# Evaluating Avoidable Transfers of Pediatric Forearm Fractures to the Emergency Department

## TL;DR

This study finds that nearly a quarter of pediatric forearm fracture transfers to a pediatric emergency department were avoidable, often due to non-displaced fractures not needing specialized care.

## Contribution

The study identifies risk factors for avoidable transfers of pediatric forearm fractures to specialized emergency departments.

## Key findings

- 38 out of 161 patients (23.6%) had avoidable transfers due to non-displaced fractures not requiring reduction or surgery.
- African American and other race patients had higher avoidable transfer rates compared to Caucasian patients.
- Younger age was the only significant factor associated with avoidable transfers in multivariate analysis.

## Abstract

Background

Forearm fractures represent approximately 20% of pediatric fractures and are commonly managed in emergency departments (EDs). While minimally displaced fractures require immobilization, displaced fractures necessitate reduction. Many non-pediatric facilities lack the resources to manage these fractures, leading to frequent transfers to pediatric emergency departments (PEDs). This study aims to evaluate the rate of avoidable transfers of pediatric forearm fractures to a PED and identify risk factors contributing to unnecessary transfers.

Methods

A retrospective cross-sectional study was conducted at a single tertiary pediatric hospital from July 1, 2022, to June 30, 2023. Patients aged 0-17 years treated for forearm fractures were identified using ICD-10 codes. Exclusion criteria included patients not transferred, incomplete treatment data, or missing initial radiographs. Collected variables encompassed demographics, fracture characteristics, transfer details, and treatments performed. Statistical analyses included chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables, with significance set at p < 0.05.

Results

Out of 445 patients identified, 161 met the inclusion criteria. The mean age was 8.0 years (SD 3.9); 70.8% were male, and 31.7% were African Americans. Avoidable transfers, defined as patients who did not require reduction or surgical intervention, accounted for 38 cases (23.6%). Non-displaced fractures were significantly associated with avoidable transfers (p < 0.001). Race was also significant, with higher rates of avoidable transfer among African American patients (42.1%) and patients of other races (47.4%) compared to Caucasian patients (10.5%) (p = 0.006). There was a statistically significant association between the source of appropriate and avoidable transfers (p = 0.012), with cases originating from clinics (n = 7), outside hospitals (n = 24), and urgent care centers (n = 7). Multivariate logistic regression identified younger age as the only significant factor associated with avoidable transfer (p = 0.047, OR: 0.74, CI: 0.5-0.98).

Conclusions

A significant proportion of pediatric forearm fracture transfers to the PED were avoidable, primarily due to patients not requiring reduction or surgical intervention. Younger age was a significant factor associated with unnecessary transfers. Enhancing education on pediatric fracture management and establishing clear guidelines may reduce unnecessary transfers, optimize resource utilization, and alleviate burdens on specialized centers.