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Lorenzo M, Cory E, Cho R, Pusic M, Fish J, Adelgais KM, Boutis K. Deliberate Practice as an Effective Method for Reducing Diagnostic Error in Identifying Burn and Bruise Injuries Suspicious for an Abusive Injury. J Pediatr 2024; 274:114183. [PMID: 38964439 DOI: 10.1016/j.jpeds.2024.114183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE To examine the effectiveness of an education intervention for reducing physician diagnostic error in identifying pediatric burn and bruise injuries suspicious for abuse, and to determine case-specific variables associated with an increased risk of diagnostic error. STUDY DESIGN This was a multicenter, prospective, cross-sectional study. A convenience sample of pediatricians and other front-line physicians who treat acutely injured children in the United States and Canada were eligible for participation. Using a web-based education and assessment platform, physicians deliberately practiced with a spectrum of 300 pediatric burn and bruise injury image-based cases. Participants were asked if there was a suspicion for abuse present or absent, were given corrective feedback after every case, and received summative diagnostic performance overall (accuracy), suspicion for abuse present (sensitivity), and absent (specificity). RESULTS Of the 93/137 (67.9%) physicians who completed all 300 cases, there was a significant reduction in diagnostic error (initial 16.7%, final 1.6%; delta -15.1%; 95% CI -13.5, -16.7), sensitivity error (initial 11.9%, final 0.7%; delta -11.2%; 95% CI -9.8, -12.5), and specificity error (initial 23.3%, final 6.6%; delta -16.7%; 95% CI -14.8, -18.6). Based on 35 627 case interpretations, variables associated with diagnostic error included patient age, sex, skin color, mechanism of injury, and size and pattern of injury. CONCLUSIONS The education intervention substantially reduced diagnostic error in differentiating the presence vs absence of a suspicion for abuse in children with burn and bruise injuries. Several case-based variables were associated with diagnostic error, and these data can be used to close specific skill gaps in this clinical domain.
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Affiliation(s)
- Melissa Lorenzo
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Emma Cory
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Romy Cho
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Martin Pusic
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard University, Boston, MA
| | - Joel Fish
- Division of Plastic Surgery, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Kathy Boutis
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada.
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Abdoo DC, Puls HT, Hall M, Lindberg DM, Anderst J, Wood JN, Parikh K, Tashijan M, Sills MR. Racial and ethnic disparities in diagnostic imaging for child physical abuse. CHILD ABUSE & NEGLECT 2024; 149:106648. [PMID: 38262182 DOI: 10.1016/j.chiabu.2024.106648] [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: 10/08/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Abstract
IMPORTANCE Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.
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Affiliation(s)
- Denise C Abdoo
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, United States of America.
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri- Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Matt Hall
- Children's Hospital Association, United States of America
| | - Daniel M Lindberg
- University of Colorado Anschutz Medical Campus, Department of Emergency Medicine, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, United States of America
| | - James Anderst
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri- Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Joanne N Wood
- Division of General Pediatrics, PolicyLab and Clinical Futures, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States of America
| | | | - Margaret Tashijan
- University of Colorado School of Medicine, Children's Hospital Colorado, United States of America
| | - Marion R Sills
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, United States of America
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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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Harding-Bremner M. Overcoming barriers to recognizing and reporting child abuse. JAAPA 2024; 37:22-27. [PMID: 38051825 DOI: 10.1097/01.jaa.0000995632.31241.e3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
ABSTRACT Infants and children under age 3 years have the highest risk of dying from child abuse and neglect. Clinicians treating children must recognize and report child abuse. Barriers to consistent recognition and reporting leave children in harm's way. Often, the signs of abuse in very young children are subtle, and clinicians may fail to recognize and report these signs. Clinicians also must understand the role of bias in the reporting of child abuse and ways to address abuse individually and as part of a larger system.
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Affiliation(s)
- Meredith Harding-Bremner
- Meredith Harding-Bremner works for AdventHealth Hendersonville (N.C.), providing medical services for children at Safelight Child Advocacy Center. The author has disclosed no potential conflicts of interest, financial or otherwise
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Alpert AB, Sayegh SJ, Strawderman M, Cunliffe S, Griggs JJ, Cerulli C. Methodologic Approaches for Using Electronic Medical Records to Identify Experiences of Violence in Transgender and Cisgender People: Closing the Gap Between Diagnostic Coding and Lived Experiences. Med Care 2023; 61:384-391. [PMID: 37072686 PMCID: PMC10168107 DOI: 10.1097/mlr.0000000000001852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Transgender people experience extreme rates of violence and the electronic medical record (EMR) remains a mostly untapped resource to study the medical sequelae of such experiences. OBJECTIVES To develop and test a method for identifying experiences of violence using EMR data. RESEARCH DESIGN Cross-sectional study utilizing EMR data. PEOPLE Transgender and cisgender people seen at a regional referral center in Upstate New York. MEASURES We tested the utility of keyword searches and structured data queries to identify specific types of violence at various ages and in various contexts among cohorts of transgender and cisgender people. We compared the effectiveness of keyword searches to diagnosis codes and a screening question, "Are you safe at home?" using McNemar's test. We compared the prevalence of various types of violence between transgender and cisgender cohorts using the χ 2 test of independence. RESULTS Of the transgender cohort, 47% had experienced some type of violence versus 14% of the cisgender cohort (χ 2P value <0.001). Keywords were significantly more effective than structured data at identifying violence among both cohorts (McNemar P values all <0.05). CONCLUSIONS Transgender people experience extreme amounts of violence throughout their lives, which is better identified and studied using keyword searches than structured EMR data. Policies are urgently needed to stop violence against transgender people. Interventions are also needed to ensure safe documentation of violence in EMRs to improve care across settings and aid research to develop and implement effective interventions.
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Affiliation(s)
- Ash Blythe Alpert
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Public Health Sciences, University of Rochester Medical Center
| | | | - Myla Strawderman
- Division of Hematology and Medical Oncology, Department of Medicine, Wilmot Cancer Institute
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Scott Cunliffe
- Division of Hematology and Medical Oncology, Department of Medicine, Wilmot Cancer Institute
| | - Jennifer J Griggs
- Division of Hematology and Oncology, Department of Internal Medicine
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Catherine Cerulli
- Department of Psychiatry, University of Rochester Medical Center
- The Susan B. Anthony Center, Rochester, NY
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Heyming T, Knudsen-Robbins C, Sharma S, Thackeray J, Schomberg J, Lara B, Wickens M, Wong D. Child physical abuse screening in a pediatric ED; Does TRAIN(ing) Help? BMC Pediatr 2023; 23:117. [PMID: 36894913 PMCID: PMC9998251 DOI: 10.1186/s12887-023-03927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/21/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Child maltreatment is distressingly prevalent yet remains under-recognized by healthcare providers. In 2015 the Ohio Children's Hospital Association developed the Timely Recognition of Abusive INjuries (TRAIN) collaborative in an effort to promote child physical abuse (CPA) screening. Our institution implemented the TRAIN initiative in 2019. The objective of this study was to examine the effects of the TRAIN initiative at this institution. METHODS In this retrospective chart review we recorded the incidence of sentinel injuries (SIS) in children presenting to the Emergency Department (ED) of an independent level 2 pediatric trauma center. SIS were defined and identified by a diagnosis of ecchymosis, contusion, fracture, head injury, intracranial hemorrhage, abdominal trauma, open wound, laceration, abrasion, oropharyngeal injury, genital injury, intoxication, or burn in a child < 6.01 months of age. Patients were stratified into pre-TRAIN (PRE), 1/2017-9/2018, or post-TRAIN (POST), 10/2019-7/2020, periods. Repeat injury was defined as a subsequent visit for any of the previously mentioned diagnoses within 12 months of the initial visit. Demographics/visit characteristics were analyzed using Chi square analysis, Fischer's exact test, and student's paired t-test. RESULTS In the PRE period, 12,812 ED visits were made by children < 6.01 months old; 2.8% of these visits were made by patients with SIS. In the POST period there were 5,372 ED visits, 2.6% involved SIS (p = .4). The rate of skeletal surveys performed on patients with SIS increased from 17.1% in the PRE period to 27.2% in the POST period (p = .01). The positivity rate of skeletal surveys in the PRE versus POST period was 18.9% and 26.3% respectively (p = .45). Repeat injury rates did not differ significantly in patients with SIS pre- versus post-TRAIN (p = .44). CONCLUSION Implementation of TRAIN at this institution appears to be associated with increased skeletal survey rates.
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Affiliation(s)
- Theodore Heyming
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA. .,Department of Emergency Medicine, University of California, Irvine, 3800 W. Chapman Ave, Suite 3200, Orange, CA, 92868, USA.
| | - Chloe Knudsen-Robbins
- University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Supriya Sharma
- Division of General Pediatrics, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90502, USA
| | - Jonathan Thackeray
- Department of Pediatrics, Dayton Children's Hospital, 1 Childrens Plaza, Dayton, OH, 45404, USA
| | - John Schomberg
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
| | - Bryan Lara
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
| | - Maxwell Wickens
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
| | - Daphne Wong
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
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Clinical Decision Support for Child Abuse: Recommendations from a Consensus Conference. J Pediatr 2023; 252:213-218.e5. [PMID: 35817134 DOI: 10.1016/j.jpeds.2022.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/22/2022]
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Brink FW, Lo CB, Shi J, Stanley R, Lindberg DM. Diagnosis codes dramatically underestimate the burden of abuse. CHILD ABUSE & NEGLECT 2023; 135:105986. [PMID: 36516562 DOI: 10.1016/j.chiabu.2022.105986] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/28/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND International Classification of Diseases (ICD) billing codes are not well-suited to estimate physical abuse prevalence among hospitalized patients and may be even less accurate in emergency departments (EDs). The Centers for Disease Control and Prevention (CDC) has recently published a child abuse and neglect syndromic surveillance definition to more accurately examine national abuse trends among ED visits. OBJECTIVE To retrospectively apply the CDC syndromic definition to a population of physically abused children and determine its sensitivity for abuse in an ED and at hospital discharge. PARTICIPANTS AND SETTING All physically abused children <5 years seen in the ED and evaluated by the child protection team from 2016 to 2020 at a large Midwestern children's hospital. METHODS Retrospective cross-sectional study utilizing the hospital's child protection team administrative database, the Pediatric Health Information System and the electronic health record to identify the study sample, chief complaint, and abuse-specific codes assigned in the ED and at hospital discharge. Abuse-specific codes were defined as all ICD-10-CM and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) codes included in the CDC syndromic definition, which was applied to the sample and its sensitivity determined. RESULTS Among the 550 abused patients identified, most were male (58.4 %), white (65.1 %), <2 years old (80.4 %), and had public insurance (81.6 %). When applying the CDC syndromic definition, only 11.6 % were identified as abused in the ED and 65.3 % were identified at hospital discharge. CONCLUSIONS The CDC syndrome surveillance definition lacks sensitivity in identifying abuse in the ED or at hospital discharge.
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Affiliation(s)
- Farah W Brink
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, United States of America; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States of America.
| | - Charmaine B Lo
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43215, United States of America
| | - Junxin Shi
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43215, United States of America
| | - Rachel Stanley
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, United States of America; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States of America; The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43215, United States of America
| | - Daniel M Lindberg
- Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, United States of America; University of Colorado Denver, Anschutz Medical Campus, 1380 Lawrence Street 80204, Denver, CO 80204, United States of America
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Liu Y, Shepherd-Banigan M, Evans KE, Stilwell L, Terrell L, Hurst JH, Gifford EJ. Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample? CHILD ABUSE & NEGLECT 2022; 134:105938. [PMID: 36330904 PMCID: PMC11025450 DOI: 10.1016/j.chiabu.2022.105938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/16/2022] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic. OBJECTIVE To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three. PARTICIPANTS AND SETTING Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231). METHODS We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed. RESULTS Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3). CONCLUSION This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.
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Affiliation(s)
- Yuerong Liu
- Center for Child and Family Policy, Duke University, Durham, NC, United States of America; Sanford School of Public Policy, Duke University, Durham, NC, United States of America.
| | - Megan Shepherd-Banigan
- Margolis Center for Health Policy, Duke University, Durham, NC, United States of America; Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States of America; Durham VA Healthcare System, Durham, NC, United States of America
| | - Kelly E Evans
- Center for Child and Family Policy, Duke University, Durham, NC, United States of America; Sanford School of Public Policy, Duke University, Durham, NC, United States of America
| | - Laura Stilwell
- Sanford School of Public Policy, Duke University, Durham, NC, United States of America; School of Medicine, Duke University, Durham, NC, United States of America
| | - Lindsay Terrell
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, United States of America; Department of Pediatrics, Duke Children's Primary Care, Duke University Medical Center, Durham, NC, United States of America
| | - Jillian H Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University, Durham, NC, United States of America; Children's Health and Discovery Initiative, Duke University, Durham, NC, United States of America
| | - Elizabeth J Gifford
- Center for Child and Family Policy, Duke University, Durham, NC, United States of America; Sanford School of Public Policy, Duke University, Durham, NC, United States of America; Margolis Center for Health Policy, Duke University, Durham, NC, United States of America; Department of Pediatrics, School of Medicine, Duke University, Durham, NC, United States of America; Children's Health and Discovery Initiative, Duke University, Durham, NC, United States of America
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Stilwell L, Golonka M, Ankoma-Sey K, Yancy M, Kaplan S, Terrell L, Gifford EJ. Electronic Health Record Tools to Identify Child Maltreatment: Scoping Literature Review and Key Informant Interviews. Acad Pediatr 2022; 22:718-728. [PMID: 35131505 PMCID: PMC9262814 DOI: 10.1016/j.acap.2022.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 01/06/2022] [Accepted: 01/29/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake. METHODS We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics. RESULTS Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation. CONCLUSIONS Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.
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Affiliation(s)
- Laura Stilwell
- Duke University School of Medicine (L Stilwell, S Kaplan), Durham, NC; Sanford School of Public Policy (L Stilwell, E Gifford), Durham, NC
| | - Megan Golonka
- Center for Child and Family Policy (M Golonka, E Gifford), Durham, NC; Department of Psychology and Neuroscience (M Golonka), Center for the Study of Adolescent Risk and Resilience, Duke University, Durham, NC.
| | | | | | - Samantha Kaplan
- Duke University School of Medicine (L Stilwell, S Kaplan), Durham, NC
| | | | - Elizabeth J Gifford
- Sanford School of Public Policy (L Stilwell, E Gifford), Durham, NC; Center for Child and Family Policy (M Golonka, E Gifford), Durham, NC; Duke Department of Pediatrics (L Terrell), Durham, NC
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Rebbe R, Mienko JA, Martinson ML. Reports and Removals of Child Maltreatment-Related Hospitalizations: A Population-Based Study. CHILD MALTREATMENT 2022; 27:235-245. [PMID: 33375836 PMCID: PMC11326083 DOI: 10.1177/1077559520984549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Despite U.S. child protective services (CPS) agencies relying on mandated reporters to refer concerns of child maltreatment to them, there is little data regarding which children mandated reporters decide to report and not to report. This study addresses this gap by utilizing a population-based linked administrative dataset to identify which children who are hospitalized for maltreatment-related reasons are reported to CPS and which are removed by CPS. The dataset was comprised of all children born in Washington State between 1999 and 2013 (N = 1,271,416), all hospitalizations for children under the age of three, and all CPS records. We identified maltreatment-related hospitalizations using standardized diagnostic codes. We examined the records for children with maltreatment-related hospitalizations to identify hospitalization-related CPS reports and if the child was removed from their parents. We tested for differences in these system responses using multinomial regression. About two-thirds of children identified as experiencing a child maltreatment-related hospitalization were not reported to CPS. We found differences in responses by maltreatment subtype and the type of diagnostic code. Children whose hospitalizations were related to abuse and associated with a specific maltreatment code had increased odds of being both reported to CPS and subsequently removed by CPS.
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Affiliation(s)
- Rebecca Rebbe
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Joseph A Mienko
- Center for Social Sector Analytics & Technology, School of Social Work, University of Washington, Seattle, WA, USA
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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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13
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Suglia SF, Cammack AL, Sharperson C, Brown J, Martins SS. National Trends in Emergency Department Visits for Child Maltreatment, 2007-2014. Pediatr Emerg Care 2022; 38:153-156. [PMID: 34910419 PMCID: PMC9347219 DOI: 10.1097/pec.0000000000002533] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To understand the prevalence of child maltreatment-related emergency department (ED) visits in the United States, we examined data from the 2007 to 2014 Nationwide Emergency Department Sample. METHODS Based on existing literature, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) ED discharge codes for children less than 10 years of age were characterized as specified child maltreatment, defined as visits with an explicit maltreatment ICD-9 CM or external causes of injury codes. The prevalence of child maltreatment visits per 100,000 children in the United States (based on Center for Disease Control Wide-ranging ONline Data for Epidemiologic Research estimates) overall and by sociodemographic factors was examined, and tests for trends over time were evaluated with Cochran-Armitage tests. Analyses were conducted in 2019. RESULTS The prevalence of child maltreatment based in ICD-9 CM discharge codes ED visits dropped from 69.2 visits per 100,000 in 2007 to 65.9 visits per 100,000 in 2014; this trend was statistically significant. The prevalence was lowest in 2010 (60.1 visits per 100,000 children). There were increases observed for some demographic groups in this period. Throughout the 8-year period examined, the prevalence of child maltreatment visits was highest for physical abuse compared with other forms of maltreatment, higher for boys compared with girls; highest for children younger than 1 year, and higher for children living in neighborhoods with the lowest median income compared with children in higher-income neighborhoods. CONCLUSIONS The Nationwide Emergency Department Sample data set is a valuable surveillance tool for examining trends in child maltreatment. Future studies should explore what factors may explain variations in child maltreatment over time to best develop prevention strategies.
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Affiliation(s)
- Shakira F Suglia
- From the Department of Epidemiology, Rollins School of Public Health
| | - Alison L Cammack
- From the Department of Epidemiology, Rollins School of Public Health
| | | | - Jocelyn Brown
- Department of Pediatrics, Columbia University Medical Center
| | - Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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14
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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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15
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Mandadi AR, Dully K, Brailsford J, Wylie T, Morrissey TK, Hendry P, Gautam S, Fishe JN. A national survey of pediatric emergency medicine physicians on improving education in child maltreatment recognition and reporting child abuse & neglect. CHILD ABUSE & NEGLECT 2021; 122:105324. [PMID: 34547715 DOI: 10.1016/j.chiabu.2021.105324] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Child maltreatment is an important public health problem with serious consequences. Even in the face of increased research and enhanced public awareness over the last decade, the rate of child fatalities due to reported child maltreatment has increased. OBJECTIVE This study describes pediatric emergency medicine (PEM) physicians' knowledge, training, confidence, and barriers in recognition and reporting suspected child maltreatment. PARTICIPANTS AND SETTING A nationally representative sample of PEM physician members of Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) participated. METHODS A cross-sectional 36-item survey study of PEM physicians with content domains including provider knowledge, preparedness, confidence, and barriers to identifying and reporting child maltreatment was conducted and distributed. RESULTS 113 of 486 members completed the survey. Confidence with recognizing and reporting child abuse (95%) was greater than in child neglect (88%). Knowledge in child maltreatment recognition and reporting was significantly correlated with confidence in reporting and recognition (p < 0.001). There was a significant relationship between knowledge and confidence for respondents from states with training in child maltreatment recognition and reporting requirement as a condition of licensure and re-licensure compared to states without the requirement (p < 0.01). Qualitative responses revealed insightful themes to improve child maltreatment training, recognition and reporting. CONCLUSION Our national survey study demonstrates that PEM-trained physicians have high confidence and knowledge with the management of child maltreatment, and that inclusion of mandated child maltreatment training in residency/fellowship and mandated training for medical licensure in all states could improve child maltreatment recognition and reporting.
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Affiliation(s)
- Akhila R Mandadi
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America.
| | - Kathleen Dully
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, United States of America
| | - Jennifer Brailsford
- Department of Research, University of Florida College of Medicine, Jacksonville, United States of America
| | - Todd Wylie
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Thomas K Morrissey
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
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16
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Blangis F, Allali S, Cohen JF, Vabres N, Adamsbaum C, Rey-Salmon C, Werner A, Refes Y, Adnot P, Gras-Le Guen C, Launay E, Chalumeau M. Variations in Guidelines for Diagnosis of Child Physical Abuse in High-Income Countries: A Systematic Review. JAMA Netw Open 2021; 4:e2129068. [PMID: 34787659 PMCID: PMC8600386 DOI: 10.1001/jamanetworkopen.2021.29068] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/04/2021] [Indexed: 01/08/2023] Open
Abstract
Importance The highly variable practices observed regarding the early detection and diagnostic workup of suspected child physical abuse contribute to suboptimal care and could be partially related to discrepancies in clinical guidelines. Objective To systematically evaluate the completeness, clarity, and consistency of guidelines for child physical abuse in high-income countries. Evidence Review For this systematic review, national or regional guidelines that were disseminated from 2010 to 2020 related to the early detection and diagnostic workup of child physical abuse in infants aged 2 years or younger by academic societies or health agencies in high-income countries were retrieved. The definitions of sentinel injuries and the recommended diagnostic workup (imaging and laboratory tests) for child physical abuse were compared. Data were analyzed from July 2020 to February 2021. Findings Within the 20 included guidelines issued in 15 countries, 168 of 408 expected statements (41%) were missing and 10 statements (4%) were unclear. Among 16 guidelines characterizing sentinel injuries, all of them included skin injuries, such as bruises, hematoma, or burns, but only 8 guidelines (50%) included intraoral injuries and fractures. All 20 guidelines agreed on the indication for radiological skeletal survey, head computed tomography, and head magnetic resonance imaging but differed for those of bone scintigraphy, follow-up skeletal survey, spinal magnetic resonance imaging, cranial ultrasonography, chest computed tomography, and abdominal ultrasonography and computed tomography. Additionally, 16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. Conclusions and Relevance These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues. These results may help identify priorities for well-designed original diagnostic accuracy studies, systematic reviews, or an international consensus process to produce clear and standardized guidelines to optimize practices and infant outcomes.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Slimane Allali
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Nathalie Vabres
- Unité d’Accueil des Enfants en Danger, Nantes University Hospital, F-44000, Nantes, France
| | - Catherine Adamsbaum
- Department of Pediatric Radiology, AP-HP, Bicêtre Hospital, F-94270, Le Kremlin Bicêtre, France
| | - Caroline Rey-Salmon
- Pediatrics and Forensic Unit, AP-HP, Hôtel-Dieu Hospital, F-75004, Paris, France
| | - Andreas Werner
- AFPA, Association Française de Pédiatrie Ambulatoire, F-30400, Villeneuve les Avignons, France
| | - Yacine Refes
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
| | - Pauline Adnot
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
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17
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Apfeld JC, Crichton KG, Minneci PC, Puls HT, Cooper JN. Identification of physical abuse-related hospitalizations in young children: Impact of the transition to ICD-10-CM coding. CHILD ABUSE & NEGLECT 2021; 118:105159. [PMID: 34147940 PMCID: PMC8292224 DOI: 10.1016/j.chiabu.2021.105159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Administrative healthcare databases are frequently used for child physical abuse (CPA)-related research and surveillance. In October 2015, the United States transitioned to the International Classification of Diseases, Clinical Modification-10th Revision (ICD-10-CM) coding regimen. ICD-10-CM expands coding related to CPA, including codes to differentiate suspected from confirmed CPA. OBJECTIVE This study examined the impact of the transition to ICD-10-CM coding on population-level trends in rates of hospitalizations coded for CPA. PARTICIPANTS AND SETTINGS Hospitalizations coded as related to CPA in children <5 years-of-age from 2010 to 2017 were identified across 19 Statewide Inpatient Databases. METHODS Interrupted time series analyses were used to assess the impact of the coding transition on hospitalizations coded for CPA, overall and by child race/ethnicity. RESULTS Of 9715 hospitalizations coded for CPA, 2797 (29%) occurred after the coding transition, including 51% coded for suspected CPA and 49% coded for confirmed CPA. There was a marginally-significant increase in the trend in CPA-related hospitalization after the coding transition among all children (0.09 per 100,000 children-per-quarter, p = 0.06), a significant increase in the trend among white children (0.15 per 100,000 children-per-quarter, p = 0.01), and no change among Black or Hispanic children. After the coding transition, hospitalizations coded for suspected CPA increased significantly overall (0.10 per 100,000 children-per-quarter, p < 0.001), and in particular among white children (0.12 per 100,000 children-per-quarter, p = 0.01) but not among Black or Hispanic children. CONCLUSIONS The transition to ICD-10-CM differentially impacted trends in hospitalizations coded for CPA by child race/ethnicity. Further research is necessary to discern the reasons for these discrepancies.
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Affiliation(s)
- Jordan C Apfeld
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus 43205, OH, USA.
| | - Kristin G Crichton
- Division of Child and Family Advocacy, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus 43205, OH, USA.
| | - Peter C Minneci
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus 43205, OH, USA; Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus 43205, OH, USA.
| | - Henry T Puls
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City 64108, MO, USA.
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus 43205, OH, USA.
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18
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Sharma S, Wong D, Schomberg J, Knudsen-Robbins C, Gibbs D, Berkowitz C, Heyming T. COVID-19: Differences in sentinel injury and child abuse reporting during a pandemic. CHILD ABUSE & NEGLECT 2021; 116:104990. [PMID: 33707071 PMCID: PMC8446928 DOI: 10.1016/j.chiabu.2021.104990] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/21/2021] [Accepted: 02/02/2021] [Indexed: 05/16/2023]
Abstract
BACKGROUND AND OBJECTIVES There is widespread concern that the COVID-19 pandemic has increased the incidence of child maltreatment. However, reports in the scientific literature documenting rates of child maltreatment during this period are scarce. This study was designed to explore whether the incidence of child maltreatment among patients presenting to a pediatric emergency department has increased during the COVID-19 pandemic. METHODS We conducted a retrospective review of patients of all ages presenting to a pediatric Emergency Department trauma center, who also had a child abuse report filing or a sentinel injury diagnosis related to their index visit. All such patients who presented to this institution from March through July of 2017 through 2020 were included in the study. RESULTS Analysis demonstrated an increase in the incidence of child maltreatment in May and June of 2020 and that there was an overall shift in distribution of types of child maltreatment during the COVID-19 pandemic. There was a significant increase in the proportion of emotional/psychological abuse (2.52 % before the pandemic to 7.00 % during the pandemic, p ≤ 0.0001) and non-medical neglect (31.5%-40.0%, p ≤ 0.0001). CONCLUSIONS We observed an increase in specific types of child maltreatment during the COVID-19 pandemic. These findings highlight the need for increased attention to children at risk for child abuse and neglect.
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Affiliation(s)
| | - Daphne Wong
- Children's Health of Orange County, Orange, CA, United States
| | - John Schomberg
- Children's Health of Orange County, Orange, CA, United States
| | | | - David Gibbs
- Children's Health of Orange County, Orange, CA, United States
| | | | - Theodore Heyming
- Children's Health of Orange County, Orange, CA, United States; Emergency Department, University of California, Irvine, United States.
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19
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Blangis F, Taylor M, Adamsbaum C, Devillers A, Gras-Le Guen C, Launay E, Bossuyt PM, Cohen JF, Chalumeau M. Add-on bone scintigraphy after negative radiological skeletal survey for the diagnosis of skeletal injury in children suspected of physical abuse: a systematic review and meta-analysis. Arch Dis Child 2021; 106:361-366. [PMID: 32998873 DOI: 10.1136/archdischild-2020-319065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/11/2020] [Accepted: 08/27/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To systematically assess the extent to which bone scintigraphy (BS) could improve the detection rate of skeletal injury in children suspected of physical abuse with an initial negative radiological skeletal survey (RSS). STUDY DESIGN We searched MEDLINE and Web of Science for series of ≥20 children suspected of physical abuse who underwent RSS and add-on BS. We assessed the risk of bias and the heterogeneity and performed random-effects meta-analyses. RESULTS After screening 1140 unique search results, we reviewed 51 full-text articles, and included 7 studies (783 children, mostly ≤3 years old). All studies were of either high or unclear risk of bias. Substantial heterogeneity was observed in meta-analyses. The summary detection rate of skeletal injury with RSS alone was 52% (95% CI 37 to 68). The summary absolute increase in detection rate with add-on BS was 10 percentage points (95% CI 6 to 15); the summary relative detection rate was 1.19 (95% CI 1.13 to 1.25); the summary number of children with a negative RSS who needed to undergo a BS to detect one additional child with skeletal injury (number needed to test) was 3 (95% CI 2 to 7). CONCLUSIONS From the available evidence, add-on BS in young children suspected of physical abuse with a negative RSS might allow for a clinically significant improvement of the detection rate of children with skeletal injury, for a limited number of BS procedures required. The quality of the reviewed evidence was low, pointing to the need for high-quality studies in this field.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France .,Inserm CIC 1413, Nantes University Hospital, F-44000 Nantes, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
| | - Melissa Taylor
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
| | - Catherine Adamsbaum
- Department of Pediatric Radiology, AP-HP, Bicêtre hospital, F-94270 Le Kremlin Bicêtre, France
| | - Anne Devillers
- Department of Nuclear Medicine, Centre Eugène Marquis, F-35000 Rennes, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Inserm CIC 1413, Nantes University Hospital, F-44000 Nantes, France.,Department of Pediatric Emergency Care, Nantes University Hospital, F-44000 Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Inserm CIC 1413, Nantes University Hospital, F-44000 Nantes, France.,Department of Pediatric Emergency Care, Nantes University Hospital, F-44000 Nantes, France
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, University of Amsterdam, Amsterdam, The Netherlands
| | - Jérémie F Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
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20
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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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21
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Rowland J, Fouchia D, Favot M. Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma. Clin Pract Cases Emerg Med 2020; 4:485-486. [PMID: 32926724 PMCID: PMC7434235 DOI: 10.5811/cpcem.2020.6.48207] [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: 05/14/2020] [Accepted: 06/17/2020] [Indexed: 11/11/2022] Open
Abstract
Case Presentation: An eight-week-old infant presented to the emergency department in cardiac arrest. Return of spontaneous circulation was obtained and the patient subsequently began seizing. Point-of-care ultrasound of the anterior fontanelle revealed an extra-axial fluid collection consistent with subdural hematoma (SDH).
Discussion: Abusive head trauma is still frequently missed on initial presentation. In addition to validated screening clinical prediction rules, point-of-care cranial ultrasound can be used as a noninvasive adjunct for detection of SDH related to abusive head trauma in infants with an open fontanelle.
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Affiliation(s)
- Jonathan Rowland
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| | - Dean Fouchia
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| | - Mark Favot
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
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22
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Hunter AA, Livingston N, DiVietro S, Schwab Reese L, Bentivegna K, Bernstein B. Child maltreatment surveillance following the ICD-10-CM transition, 2016-2018. Inj Prev 2020; 27:injuryprev-2019-043579. [PMID: 32238436 DOI: 10.1136/injuryprev-2019-043579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/28/2020] [Accepted: 03/07/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Child maltreatment is poorly documented in clinical data. The International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) represents the first time that confirmed and suspected child maltreatment can be distinguished in medical coding. The utility of this distinction in practice remains unknown. This study aims to evaluate the application of these codes by patient demographic characteristics and injury type. METHODS We conducted secondary data analysis of emergency department (ED) discharge records of children under 18 years with an ICD-10-CM code for confirmed (T74) or suspected (T76) child maltreatment. Child age, sex, race/ethnicity, insurance status and co-occurring injuries (S00-T88) were compared by maltreatment type (confirmed or suspected). RESULTS From 2016 to 2018, child maltreatment was documented in 1650 unique ED visits, or 21.7 per 10 000 child ED visits. Suspected maltreatment was documented most frequently (58%). Half of all maltreatment-related visits involved sexual abuse, most often in females and individuals of non-Hispanic white race. Physical abuse was coded in 36% of visits; injuries to the head were predominant. Non-Hispanic black children were more frequently documented with confirmed physical abuse than suspected (38.7% vs 23.7%, p<0.01). The rate of co-occurring injuries documented with confirmed and suspected maltreatment differed by 30% (9.2 vs 12.5 per 10 000 ED visits, respectively). CONCLUSIONS The ability to discriminate confirmed and suspected maltreatment may help mitigate clinical barriers to maltreatment surveillance associated with delayed diagnosis and subsequent intervention. Racial disparities in suspected and confirmed cases were identified which may indicate biased diagnostic behaviours in the ED.
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Affiliation(s)
- Amy A Hunter
- Injury Prevention Center, Connecticut Children's and Hartford Hospital, Hartford, Connecticut, USA
- Department of Public Health Sciences, University of Connecticut, Farmington, Connecticut, USA
- Department of Pediatrics, University of Connecticut, Connecticut Children's, Hartford, Connecticut, USA
| | - Nina Livingston
- Department of Pediatrics, University of Connecticut, Connecticut Children's, Hartford, Connecticut, USA
| | - Susan DiVietro
- Injury Prevention Center, Connecticut Children's and Hartford Hospital, Hartford, Connecticut, USA
- Department of Pediatrics, University of Connecticut, Connecticut Children's, Hartford, Connecticut, USA
| | - Laura Schwab Reese
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Kathryn Bentivegna
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Bruce Bernstein
- School of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
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23
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Abstract
Child abuse affects more than 10% of children in the United States. For most children it is the result of family dysfunction. Child abuse affects children from all socioeconomic classes. Pediatricians have an important role to play in prevention and early detection of abuse. There are sentinel injuries, now summarized as Clinical Prediction Rules that can guide the general pediatrician to take more definitive steps to suspect and report child abuse and neglect. Primary prevention should be part of the anticipatory guidance and support that pediatricians provide to all of their families.
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24
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Impact of Project ECHO on Community ED Providers' Perceptions of Child Abuse Knowledge and Access to Subspecialists for Child Abuse and Neglect. Acad Pediatr 2019; 19:985-987. [PMID: 31299431 PMCID: PMC6823128 DOI: 10.1016/j.acap.2019.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 11/23/2022]
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25
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Pierce MC. If You Build It, Will They Come? Getting Medical Professionals to Use the Bridge of Evidence for Improved Recognition of Physical Child Abuse. J Pediatr 2019; 204:13-15. [PMID: 30243542 DOI: 10.1016/j.jpeds.2018.08.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/31/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Mary Clyde Pierce
- Divisions of Pediatric Emergency Medicine and Child Abuse Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago, Illinois.
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