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MacGregor F, Breckons M, Swainston K. Organisational barriers and facilitators to the implementation of best practices within paediatric forensic radiographic practice - A scoping review. Radiography (Lond) 2024; 30:43-51. [PMID: 37866157 DOI: 10.1016/j.radi.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/12/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Implementation and application of evidence-based practice through legislation, international and national guidelines and local protocols is integral to the successful undertaking of forensic radiographic practice, because of its medico-legal role. This research aims to evaluate those organisational barriers and facilitators to its effective implementation. METHODS This scoping review was undertaken according to the JBI updated guidelines using the PCC mnemonic. A systematic search of 10 databases was undertaken to identify literature addressing the research question relating to this aspect of forensic radiography practice. Handsearching and snowballing were also included to enhance this search strategy. The search focussed on forensic imaging of paediatrics, the living and deceased. RESULTS Of the 301 papers initially selected, 9 articles were identified as eligible for inclusion, encompassing an international perspective. Through Inductive Content Analysis, 5 conceptual categories were developed: ineffective organisational governance, education translation, system brakes, default practice, and value-based judgement. CONCLUSION The results indicate that there are many complex and multifactorial organisational issues impacting upon effective implementation of best practices within paediatric forensic imaging. There is a need to address these issues, before attempting strategies for future implementation. It is essential to recognise that there can be no one-size-fits approach, but rather tailored strategies are required recognising individual needs within the multi-disciplinary scope of forensic radiographic practice. IMPLICATIONS FOR PRACTICE Failure to recognise and address the identified issues impacting upon effective implementation, may have significant implications on the processes and individuals involved in the forensic imaging acquisition pathway. Successful addressing of these issues may enable the professionals involved in organisational governance to create a more conducive and receptive environment for best-practice implementation.
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Affiliation(s)
- F MacGregor
- School of Health & Life Sciences, Teesside University, Middlesbrough, TS1 3BX, England; Population Health Sciences Institute, Newcastle University, Newcastle, NE2 4DR, England.
| | - M Breckons
- Population Health Sciences Institute, Newcastle University, Newcastle, NE2 4DR, England
| | - K Swainston
- School of Psychology, Faculty of Medical Sciences, Newcastle University, Newcastle, NE2 4DR, England
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Chen HH, Wang IA, Hsieh TW, Tsay JH, Chen CY. Early predictors for maltreatment-related injuries in infancy and long-term mortality: a population-based study. BMC Public Health 2023; 23:2232. [PMID: 37957616 PMCID: PMC10641954 DOI: 10.1186/s12889-023-17180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Incidence, health consequences, and social burden associated with child maltreatment appeared to be borne disproportionately by very young children. We conducted a population-based data linkage study to explore child- and family-level factors that affect receiving different diagnoses of maltreatment injuries and investigate excessive mortality throughout toddlerhood. METHODS We conducted a retrospective cohort study comprising 2.2 million infants born in 2004-2014 in Taiwan. Incident cases of child maltreatment were defined by hospitalization or emergency department visits for three heterogeneous diagnostic groups of maltreatment-related injuries (i.e., maltreatment syndrome, assaults, and undetermined causes) within 12 months after birth. The generalized linear model and landmark survival analyses were used to evaluate risk factors. RESULTS An estimated 2.9‰ of infants experienced at least one maltreatment-related injury, with a three-year mortality rate of 1.3%. Low birthweight was associated with increased risk of receiving the diagnosis of three maltreatment injuries, particularly maltreatment syndrome (adjusted Incidence Rate Ratio [aIRR] = 4.08, 95% confidence interval [CI]: 2.93-5.68). Socially advantaged family condition was inversely linked with receiving the diagnosis of maltreatment syndrome and assaults (e.g., high income: aIRR = 0.55 and 0.47), yet positively linked with undetermined cause (aIRR = 2.05, 95% CI: 1.89-2.23). For infants exposed to maltreatment, low birth weight and non-attendance of postnatal care were highly predictive of fatality; low birthweight served as a vital predictor for premature death during toddlerhood (aIRR = 6.17, 95% CI: 2.36-15.4). CONCLUSIONS Raising awareness of maltreatment-related injuries in infancy and predictors should be a priority for appropriate follow-up assessment and timely intervention.
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Affiliation(s)
- Hsin-Hung Chen
- Institute of Public Health, National Yang Ming Chiao Tung University, Medical Building II, No. 155, Sec. 2, Linong Street, Taipei, 112, Taiwan
- Division of Pediatric Neurosurgery, The Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - I-An Wang
- Center of Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Tan-Wen Hsieh
- Center of Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Jen-Huoy Tsay
- Department of Social Work, National Taiwan University, Taipei, Taiwan
| | - Chuan-Yu Chen
- Institute of Public Health, National Yang Ming Chiao Tung University, Medical Building II, No. 155, Sec. 2, Linong Street, Taipei, 112, Taiwan.
- Center of Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan.
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Crumm CE, Brown ECB, Vora SB, Lowry S, Schlatter A, Rutman LE. The Impact of an Emergency Department Bruising Pathway on Disparities in Child Abuse Evaluation. Pediatr Emerg Care 2023; 39:580-585. [PMID: 37391189 DOI: 10.1097/pec.0000000000002998] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
OBJECTIVES Previous research has shown racial, ethnic, and socioeconomic disparities in provider medical evaluations and reporting to child protective services (CPS) and law enforcement (LE) for cases of suspected child physical abuse. Our hospital standardized evaluation and reporting of high-risk bruising using a clinical pathway. We aimed to assess whether standardization impacted disparity. METHODS We performed a retrospective observational study including children evaluated in the emergency department who had a social work consult for concern for child abuse or neglect between June 2012 and December 2019. From this group, we identified children with high-risk bruising. We compared outcomes (receipt of skeletal survey, CPS report, or LE report) before and after implementation of a standard bruising evaluation pathway to determine how the intervention changed practice among various racial, ethnic, and socioeconomic groups. RESULTS During the study period, 2129 children presented to the ED and received a social work consult for child abuse or neglect. Of these, 333 had high-risk bruising. Children without private insurance had a higher risk of having a CPS (adjusted relative risk, 1.32; 95% confidence interval, 1.09-1.60) or LE (adjusted relative risk, 1.48; 95% confidence interval, 1.11-1.97) report prepathway, but not after pathway implementation. No significant associations were seen for race or ethnicity. CONCLUSIONS A standardized clinical pathway for identification and evaluation of high-risk bruising may help to decrease socioeconomic disparities in reporting high-risk bruising. Larger studies are needed to fully evaluate disparities in assessment and reporting of child abuse.
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Affiliation(s)
| | | | | | - Sarah Lowry
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA
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Elliott LE, Gittelman MA, Kurowski EM, Duma EM, Pomerantz WJ. Impact of standardization on racial and socioeconomic disparities in non-accidental trauma evaluations in infants in a pediatric emergency department. Inj Epidemiol 2023; 10:31. [PMID: 37400912 PMCID: PMC10318634 DOI: 10.1186/s40621-023-00441-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Studies have illustrated racial and socioeconomic disparities in evaluation of non-accidental trauma (NAT). We aimed to investigate how implementation of a standardized NAT guideline in a pediatric emergency department (PED) impacted racial and socioeconomic disparities in NAT evaluation. RESULTS 1199 patients (541 pre- and 658 post-guideline) were included for analysis. Pre-guideline, patients with governmental insurance were more likely than those with commercial insurance to have a social work (SW) consult completed (57.4% vs. 34.7%, p < 0.001) and a Child Protective Services (CPS) report filed (33.4% vs. 13.8%, p < 0.001). Post-guideline, these disparities were still present. There were no differences in race, ethnicity, insurance type, or social deprivation index (SDI) in rates of complete NAT evaluations pre- or post-guideline implementation. Overall adherence to all guideline elements increased from 19.0% before guideline implementation to 53.2% after (p < 0.001). CONCLUSION Implementation of a standardized NAT guideline led to significant increase in complete NAT evaluations. Guideline implementation was not associated with elimination of pre-existing disparities in SW consults or CPS reporting between insurance groups.
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Affiliation(s)
- Laura Even Elliott
- Division of Emergency Medicine, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #1005, Cincinnati, OH 45229 USA
| | - Michael A. Gittelman
- Division of Emergency Medicine, Comprehensive Children’s Injury Center, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #2008, Cincinnati, OH 45229 USA
| | - Eileen M. Kurowski
- Division of Emergency Medicine, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #7014, Cincinnati, OH 45229 USA
| | - Elena M. Duma
- Division of Emergency Medicine, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #2008, Cincinnati, OH 45229 USA
| | - Wendy J. Pomerantz
- Division of Emergency Medicine, Comprehensive Children’s Injury Center, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #2008, Cincinnati, OH 45229 USA
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Milner JD, Hartnett DA, DeFroda SF, Slingsby BA, Silber ZS, Blackburn AZ, Daniels AH, Cruz AI. Orthopedic manifestations of child abuse. Pediatr Res 2022; 92:647-652. [PMID: 34819655 DOI: 10.1038/s41390-021-01850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 11/09/2022]
Abstract
Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness. IMPACT: Child abuse is common in the United States but often remains undetected. Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries. Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.
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Affiliation(s)
- John D Milner
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA.
| | - Davis A Hartnett
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Brett A Slingsby
- Department of Pediatrics, The Lawrence A. Aubin Sr. Child Protection Center, Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Zachary S Silber
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Amy Z Blackburn
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
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Tiyyagura G, Asnes AG, Leventhal JM, Shapiro ED, Auerbach M, Teng W, Powers E, Thomas A, Lindberg DM, McClelland J, Kutryb C, Polzin T, Daughtridge K, Sevin V, Hsiao AL. Development and Validation of a Natural Language Processing Tool to Identify Injuries in Infants Associated With Abuse. Acad Pediatr 2022; 22:981-988. [PMID: 34780997 PMCID: PMC9095755 DOI: 10.1016/j.acap.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Medically minor but clinically important findings associated with physical child abuse, such as bruises in pre-mobile infants, may be identified by frontline clinicians yet the association of these injuries with child abuse is often not recognized, potentially allowing the abuse to continue and even to escalate. An accurate natural language processing (NLP) algorithm to identify high-risk injuries in electronic health record notes could improve detection and awareness of abuse. The objectives were to: 1) develop an NLP algorithm that accurately identifies injuries in infants associated with abuse and 2) determine the accuracy of this algorithm. METHODS An NLP algorithm was designed to identify ten specific injuries known to be associated with physical abuse in infants. Iterative cycles of review identified inaccurate triggers, and coding of the algorithm was adjusted. The optimized NLP algorithm was applied to emergency department (ED) providers' notes on 1344 consecutive sample of infants seen in 9 EDs over 3.5 months. Results were compared with review of the same notes conducted by a trained reviewer blind to the NLP results with discrepancies adjudicated by a child abuse expert. RESULTS Among the 1344 encounters, 41 (3.1%) had one of the high-risk injuries. The NLP algorithm had a sensitivity and specificity of 92.7% (95% confidence interval [CI]: 79.0%-98.1%) and 98.1% (95% CI: 97.1%-98.7%), respectively, and positive and negative predictive values were 60.3% and 99.8%, respectively, for identifying high-risk injuries. CONCLUSIONS An NLP algorithm to identify infants with high-risk injuries in EDs has good accuracy and may be useful to aid clinicians in the identification of infants with injuries associated with child abuse.
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Affiliation(s)
- Gunjan Tiyyagura
- Yale University School of Medicine (G Tiyyagura, AG Asnes, JM Leventhal, ED Shapiro, M Auerbach, W Teng, E Powers, A Thomas, AL Hsiao), New Haven, CT.
| | | | | | | | - Marc Auerbach
- Yale University School of Medicine, New Haven, CT, 06511
| | - Wei Teng
- Yale University School of Medicine, New Haven, CT, 06511
| | - Emily Powers
- Yale University School of Medicine, New Haven, CT, 06511
| | - Amy Thomas
- Yale University School of Medicine, New Haven, CT, 06511
| | | | | | - Carol Kutryb
- 3M
- M*Modal Health Information Systems, Pittsburg, PA 15217
| | - Thomas Polzin
- 3M
- M*Modal Health Information Systems, Pittsburg, PA 15217
| | | | - Virginia Sevin
- 3M
- M*Modal Health Information Systems, Pittsburg, PA 15217
| | - Allen L. Hsiao
- Yale University School of Medicine, New Haven, CT, 06511
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Chaiyachati BH, Wood JN, Carter C, Lindberg DM, Chun TH, Cook LJ, Alpern ER. Emergency Department Child Abuse Evaluations During COVID-19: A Multicenter Study. Pediatrics 2022; 150:e2022056284. [PMID: 35707943 PMCID: PMC10947367 DOI: 10.1542/peds.2022-056284] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The reported impacts of the COVID-19 pandemic on child maltreatment in the United States have been mixed. Encounter trends for child physical abuse within pediatric emergency departments may provide insights. Thus, this study sought to determine the change in the rate of emergency department encounters related to child physical abuse. METHODS A retrospective study within the Pediatric Emergency Care Applied Research Network Registry. Encounters related to child physical abuse were identified by 3 methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or age-restricted skeletal survey completion. The primary outcomes were encounter rates per day and clinical severity before (January 2018-March 2020) and during the COVID-19 pandemic (April 2020-March 2021). Multivariable Poisson regression models were fit to estimate rate ratios with marginal estimation methods. RESULTS Encounter rates decreased significantly during the pandemic for 2 of 3 identification methods. In fully adjusted models, encounter rates were reduced by 19% in the diagnosis-code cohort (adjusted rate ratio: 0.81 [99% confidence interval: 0.75-0.88], P <.001), with the greatest reduction among preschool and school-aged children. Encounter rates decreased 10% in the injury cohort (adjusted rate ratio: 0.90 [confidence interval: 0.82-0.98], P = .002). For all 3 methods, rates for lower-severity encounters were significantly reduced whereas higher-severity encounters were not. CONCLUSIONS Encounter rates for child physical abuse were reduced or unchanged. Reductions were greatest for lower-severity encounters and preschool and school-aged children. This pattern calls for critical assessment to clarify whether pandemic changes led to true reductions versus decreased recognition of child physical abuse.
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Affiliation(s)
- Barbara H. Chaiyachati
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA
- SafePlace: The Center for Child Protection and Health, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Joanne N. Wood
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA
- SafePlace: The Center for Child Protection and Health, Children’s Hospital of Philadelphia, Philadelphia, PA
- PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Camille Carter
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Daniel M. Lindberg
- Department of Emergency Medicine and Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, Denver, CO
| | - Thomas H. Chun
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Hasbro Children’s Hospital, Warren Alpert Medical School of Medicine at Brown University, Providence, RI
| | - Lawrence J. Cook
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Ashraf IJ, Faivus Ackley D, Razawich K, Botash A, Schafer M, Pekarsky A. Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma. Pediatr Qual Saf 2022; 7:e567. [PMID: 35720876 PMCID: PMC9197371 DOI: 10.1097/pq9.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 04/09/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment. Methods Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year. Results After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months. Conclusions Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.
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Affiliation(s)
- Iram J Ashraf
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Danielle Faivus Ackley
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Kristin Razawich
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Ann Botash
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Melissa Schafer
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Alicia Pekarsky
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
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Rasooly IR, Dang K, Nawab US, Shaw KN, Wood JN. Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse. Diagnosis (Berl) 2022; 9:352-358. [PMID: 35475729 DOI: 10.1515/dx-2022-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/21/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis. METHODS We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process. RESULTS The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR). CONCLUSIONS Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning.
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Affiliation(s)
- Irit R Rasooly
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness & PolicyLab, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Khoi Dang
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ursula S Nawab
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathy N Shaw
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness & PolicyLab, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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10
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Henry MK, Schilling S, Shults J, Feudtner C, Katcoff H, Egbe TI, Johnson MA, Andronikou S, Wood JN. Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals. JAMA Netw Open 2022; 5:e225005. [PMID: 35442455 PMCID: PMC9021910 DOI: 10.1001/jamanetworkopen.2022.5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement. OBJECTIVE To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022. EXPOSURES Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital. MAIN OUTCOMES AND MEASURES Use of neuroimaging by CT or MRI. RESULTS Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001). CONCLUSIONS AND RELEVANCE This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.
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Affiliation(s)
- M. Katherine Henry
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samantha Schilling
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Justine Shults
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics, Children's Hospital of Philadelphia
| | - Hannah Katcoff
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Teniola I. Egbe
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell A. Johnson
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joanne N. Wood
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Policy Lab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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11
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Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-021-00221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).
Recent Findings
Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.
Summary
Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.
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12
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Shum M, Asnes AG, Leventhal JM, Gaither JR, Bechtel K, Powers E, Tiyyagura G. The impact of a child abuse guideline on differences between pediatric and community emergency departments in the evaluation of injuries. CHILD ABUSE & NEGLECT 2021; 122:105374. [PMID: 34737120 DOI: 10.1016/j.chiabu.2021.105374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Although child physical abuse is missed more frequently in community (CEDs) vs. pediatric emergency departments (PEDs), little information exists describing how evaluations of high-risk injuries differ between these settings. OBJECTIVES To determine differences in evaluations of infants for abuse between a PED and CEDs and whether a child abuse guideline reduced these differences. PARTICIPANTS AND SETTING Infants presenting to one PED (n = 162) and three CEDs (n = 159) with 3 injury categories: 1) Injuries for which the American Academy of Pediatrics recommends skeletal survey (SS) testing (infants <5-months with an oral injury or bruising, <9-months with a non-skull fracture, and < 12-months with an intracranial hemorrhage); 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries. METHODS We assessed differences in SS testing and child protective services (CPS) reporting between the PED and CEDs before and after implementation of a child abuse guideline. RESULTS The median (IQR) age was 4 months (2-7). Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01-8.10; Category 2: aOR 10.1, CI: 1.2-88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3-26.7; Category 2: aOR 12.0, CI: 1.4-103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category. CONCLUSIONS Implementation of a child abuse guideline minimized differences between a PED and CEDs in the evaluation of infants with injuries concerning for abuse.
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Affiliation(s)
- May Shum
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Andrea G Asnes
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - John M Leventhal
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Julie R Gaither
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Kirsten Bechtel
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Emily Powers
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Gunjan Tiyyagura
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
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13
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Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol 2021; 51:853-860. [PMID: 33999229 DOI: 10.1007/s00247-020-04864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
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Affiliation(s)
- Colleen E Bennett
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Cindy W Christian
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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14
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Rosen NG, Escobar MA, Brown CV, Moore EE, Sava JA, Peck K, Ciesla DJ, Sperry JL, Rizzo AG, Ley EJ, Brasel KJ, Kozar R, Inaba K, Hoffman-Rosenfeld JL, Notrica DM, Sayrs LW, Nickoles T, Letton RW, Falcone RA, Mitchell IC, Martin MJ. Child physical abuse trauma evaluation and management: A Western Trauma Association and Pediatric Trauma Society critical decisions algorithm. J Trauma Acute Care Surg 2021; 90:641-651. [PMID: 33443985 DOI: 10.1097/ta.0000000000003076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Nelson G Rosen
- From the Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (N.G.R., R.A.F.), Cincinnati, Ohio; Department of Surgery, Mary Bridge Children's Hospital (M.A.E.), Tacoma, Washington; Division of Acute Care Surgery, Dell Medical School (C.V.B.), Austin, Texas; Department of Surgery, University of Colorado School of Medicine (E.E.M.), Denver, Colorado; Division of Trauma, MedStar Hospital Center (J.A.S.), Washington, DC; Department of Surgery, Scripps Mercy (K.P.), San Diego, California; Acute Care Surgery Division, Morsani College of Medicine (D.J.C.), Tampa, Florida; Division of Trauma Surgery, University of Pittsburgh (J.L.S.), Pittsburgh, Pennsylvania; Department of Surgery, Inova Trauma Center (A.G.R.), Falls Church, Virginia; Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health/Science University (K.J.B.), Portland, Oregon; Department of Surgery, University of Maryland School of Medicine (R.K.), Baltimore, Maryland; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Keck School of Medicine (K.I.), Los Angeles, California; Department of Pediatrics, Albert Einstein College of Medicine (J.L.H.-R.), Bronx, New York; Division of Pediatric Surgery, Phoenix Children's Hospital (D.M.N., L.W.S., T.N.), Phoenix, Arizona; Department of Surgery, Nemours Children's Specialty Care (R.W.L.), Jacksonville, Florida; Departments of Surgery, UT Health San Antonio and Baylor College of Medicine (I.C.M.), San Antonio, Texas; and the Department of Surgery, Scripps Mercy Hospital (M.J.M.), San Diego, California
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15
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Shum M, Asnes A, Leventhal JM, Bechtel K, Gaither JR, Tiyyagura G. The Use of Experts to Evaluate a Child Abuse Guideline in Community Emergency Departments. Acad Pediatr 2021; 21:521-528. [PMID: 33160081 DOI: 10.1016/j.acap.2020.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/25/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Guidelines and pathways exist to help frontline providers evaluate injured children for suspected child abuse. Little, however, is known about whether the decision-making resulting from these interventions is correct. Therefore, in the absence of an available gold-standard test, we used experts' judgments to examine the appropriateness of these clinical decisions. We evaluated community emergency department (ED) providers' adherence to a guideline recommending a child protection team (CPT) consultation for infants with injuries associated with abuse. We then compared providers' decision-making to experts' recommendations before and after guideline implementation. METHODS Two experts conducted a blinded, retrospective review of injured infants from 3 community EDs (N = 175). Experts rated the likelihood that an injury was abusive, indeterminate, or accidental, and made recommendations that were compared with skeletal survey (SS) testing and child protective services (CPS) reporting by providers before and after guideline implementation. RESULTS Postguideline implementation, there was a significant increase in CPT consultations in indeterminate cases (14.3% vs 72.2%, P < .001) and in SS testing when experts recommended SS (20.6% vs 56.8%, P = .002). In contrast, a higher percentage of cases for whom the experts did not recommend reporting were reported to CPS (1.8% vs 14.6%, P = .02). CONCLUSIONS Providers consulted the CPT most often for indeterminate cases. SS testing was in line with expert recommendations, but CPS reporting diverged from expert recommendations. Interventions linking community ED providers with a CPT may improve the evaluation of infants with injuries concerning for abuse.
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Affiliation(s)
- May Shum
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Andrea Asnes
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - John M Leventhal
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Kirsten Bechtel
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Julie R Gaither
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Gunjan Tiyyagura
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn.
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16
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Tiyyagura G, Emerson B, Gaither JR, Bechtel K, Leventhal JM, Becker H, Della Guistina K, Balga T, Mackenzie B, Shum M, Shapiro ED, Auerbach MA, McVaney C, Morrell P, Asnes AG. Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments. Acad Emerg Med 2021; 28:70-81. [PMID: 32931628 DOI: 10.1111/acem.14132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/20/2020] [Accepted: 09/06/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children < 12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12 months. METHODS We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan-do-study-act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children < 1 year old with high-risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). RESULTS Evidence of special cause was identified beginning in June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8-month period, the CPT was consulted for a mean of 47.5% of children with high-risk injuries; this was sustained for an additional 7 months. The average percentage of infants with high-risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. CONCLUSION Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high-risk injuries. Such interventions may improve recognition of physical abuse.
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Affiliation(s)
- Gunjan Tiyyagura
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Beth Emerson
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Julie R. Gaither
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Kirsten Bechtel
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - John M. Leventhal
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Heather Becker
- the Department of Emergency Medicine Bridgeport Hospital Bridgeport CTUSA
| | | | - Thomas Balga
- and the Department of Emergency Medicine Yale New Haven Hospital New Haven CT USA
| | - Bonnie Mackenzie
- and the Department of Emergency Medicine Lawrence and Memorial Hospital Norwich CTUSA
| | - May Shum
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Eugene D. Shapiro
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Marc A. Auerbach
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Caitlin McVaney
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Patricia Morrell
- and the Department of Surgery Yale New Haven Hospital New Haven CT USA
| | - Andrea G. Asnes
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
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17
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Fortin K, Wood JN. Utility of screening urinalysis to detect abdominal injuries in suspected victims of child physical abuse. CHILD ABUSE & NEGLECT 2020; 109:104714. [PMID: 32979848 DOI: 10.1016/j.chiabu.2020.104714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Urinalysis, liver enzymes (LE) and lipase are used to screen for abdominal injuries in children with suspected physical abuse (SPA). However, data on the utility of urinalysis is limited. OBJECTIVES Describe the prevalence of hematuria in evaluations for SPA. Determine test characteristics of hematuria, LE and lipase to identify kidney and other abdominal injuries among children with SPA. PARTICIPANTS AND SETTING Children < 7 years receiving a urinalysis during evaluation for SPA by a hospital child protection team. METHODS Demographic, clinical, and laboratory data including presence of hematuria (blood on urine dipstick), elevated LE (> 80 U/L) and elevated lipase (> 100 U/L) were abstracted retrospectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the overall study population and for patients without abdominal symptoms. RESULTS Ten percent of patients had hematuria (N = 237). Prevalence of abdominal and kidney injuries was 7 % and 1 % respectively. Of 3 patients with kidney injury, 2 had hematuria and all had elevated LE. Sensitivity (67 %) and NPV (99 %) of hematuria to detect kidney injuries were lower than LE and the same as lipase. Specificity (91 %) and PPV (8%) of hematuria to detect kidney injury were greater than LE and similar to lipase. Sensitivity of hematuria to detect any abdominal injury (50 %) was lower than LE (81 %). Sensitivity of hematuria to detect occult abdominal injury was 0 %. CONCLUSIONS Hematuria alone did not lead to detection of kidney injury. Test characteristics of hematuria were largely similar or inferior to LE and lipase.
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Affiliation(s)
- Kristine Fortin
- Perelman School of Medicine at the University of Pennsylvania, Division of General Pediatrics, Children's Hospital of Philadelphia, United States.
| | - Joanne N Wood
- Perelman School of Medicine at the University of Pennsylvania, Division of General Pediatrics, Children's Hospital of Philadelphia, United States; Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, United States
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