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Naik-Mathuria B, Johnson BL, Todd HF, Donaruma-Kwoh M, Bachim A, Rubalcava D, Vogel AM, Chen L, Escobar MA. Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department. J Pediatr Surg 2023; 58:1789-1795. [PMID: 36841704 DOI: 10.1016/j.jpedsurg.2023.01.046] [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: 07/29/2022] [Revised: 01/11/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk. METHODS A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data. RESULTS Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211). CONCLUSION The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bindi Naik-Mathuria
- Department of Surgery, Division of Pediatric Surgery, University of Texas Medical Branch, Galveston, TX, USA.
| | - Brittany L Johnson
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Hannah F Todd
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Marcella Donaruma-Kwoh
- Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Angela Bachim
- Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Rubalcava
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital Baylor College of Medicine, Houston, TX, USA
| | - Adam M Vogel
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Liang Chen
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Mauricio A Escobar
- Department of Pediatric Surgery and Pediatric Trauma, Mary Bridge Children's Hospital, Tacoma, WA, USA
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Diyaolu M, Ye C, Huang Z, Han R, Wild H, Tennakoon L, Spain DA, Chao SD. Disparities in detection of suspected child abuse. J Pediatr Surg 2023; 58:337-343. [PMID: 36404182 PMCID: PMC11446255 DOI: 10.1016/j.jpedsurg.2022.10.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse. METHODS The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race. RESULTS Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type. CONCLUSIONS Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Modupeola Diyaolu
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Chaonan Ye
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Zhuoyi Huang
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ryan Han
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Hannah Wild
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Lakshika Tennakoon
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie D Chao
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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The prevalence of non-accidental trauma among children with polytrauma: A nationwide level-I trauma centre study. J Forensic Leg Med 2022; 90:102386. [DOI: 10.1016/j.jflm.2022.102386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/31/2022] [Accepted: 06/02/2022] [Indexed: 11/19/2022]
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Moving Toward Standardized Pediatric Performance Improvement Measures in Child Physical Abuse: A Modified Delphi Approach. J Trauma Nurs 2021; 27:254-261. [PMID: 32890238 DOI: 10.1097/jtn.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limited guidance exists for pediatric trauma centers (PTCs) regarding best practice for measuring and reviewing performance improvement (PI) in the child physical abuse population. To move PTC programs toward standardized guidelines and PI practices, current practice and points of consensus among level 1 and 2 PTCs across the United States were assessed. METHODS Utilizing a two-round, modified Delphi methodology, electronic surveys were distributed to pediatric trauma program managers and coordinators representing 125 PTCs. Survey data included demographics, coding practices, definitions, current PI measures, prevention programs, and opinions regarding key components of child physical abuse guidelines. RESULTS In Round 1, responses were received from 90 (72%) PTCs [47 (84%) ACS-verified level 1 PTCs; 29 (73%) ACS-verified level 2 PTCs; and 14 (48%) state PTCs]. Of the respondents, 87% agreed that establishing a national consensus for child physical abuse PI is important, and 92% agreed that their institution would benefit from standardized guidelines. Although PI process varied among PTCs in terms of measures, review, and coding practices, several points of consensus were achieved. CONCLUSION Survey results demonstrate areas of consistency and a foundation for consensus among PTCs. Results also identify areas of practice diversity that may benefit from an attempt to standardize PI across centers.
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Recidivism following childhood maltreatment necessitating inpatient care in the United States. Am J Surg 2021; 223:774-779. [PMID: 34325911 DOI: 10.1016/j.amjsurg.2021.07.039] [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: 02/10/2021] [Revised: 06/06/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population. METHODS The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries. RESULTS NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers. CONCLUSION Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children. LEVEL OF EVIDENCE III. TYPE OF EVIDENCE Case Control Study.
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Henry MK, Bennett CE, Wood JN, Servaes S. Evaluation of the abdomen in the setting of suspected child abuse. Pediatr Radiol 2021; 51:1044-1050. [PMID: 33755750 DOI: 10.1007/s00247-020-04944-2] [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: 06/01/2020] [Revised: 08/19/2020] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.
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Affiliation(s)
- M Katherine Henry
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South St., Philadelphia, PA, 19146, USA. .,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Colleen E Bennett
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne N Wood
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South St., Philadelphia, PA, 19146, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabah Servaes
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Theodorou CM, Nuño M, Yamashiro KJ, Brown EG. Increased mortality in very young children with traumatic brain injury due to abuse: A nationwide analysis of 10,965 patients. J Pediatr Surg 2021; 56:1174-1179. [PMID: 33752910 PMCID: PMC8131228 DOI: 10.1016/j.jpedsurg.2021.02.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/05/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of death and disability in young children; however, the impact of mechanism on outcomes has not been fully evaluated. We hypothesized that children with TBI due to abuse would have a higher mortality than children with accidental TBI due to motor vehicle collisions (MVC). METHODS We performed a retrospective review of the National Kids' Inpatient (KID) hospitalizations database of children <2 years old with TBI due to abuse or MVC (2000-2016). The primary outcome was mortality. Secondary outcomes were length of stay (LOS) and hospital charges. We investigated predictors of mortality with multivariable regression. RESULTS Of 10,965 children with TBI, 65.2% were due to abuse. Overall mortality was 9.8% (n = 1074). Abused children had longer LOS (5.7 vs 1.6 days, p < 0.0001) and higher hospital charges ($34,314 vs $19,360, p < 0.0001) than children with TBI due to MVC. The odds of mortality were 42% higher in children with abusive head trauma (OR 1.42, 95% CI 1.10-1.83, p = 0.007) compared to MVCs after adjusting for age, race, sex, neurosurgical intervention, injury severity, and insurance. CONCLUSION Children with abusive traumatic brain injury have increased risk of mortality, longer LOS, and higher hospital charges compared to children with TBI due to motor vehicle collision after adjusting for relevant confounders. Resources must be directed at prevention and early identification of abuse.
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Affiliation(s)
- Christina M Theodorou
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery. Sacramento, CA USA.
| | - Miriam Nuño
- University of California Davis, Department of Public Health Sciences, Division of Biostatistics. Sacramento, USA
| | - Kaeli J Yamashiro
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery. Sacramento, CA USA
| | - Erin G Brown
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery. Sacramento, CA USA
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Risk factors for avoidable transfer to a pediatric trauma center among patients 2 years and older. J Trauma Acute Care Surg 2020; 86:92-96. [PMID: 30312251 DOI: 10.1097/ta.0000000000002087] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Effective and sustainable pediatric trauma care requires systems of regionalization and interfacility transfer. Avoidable transfer, also known as secondary overtriage, occurs when a patient is transferred to a regional trauma center after initial evaluation at another facility that is capable of providing definitive care. The purpose of this study was to identify risk factors for avoidable transfer among pediatric trauma patients in southwest Florida. METHODS All pediatric trauma patients 2 years and older transferred from outlying hospitals to the emergency department of a single state-designated pediatric trauma center between 2009 and 2017 were obtained from the institutional registry. Transfers were classified as avoidable if the patient suffered only minor injuries (International Classification of Diseases-9th Rev. Injury Severity Score > 0.9), did not require invasive procedures or intensive care unit monitoring, and was discharged within 48 hours. Demographics and injury characteristics were compared for avoidable and nonavoidable transfers. Logistic regression was used to estimate the independent effects of age, sex, insurance type, mechanism of injury, diagnosis, within region versus out-of-region residence, suspected nonaccidental trauma, and abnormal Glasgow Coma Scale score on the risk of avoidable transfer. RESULTS A total of 3,876 transfer patients met inclusion criteria, of whom 1,628 (42%) were classified as avoidable. Among avoidable transfers, 29% had minor head injuries (isolated skull fractures, concussions, and mild traumatic brain injury not otherwise specified), and 58% received neurosurgery consultation. On multivariable analysis, the strongest risk factors for avoidable transfer were diagnoses of isolated skull fracture or concussion. Suspected nonaccidental trauma was predictive of nonavoidable transfer. CONCLUSION Among injured children 2 years and older, those with minor head injuries were at greatest risk for avoidable transfer. Many were transferred because of a perceived need for evaluation by a pediatric neurosurgeon. Future projects seeking to reduce avoidable transfers should focus on children with isolated skull fractures and concussions, in whom there is no suspicion of nonaccidental trauma. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Rosenfeld EH, Johnson B, Wesson DE, Shah SR, Vogel AM, Naik-Mathuria B. Understanding non-accidental trauma in the United States: A national trauma databank study. J Pediatr Surg 2020; 55:693-697. [PMID: 31103270 DOI: 10.1016/j.jpedsurg.2019.03.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/07/2019] [Accepted: 03/28/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database. METHODS Children <15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression. RESULTS Of 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children <1 year and 31% of trauma deaths in children <5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age. CONCLUSION Non-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts. LEVEL OF EVIDENCE III STUDY TYPE: Prognostic and Epidemiological.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Brittany Johnson
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - David E Wesson
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Sohail R Shah
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Bindi Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
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Dudas L, Petrohoy G, Esernio-Jenssen D, Lansenderfer C, Stirparo J, Dunstan M, Browne M. Every child, every time: hospital-wide child abuse screening increases awareness and state reporting. Pediatr Surg Int 2019; 35:773-778. [PMID: 31115655 DOI: 10.1007/s00383-019-04485-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE A review of our child abuse evaluation system demonstrated a lack of standardization leading to low reporting levels. The purpose of this quality improvement initiative was to develop a standard child abuse screening tool; an education program increasing awareness to child abuse; and to measure the impact of the screening tool in reporting. METHODS A screening tool was developed and implemented for all trauma patients < 15 years of age; staff was educated; and a child protection team (CPT) was established. Within 9 months, screening was extended to all patients admitted to the children's hospital. Screening compliance, number of child abuse reporting forms (CY-47) filed, and consultations to the CPT were monitored. RESULTS Initially, there was an average screening compliance of 56%. After making the program hospital-wide, the compliance rate increased to an average of 96%; and the average number of CPT consults increased from 2 to 10 per month. Over this study period, the average number of CY-47s filed increased from 6.1 to 7.3 per month. CONCLUSIONS Hospital-wide use of an objective screening tool, frequent re-education, and the support of an experienced child protection team led to improved child abuse screening compliance and more consistent suspected-abuse reporting rates.
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Affiliation(s)
- Lauren Dudas
- Division of General and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA
| | - Gwenda Petrohoy
- Division of General and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA
| | - Debra Esernio-Jenssen
- Department of Pediatrics, Section of Child Protection Medicine, Lehigh Valley Reilly Children's Hospital, Lehigh Valley Health Network, Allentown, PA, 18103, USA
| | - Cheryl Lansenderfer
- Division of General and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA
| | - Joseph Stirparo
- Division of General and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA
| | - Michele Dunstan
- Division of General and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Department of Surgery, Lehigh Valley Reilly Children's Hospital, Lehigh Valley Health Network, 1210 S Cedar Crest Blvd, Suite 1100, Allentown, PA, 18103, USA.
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Abstract
PURPOSE More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT). METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16 years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis. RESULTS From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9 years, p < 0.001) and higher median injury severity score (10 vs. 5, p < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2 days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001). CONCLUSION Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.
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Child abuse and the pediatric surgeon: A position statement from the Trauma Committee, the Board of Governors and the Membership of the American Pediatric Surgical Association. J Pediatr Surg 2019; 54:1277-1285. [PMID: 30948199 DOI: 10.1016/j.jpedsurg.2019.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/24/2019] [Accepted: 03/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The pediatric surgeon is in a unique position to assess, stabilize, and manage a victim of child physical abuse (formerly nonaccidental trauma [NAT]) in the setting of a formal trauma system. METHODS The American Pediatric Surgical Association (APSA) endorses the concept of child physical abuse as a traumatic disease that justifies the resource utilization of a trauma system to appropriately evaluate and manage this patient population including evaluation by pediatric surgeons. RESULTS APSA recommends the implementation of a standardized tool to screen for child physical abuse at all state designated trauma or ACS verified trauma and children's surgery hospitals. APSA encourages the admission of a suspected child abuse patient to a surgical trauma service because of the potential for polytrauma and increased severity of injury and to provide reliable coordination of services. Nevertheless, APSA recognizes the need for pediatric surgeons to participate in a multidisciplinary team including child abuse pediatricians, social work, and Child Protective Services (CPS) to coordinate the screening, evaluation, and management of patients with suspected child physical abuse. Finally, APSA recognizes that if a pediatric surgeon suspects abuse, a report to CPS for further investigation is mandated by law. CONCLUSION APSA supports data accrual on abuse screening and diagnosis into a trauma registry, the NTDB and the Pediatric ACS TQIP® for benchmarking purposes and quality improvement.
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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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Insurance status and pediatric mortality in nonaccidental trauma. J Surg Res 2018; 231:126-132. [DOI: 10.1016/j.jss.2018.05.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/23/2018] [Accepted: 05/21/2018] [Indexed: 11/18/2022]
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Gan T, Draus JM. Improving Follow-up Skeletal Survey Compliance in Suspected Nonaccidental Trauma Patients: What's the FUSS About? Pediatr Qual Saf 2018; 3:e094. [PMID: 30229204 PMCID: PMC6135555 DOI: 10.1097/pq9.0000000000000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 06/22/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Nonaccidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. The skeletal survey (SS) and follow-up skeletal survey (FUSS) are essential in the evaluation of selected NAT patients. We identified that our clinically indicated FUSS completion rate was suboptimal. We hypothesized that implementing an intervention of postdischarge follow-up in our pediatric surgery clinic would improve FUSS completion rates. METHODS A follow-up clinic for NAT patients was established in July 2013. A retrospective review was performed of all suspected NAT cases younger than 2 years old seen at Kentucky Children's Hospital between November 2012 and February 2014. The study population was divided into pre (Group 1) and postintervention (Group 2). Bivariate analysis was performed. RESULTS Group 1 consisted of 50 patients (58% male; median age, 9 months). Forty-7 (94%) had an SS; fractures were identified in 37 (74%) patients. Only 20 patients (40%) had FUSS; of those, 4 had newly identified fractures. Group 2 consisted of 52 patients (54% male; median age, 7 months). All 52 children (100%) had an SS; fractures were identified in 35 (67%) patients. Forty-seven patients (90%) had FUSS. Of those, 6 had new radiographic findings. Thirty-five patients (67%) were seen in our clinic. This improvement in FUSS (40% versus 90%) was statistically significant, P < 0.001. CONCLUSION The decision to follow NAT patients in our clinic had significantly increased our rates of FUSS completion. This additional clinic follow-up also provided more evidence for NAT evaluation.
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Affiliation(s)
- Tong Gan
- From the Department of Surgery, Division of Pediatric Surgery, Kentucky Children’s Hospital, University of Kentucky, Lexington, Ky
| | - John M. Draus
- From the Department of Surgery, Division of Pediatric Surgery, Kentucky Children’s Hospital, University of Kentucky, Lexington, Ky
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16
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Sociodemographic determinants of non-accidental traumatic injuries in children. Am J Surg 2018; 215:1037-1041. [DOI: 10.1016/j.amjsurg.2018.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 03/31/2018] [Accepted: 05/11/2018] [Indexed: 11/22/2022]
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Sola R, Waddell VA, Peter SDS, Aguayo P, Juang D. Non-accidental trauma: A national survey on management. Injury 2018; 49:921-926. [PMID: 29555082 DOI: 10.1016/j.injury.2018.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/23/2018] [Accepted: 03/07/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-accidental trauma (NAT) has significant societal and health care implications. Standardized care has been shown to improve outcomes. The purpose of our study was to survey trauma centers and elucidate the continued variable management of NAT. METHODS After institutional review board approval, an email survey was sent to Level 1 and 2 ACS verified trauma centers along with general and pediatric surgery training programs. Trauma hospital characteristics and NAT management were analyzed. RESULTS A total of 493 emails were sent and 91 responses (18%) were received. There were 74 (81%) pediatric surgeons who responded and 15(17%) adult general surgeons. The most common location of respondents were children's hospitals within academic/community hospitals (58%) followed by stand-alone children hospitals (42%), and adult only hospitals (9%). 51 (57%) providers reported using a screening tool; most commonly used by the emergency department (52%). 75% of providers reported utilizing management protocols in which 71% were initiated by trauma surgery. The most common consulting and admitting service for NAT was trauma surgery (86% and 84%). When comparing stand-alone and affiliated children hospitals, there was no difference in the use of a screening tool (54% vs. 59%; p = 0.84), and management protocol (70% vs. 85%; p = 0.19). However, those providers from pediatric trauma centers used a management protocol more often than providers from adult trauma centers (78% vs. 38%; p = 0.04). No providers from adult trauma centers had intentions to initiate a management protocol in the future. CONCLUSION Screening and management of non-accidental trauma continues to vary across the country. Future studies focusing on standardization and outreach/education to adult trauma centers is warranted.
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Affiliation(s)
- Richard Sola
- Department of General Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Valerie A Waddell
- Department of General Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Shawn D St Peter
- Department of General Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Pablo Aguayo
- Department of General Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - David Juang
- Department of General Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.
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Yu YR, DeMello AS, Greeley CS, Cox CS, Naik-Mathuria BJ, Wesson DE. Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers. J Pediatr Surg 2018. [PMID: 29523358 DOI: 10.1016/j.jpedsurg.2018.02.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers. METHODS We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries. RESULTS Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001). CONCLUSION Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority. TYPE OF STUDY Retrospective Review. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yangyang R Yu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Annalyn S DeMello
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Christopher S Greeley
- Department of Pediatrics, Section of Public Health Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Charles S Cox
- Department of Pediatric Surgery, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Bindi J Naik-Mathuria
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - David E Wesson
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.
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Schears RM, Farzal Z, Farzal Z, Fischer AC. The radiation footprint on the pediatric trauma patient. Int J Emerg Med 2018; 11:18. [PMID: 29541949 PMCID: PMC5852158 DOI: 10.1186/s12245-018-0175-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/15/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The actual baseline of radiation exposure used in evaluating pediatric trauma is not known and has relied on estimates in the literature that may not reflect clinical reality. Our objectives were to determine the baseline amount of radiation delivered in a pediatric trauma evaluation and correlate radiation exposure with trauma activation status to identify the cohort most at risk. METHODS We retrospectively evaluated trauma patients (N = 1050) at an independent Level I children's hospital for each level of trauma activation (consults, alerts, stats) from June 2010 to January 2011. Those patients with full dosimetry (N = 215) were analyzed for demographics, mechanism of injury, Injury Severity Score, imaging modalities, and total effective radiation dosages during the full trauma assessment from the time of injury to discharge. RESULTS Demographics included gender (143 males, 72 females) and average age (5.5 years [range < 1-16]). The most radiation was conferred from CTs and greatest in trauma stats, followed by alerts, then consults (p < 0.001 for stat and alert doses compared to consults). Repeated imaging was common: 35% of stats had 2-3 CTs and 40% had 4-10 CTs (range 0-10 CTs). The average non-accidental trauma consult utilized four times as many CTs as the average consult (p = 0.002). Most outside hospital CTs (66%) delivered more radiation: 50.0% were at least double the standard pediatric dosage. CONCLUSIONS This study is the first to identify the actual baseline of radiation exposure for one trauma evaluation and correlate radiation exposure with trauma activation status. Factors associated with highest radiation include stat activations, suspected non-accidental traumas (NAT), and outside hospital system imaging.
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Affiliation(s)
- Raquel M. Schears
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Zainab Farzal
- Department of Otolaryngology, University North Carolina, Children’s Hospital, 101 Manning Drive, Chapel Hill, NC USA
| | - Zehra Farzal
- Department of Neurology, MedStar Georgetown University Hospital, Reservoir Rd NW, Washington, DC, 3800 USA
| | - Anne C. Fischer
- Florida Atlantic University/St. Mary’s Medical Center, 927 45th Street, Suite 301, West Palm Beach, FL 33407 USA
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Draus JM. A Multidisciplinary Child Protection Team Improves the Care of Nonaccidental Trauma Patients. Am Surg 2017. [DOI: 10.1177/000313481708300521] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We initiated a multidisciplinary Child Protection Team (CPT) as a subgroup of our pediatric multidisciplinary trauma peer review committee. Meetings are held monthly. Nonaccidental trauma (NAT) patients from the preceding month are reviewed. The meeting has two parts. During the open part, detectives and child protective services (CPS) workers are invited to discuss specific cases. The closed part focuses on improvement of specific processes and future outcomes. Attendance is recorded and minutes are kept. We sought to review accomplishments of this group. We retrospectively reviewed the minutes from our CPT meetings conducted between February 2014 and April 2015. We tracked attendance, cases reviewed, process improvement projects, and corrective action plans. Meeting attendance was very good—78 per cent. During the 15-month study period, we had 141 suspected NAT patients; 96 were reviewed at our meetings. CPS workers attended 53 per cent of the meetings; 13 investigations were discussed. We established a clinical practice guideline for the evaluation of NAT patients. We created a mechanism to improve compliance with follow-up skeletal surveys. Six corrective letters were sent to individuals notifying them of care concerns and opportunities for improvement. Equipment needs were identified, and we obtained a digital camera and speaker phone. We have conducted multiple educational sessions to increase awareness. Our CPT meeting has improved the care of our NAT patients and provided better communication between our hospital staff and CPS workers. We have improved inhospital processes for our NAT patients. We have provided educational opportunities to outside care providers.
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Affiliation(s)
- John M. Draus
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
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22
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Pflugeisen BM, Escobar MA, Haferbecker D, Duralde Y, Pohlson E. Impact on Hospital Resources of Systematic Evaluation and Management of Suspected Nonaccidental Trauma in Patients Less Than 4 Years of Age. Hosp Pediatr 2017; 7:219-224. [PMID: 28325786 DOI: 10.1542/hpeds.2016-0157] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE There has been an increasing movement worldwide to create systematic screening and management procedures for atypical injury patterns in children with the hope of better detecting and evaluating nonaccidental trauma (NAT). A legitimate concern for any hospital considering implementation of a systematic evaluation process is the impact on already burdened hospital resources. We hypothesized that implementation of a guideline that uses red flags related to history, physical, or radiologic findings to trigger a standardized NAT evaluation of patients <4 years would not negatively affect resource utilization at our level II pediatric trauma center. METHODS NAT cases were evaluated retrospectively before and prospectively after implementation of the NAT guideline (n = 117 cases before implementation, n = 72 cases postimplementation). Multiple linear and logistic regression, χ2, and Wilcoxon rank-sum tests were used to evaluate human, laboratory, technology, and hospital resource usage between cohorts. RESULTS Human (child abuse intervention department, ophthalmology, and evaluation by a pediatric surgeon for admitted patients), laboratory (urine toxicology and liver function tests), and imaging (skeletal survey and head or abdominal computed tomography) resource use did not differ significantly between cohorts (all P > .05). Emergency department and hospital lengths of stays also did not differ between cohorts. A significant 13% decrease in the percentage of patients admitted to the hospital was observed (P = .01). CONCLUSIONS Structured evaluation and management of pediatric patients with injuries atypical for their age does not confer an added burden on hospital resources and may reduce the percentage of such patients who are hospitalized.
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Affiliation(s)
| | - Mauricio A Escobar
- Department of Pediatric Surgery
- University of Washington School of Medicine, Seattle, Washington
| | - Dustin Haferbecker
- University of Washington School of Medicine, Seattle, Washington
- Inpatient Services, and
| | - Yolanda Duralde
- Child Abuse Intervention Department, Mary Bridge Children's Hospital, Tacoma, Washington; and
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Litz CN, Ciesla DJ, Danielson PD, Chandler NM. A closer look at non-accidental trauma: Caregiver assault compared to non-caregiver assault. J Pediatr Surg 2017; 52:625-627. [PMID: 27624565 DOI: 10.1016/j.jpedsurg.2016.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/04/2016] [Accepted: 08/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to examine the outcomes of non-accidental trauma (NAT) patients compared to other trauma (OT) patients across the state of Florida. In addition, NAT and OT patients with a mechanism of injury of assault were further analyzed. METHODS A statewide database was reviewed from January 2010 to December 2014 for patients aged 0-18years who presented following trauma. Patients were sorted by admitting diagnosis into two groups: rule out NAT and all other diagnoses. Patients with a mechanism of assault were subanalyzed and outcomes were compared. RESULTS There were 46,557 patients included. NAT patients were younger, had more severe injuries and had a higher mortality rate compared to OT patients. Assault was the mechanism of injury in 95% of NAT patients. NAT assault patients were younger, required more intensive care unit (ICU) resources, and had a higher mortality rate compared to other assault patients. CONCLUSION Non-accidental trauma patients require more resources and have a higher mortality rate compared to accidental trauma patients, and these differences remain even when controlling for the mechanism of injury. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cristen N Litz
- Johns Hopkins All Children's Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, Saint Petersburg, FL 33701, USA.
| | - David J Ciesla
- University of South Florida, Morsani College of Medicine, 1 Tampa General Circle, G417, Tampa, FL 33606, USA.
| | - Paul D Danielson
- Johns Hopkins All Children's Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, Saint Petersburg, FL 33701, USA.
| | - Nicole M Chandler
- Johns Hopkins All Children's Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, Saint Petersburg, FL 33701, USA.
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Gonzalez DO, Deans KJ. Hospital-based screening tools in the identification of non-accidental trauma. Semin Pediatr Surg 2017; 26:43-46. [PMID: 28302284 DOI: 10.1053/j.sempedsurg.2017.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Over 700,000 children are victims of abuse and neglect each year in the United States. Effective screening programs that entail broad capture of suspected non-accidental trauma (NAT) may help to identify sentinel injuries. This can facilitate earlier detection and psychosocial interventions in hopes of decreasing recurrent NAT, which confers a higher mortality rate. The purpose of this article is to outline essential components of hospital-based NAT screening tools and highlight existing programs. In general, these tools should include several components: education sessions for healthcare providers on how to identify signs of NAT, automated notes or checklists within the electronic medical record to prompt specialty referrals, and a multidisciplinary team of experts that can address the needs of these children in the acute care setting.
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Affiliation(s)
- Dani O Gonzalez
- Department of Surgery, Center for Surgical Outcomes Research, The Research Institute, Nationwide Children׳s Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children׳s Hospital, 700 Children׳s Dr, Columbus, Ohio 43205
| | - Katherine J Deans
- Department of Surgery, Center for Surgical Outcomes Research, The Research Institute, Nationwide Children׳s Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children׳s Hospital, 700 Children׳s Dr, Columbus, Ohio 43205.
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Magoteaux S, Gilbert M, Langlais CS, Garcia-Filion P, Notrica DM. Should Children with Suspected Nonaccidental Injury Be Admitted to a Surgical Service? J Am Coll Surg 2016; 222:838-43. [DOI: 10.1016/j.jamcollsurg.2015.12.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/29/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
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Abstract
PURPOSE Each year, nearly 1 million children in the USA are victims of non-accidental trauma (NAT). Missed diagnosis or poor case management often leads to repeat/escalation injury. Victims of recurrent NAT are at higher risk for severe morbidity and mortality resulting from abuse. The objective of this review is to describe the evolution and implementation of this tool and evaluate our institutional response to NAT prior to implementation. METHODS A systematic guideline for the evaluation of pediatric patients in which NAT is suspected or confirmed was developed and implemented at a level II pediatric trauma hospital. To understand the state of our institution prior to implementation of the guideline, a review of 117 confirmed NAT cases at our hospital over the prior 4 years was conducted. RESULTS In the absence of a systematic management guideline, important and relevant social and family history red flags were often missing in the initial evaluation. Patients with perineal bruising experienced significantly higher mortality than patients without perineal bruising (27.3 vs. 5.7%; p = 0.03) and were significantly more likely to require surgery (45.5 vs. 14.2%; p = 0.02). CONCLUSION Development and implementation of a standardized tool for the differentiation and diagnosis of NAT and creation of a structured electronic medical record note should improve the description and documentation of child abuse cases in a community hospital setting. A retrospective analysis demonstrated that in the absence of such a tool, management of NAT may be inconsistent or incomplete. Perineal injury is an especially ominous red flag finding.
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Block L, King TW, Gosain A. Debridement Techniques in Pediatric Trauma and Burn-Related Wounds. Adv Wound Care (New Rochelle) 2015; 4:596-606. [PMID: 26487978 DOI: 10.1089/wound.2015.0640] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Significance: Traumatic injuries are the leading cause of morbidity and mortality in children. The purpose of this review is to provide an overview of the initial assessment and management of traumatic and burn wounds in children. Special attention is given to wound cleansing, debridement techniques, and considerations for pain management and psychosocial support for children and families. Recent Advances: Basic and translational research over the last 5-7 years has advanced our knowledge related to the optimal care of acute pediatric traumatic and burn wounds. Data concerning methods, volume, solution and timing for irrigation of acute traumatic wounds, timing and methods of wound debridement, including hydrosurgery and plasma knife coblation, and wound dressings are presented. Additionally, data concerning the long-term psychosocial outcomes following acute injury are presented. Critical Issues: The care of pediatric trauma and burn-related wounds requires prompt assessment, pain control, cleansing, debridement, application of appropriate dressings, and close follow-up. Ideally, a knowledgeable multidisciplinary team cares for these patients. A limitation in the care of these patients is the relative paucity of data specific to the care of acute traumatic wounds in the pediatric population. Future Directions: Research is ongoing in the arenas of new debridement techniques and instruments, and in wound dressing technology. Dedicated research on these topics in the pediatric population will serve to strengthen and advance the care of pediatric patients with acute traumatic and burn wounds.
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Affiliation(s)
- Lisa Block
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Timothy W. King
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Pediatric Trauma Program, American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
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Ward A, Iocono JA, Brown S, Ashley P, Draus JM. Non-accidental Trauma Injury Patterns and Outcomes: A Single Institutional Experience. Am Surg 2015. [DOI: 10.1177/000313481508100912] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Non-accidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. We sought to better understand the injury patterns and outcomes of NAT victims who were treated at our level I pediatric trauma center. Trauma registry data were used to identify NAT victims between January 2008 and December 2012. Demographic data, injury severity, hospital course, and outcomes were evaluated. One hundred and eighty-eight cases of suspected NAT were identified. Children were mostly male and white. The median age was 1.1 years; the median Injury Severity Score was 9. Traumatic brain injuries, lower extremity fractures, and skull fractures were the most common injuries. Twenty-seven per cent required medical procedures; most were performed by orthopedic surgery. Twenty-four per cent required admission to the pediatric intensive care unit. The median length of stay was two days. The mortality rate was 9.6 per cent. We generated a hot spot map of our catchment area and identified areas of our state where NAT occurs at increased rates. NAT victims sustain significant morbidity and mortality. Due to the severity of injuries, pediatric trauma surgeons should be involved in the evaluation and management of these children. Much work is needed to prevent the death and disability incurred by victims of child abuse.
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Affiliation(s)
- Austin Ward
- Graduate Medical Education, General Surgery Residency Program
| | | | - Samuel Brown
- College of Medicine, Orthopedic Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Phillip Ashley
- Graduate Medical Education, Orthopedic Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - John M. Draus
- Division of Pediatric Surgery, Department of Surgery
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Naik-Mathuria B, Akinkuotu A, Wesson D. Role of the surgeon in non-accidental trauma. Pediatr Surg Int 2015; 31:605-10. [PMID: 25772160 DOI: 10.1007/s00383-015-3688-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2015] [Indexed: 11/24/2022]
Abstract
Non-accidental trauma (NAT) represents a significant cause of morbidity and mortality in the pediatric population. The management of these patients often involves many care providers including the surgeon. Victims of NAT often present with multiple injuries and as such should be treated as trauma patients with complete trauma evaluation including primary, secondary and tertiary surveys. Common injury patterns in NAT include extremity fractures, closed head injury and intra-abdominal injury. Brain imaging is of importance to rule out acute or sub-acute intracranial hemorrhage. Children under the age of 5 years with acute intracranial pathology should also be evaluated by an ophthalmologist to rule out retinal hemorrhages, which are considered pathognomonic for child abuse from violent shaking. In instances when abdominal injury is suspected, prompt evaluation by a surgeon is recommended along with CT imaging. Finding of extremity fractures should prompt evaluation by an orthopedic surgeon. At our institution, all patients with suspected NAT are admitted to the pediatric surgery service for complete evaluation and management. We encourage other pediatric trauma centers to employ a similar approach so that these complicated patients are managed safely and effectively.
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Affiliation(s)
- Bindi Naik-Mathuria
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, 6701 Fannin Street Suite 1210, Houston, TX, 77005, USA,
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Abstract
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
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Melzer JM, Baldassari CM. Hypoharyngeal injury in an infant from non-accidental trauma. Int J Pediatr Otorhinolaryngol 2014; 78:2312-3. [PMID: 25305065 DOI: 10.1016/j.ijporl.2014.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/12/2014] [Accepted: 09/16/2014] [Indexed: 10/24/2022]
Abstract
Non-accidental trauma is a sad but commonly described mechanism of injury in the pediatric literature. However, the otolaryngologist infrequently encounters the initial presentation of non-accidental trauma despite the fact that a significant percentage of injuries take place in the head and neck. This case report seeks to discuss otolaryngologic presentations of non-accidental trauma in the pediatric population as well as to discuss management strategies. The case of a 3 month old female with a hypopharyngeal injury and esophageal perforation is presented and discussed.
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Affiliation(s)
- Jonathan M Melzer
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center, Portsmouth, VA, United States.
| | - Cristina M Baldassari
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, United States; Department of Pediatric Otolaryngology, Children's Hospital of The King's Daughters, Norfolk, VA, United States
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Hallmarks of Non-accidental Trauma: A Surgeon’s Perspective. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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