Sedation for forearm fracture reduction in the Pediatric emergency Department. Impact on length of stay and hospitalization

Background

Children with forearm fractures who present to the emergency department (ED) commonly need a reduction. Historically the reduction took place in the operating rooms. In recent years it has been also performed safely and with no complications under sedation in the ED.

We aim to compare the length of stay and hospitalization rates of pediatric patients who underwent radial or ulnar fracture reduction under sedation in the pediatric ED, versus children with radial or ulnar fractures who presented to the general trauma ED (where no Pediatric sedation service is available).

Methods

This is a retrospective observational study in a regional hospital serving northeastern Israel. In our institution, up until 2017, all pediatric trauma patients used to present to the general trauma ED where no sedation service for pediatric patients was available. From 2017, pediatric trauma patients presented to the Pediatric Emergency Department where sedation was available. The study population consisted of all patients younger than 18 years presenting to the emergency department with ulnar or radial fracture that needed a reduction. We compared the patients presenting to the general trauma ED between 1.1.15-30.6.16 and the patients presenting to the Pediatric ED between 1.1.18-30.6.19. Primary outcome measures were hospitalization rates and length of stay. Secondary outcome measure was the rate of analgesic medication provided during the visit.

Results

We evaluated 175 patients . 96 presented to the PED and 79 presented to the general trauma ED. The two groups had similar demographic features

Our data showed that patients treated with fracture reduction in the Pediatric ED had a lower hospitalization rates 6.3% compared to patients treated in the general trauma ED 21.5% with significant p value 0.003.
All the patients on the pediatric ED underwent reduction procedure under sedation
while only 20% General Trauma ED underwent reduction with hematoma block and no one underwent this procedure under sedation.

The Length of stay in the ED for those who were discharged home was 279.7±193 SD in Pediatric ED versus 186.6±92SD in General Trauma ED.

Conclusion

• All Pediatric patients with forearm fractures needing reduction are treated with less hospitalization (more than 3 times decrease in hospitalization rate ) when treated in the Pediatric ED, under sedation, compared to the general trauma ED .

• Despite the need for more resources to perform procedural sedation in the Pediatric ED (staff, time and medications), patients who underwent closed forearm fracture reduction under sedation in the Pediatric ED, had only 93 minutes increase in LOS when compared to the general ED.

• Sedation provided not only quality of care but was also time and resource effectiveness.

• Our results could guide local policy makers with resource allocation.