A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures

Abstract

Background and objective: Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures.

Methods: We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database.

Results: We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%.

Conclusions: We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.

FIGURE 1

Key driver diagram.

FIGURE 2

Statistical process control chart (p-chart) showing the hospital admission rate for children with isolated skull fracture over the study period.

FIGURE 3

CUSUM: hospital admissions prevented over time.

FIGURE 4

Trends in quarterly hospital admission rate for children with isolated skull fractures at Boston Children’s Hospital and the 37 other hospitals contributing to the Pediatric Health Information System administrative database.