A Triage System for Referrals of Pediatric Skull Deformities

Abstract

The clinical pathways for craniosynostosis and nonsynostotic skull deformity are entirely different. At the Dutch Craniofacial Center (DCFC), all patients were assessed in the same multidisciplinary craniofacial clinic, a common practice in countries with developed health care. However, the high volume of referrals of nonsynostotic cases frequently resulted in the capacity of these clinics being exceeded, with some patients being assessed in the general pediatric plastic surgery clinic instead. In these general clinics, not all the multidisciplinary team members are routinely present, so patients with craniosynostosis had to make a second journey for further assessment, causing inconvenience, expense, and potential delay in treatment. With triage at the community level unreliable and triage at clinic level inefficient, we decided to trial a triage system to increase efficiency and to ensure patients enter the correct clinical pathway earlier.The 2 craniofacial secretaries were issued with a flowchart to be completed for each new referral. The flowcharts were designed to triage the patients into true craniosynostosis with an appointment for the multidisciplinary clinic or nonsynostotic deformity with an appointment with the craniofacial nurse practitioner (CNP). During a 3-month period, 107 referrals were made. The triage category listed on the initial flowchart for each patient was compared, with the final diagnosis made in the multidisciplinary and CNP clinics.None of the patients triaged as nonsynostotic deformity on the flowcharts were found to be true craniosynostosis after clinical assessment by the CNP. Radiographic assessment or assessment by the craniofacial surgeons in the DCFC confirmed this.The flowchart questionnaire used at the DCFC is a highly sensitive and therefore safe method for detecting craniosynostosis. It has helped to improve efficiency by ensuring patients are seen in an appropriate setting.

Guideline for Care of Patients With the Diagnoses of Craniosynostosis

“…These data are from the Birmingham craniofacial center and could therefore well compare with the situation in the Netherlands. 1 , 2 For the situation in the Netherlands only the information from an article by Bredero-Boelhouwer is available, 3 in which 18 children were identified by the referrers as having craniosynostosis and in 14 of whom this diagnosis was confirmed in the tertiary center. Of the 89 referrals with the initial diagnosis nonsynostotic occipital plagiocephaly (NSOP) made by the referrer, 10 patients appeared to have a craniosynostosis.…”

“…A craniosynostosis or positional skull deformity is primarily recognized by physical examination, notably skull shape 4 , 6 in combination with history taking, 3 , 5 and an imaging study is rarely indicated. 6 Both history taking and physical examination are well possible in the primary and secondary healthcare sectors.…”

“…This will prevent delay in start of treatment as a possible consequence of the increase of patients of positional head shape deformities. 3 This flowchart has been validated only in a tertiary center. There are no other publications on referral patterns in children with abnormal skull shape.…”

Cranial Ultrasound as a First-Line Imaging Examination for Craniosynostosis

“…However, in many places throughout the world, access to a neurosurgeon is low, and responsibility for making the initial diagnosis rests with a family practitioner or pediatrician. 29 In this setting, imaging studies are essential. When imaging is key to the diagnosis, we suggest that CUS may become the first-line technique, avoiding routine use of radiography as an initial examination (Fig 8).…”

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

“…If a skull deformity is present, the physical examination and clinical history (key features described in the next subheads) are the most helpful and revealing pieces of information in the child's evaluation. A previous published anamnestic flowchart12 serves as a guideline to distinguish craniosynostosis from positional skull deformities. The key questions to differentiate the craniosynostoses from the nonsynostotic deformities are: (1) “Is deformity present at birth?” Craniosynostosis is present at birth, whereas nonsynostotic deformities develop in the neonatal period; (2) Is there a preferred sleep position?…”