.29/patient. Furthermore, children with isolated head injuries accounted for 54% of overall preventable PICU charges at $5,393 528.70. In comparison, injured children admitted to non-PICU bed for > 24 hours had significantly lower median charge of $6,051.90, despite longer median stay (44 h).²¹

Discussion

Guidelines for Management of Mild TBI in Pediatric Population

This systematic review highlights the persistent need for guidelines for transfer of pediatric trauma patients with mild TBI. A study recently published by Candy et al²² examined providers’ decisions to transfer pediatric trauma patients via response to various clinical vignettes at both adult level III trauma centers (TCs) or mixed L3TCs/PTCs. They found that recommendations to transfer was high for all respondents and that providers at PTCs were significantly more likely to recommend transfer of children than physicians from L3TCs, regardless of GCS, with the discordance decreasing as GCS decreased. Additionally, access to a surgeon willing to consult on a patient < 10 years old was associated with a decreased probability of deciding to transfer a patient in L3TCs physicians. Streamlining admission and transfer decisions for pediatric mild TBI reduces cost to patients and the health care system, while freeing up resources at PTCs to manage those in need of pediatric critical care and surgical services.

Hospital admission is not necessary in children with normal head CT scans and/or isolated nondisplaced skull fractures following blunt head trauma with normal GCS in the absence of suspicion for non-accidental trauma. PECARN guidelines should be followed to determine need for head CT.¹³ The PECARN guidelines were developed from a 2009, multicenter study that looked at 42 000 pediatric patients with minor blunt TBI. These guidelines determined children either < 2 years old or ≥2 years old who were at very low risk of clinically important TBI (ci-TBI) for which CT head imaging could be avoided. It is those patients that fall in the intermediate risk category where the decision of observation vs obtaining a head CT that creates concern for providers inexperienced with the care of injured children. Longer observation time in the ED prior to disposition may allow for fewer unwarranted admissions and lower costs for the health care system and patients. Close outpatient follow-up with a pediatric TBI specialist is a possible alternative to admission in children with mild TBI. Additionally, we theorize that allowing for remote evaluation/consultation of the injured child by a pediatric TBI specialist with the assistance of teleradiology and telemedicine may decrease the rates of unnecessary transfers to a PTC in the future. Even patients with low-risk injury patterns that have been found to have excellent outcomes and low risk of evolving, such as nondisplaced skull fracture and no intracranial hematoma or small (<.3 cm) hematoma with no midline shift, can be managed at non-PTC hospitals with general pediatric units.

Our conclusions are not without acknowledgment of the difficulties with implementing these guidelines in the management of pediatric mild traumatic brain injuries within larger trauma systems. Early strict adherence to these guidelines may be difficult as hospitals with little to no experience in pediatric TBI management may feel more comfortable with routinely transferring patients for further management. Moreover, a lack of confidence in non-PTCs’ ability to manage these patients may be present in providers from PTCs lending recommendations on transfer decisions. The increased use of telehealth may be a method of alleviating these concerns and increasing confidence in both non-PTC providers seeking assistance and PTC providers lending guidance in the future. However, telemedicine has the potential for medicolegal implications if a formal consult has not been requested by the referring facility. Furthermore, most neurosurgeons and radiologists will not feel comfortable with over-reading another institutions imaging if they do not have privileges at that hospital. Likely to overcome this, a chart would have to be created at the consulting hospital and the neurosurgeon (or radiologist) would need to be able to officially document in the medical record. Therefore, we acknowledge that this is currently a barrier to this type of consultation and management of the patient, but may be a future direction for our health care system. Despite these acknowledged limitations, it is our hope that this decision-making algorithm will help improve providers’ confidence in making these decisions in an informed way and reduce the number of unnecessary transfer and admission to PTC.

Observation at Non-PTC Hospital Criteria

Our decision-making algorithm (Figure 2) was derived through synthesis of the data reviewed. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the criteria listed below. Unnecessary transfer and admission has been defined in detail in the manuscript for each of the source papers, though most agreed these were patients who did not need any surgical intervention and were discharged quickly (timeline definition different depending on source). We recommend a 4- to 6-hour observation at a non-PTC hospital if transfer is not indicated based on adherence to this algorithm. This recommendation is made in alignment with those made by subsequent PECARN papers and papers investigating the effect of patient observation in the ED on clinical outcomes.^23-27

1.Blunt head trauma.

2.No concern for non-accidental trauma (NAT).

3.Low risk on PECARN assessment.

4.Intermediate risk on PECARN assessment with negative imaging, or imaging findings of the following:

a. Isolated, nondisplaced/nondepressed skull fractures, and no intracranial hemorrhage/hematoma.

b EDH or SDH <.3 cm with no midline shift.

Footnotes

Acknowledgements

We gratefully acknowledge the librarian staff of the Emory Woodruff Health Sciences Library and their assistance with the literature search.

Author Contribution

Literature search, data collection, data analysis, data interpretation, and writing of the manuscript was performed by Olivia A. Keane, MD¹ with oversight and significant assistance from Matthew T. Santore, MD.¹ Critical revision and editing of the manuscript was largely assisted by Mauricio A. Escobar Jr,² MD, Lucas P. Neff, MD,³ Joshua J. Chern,⁵ and Ian C. Mitchell, MD.⁴

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Olivia A. Keane

Mauricio A. Escobar

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