Prevalence of Abuse and Additional Injury in Young Children With Rib Fractures as Their Presenting Injury

Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency

OBJECTIVES

Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs.

METHODS

A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes.

RESULTS

There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods.

CONCLUSIONS

Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.

Micro-CT in a forensic examination of a fatal child abuse case: A case report

Child abuse is a serious concern that can cause the death of a child. In such cases the medico-legal evidence is often pivotal but complex, drawing across multiple medical disciplines and techniques. One key specialism is histopathology, which is considered the gold standard for estimating the age of individual fractures. Another is micro-CT imaging, which can visualise the location of trauma across the body. This case report demonstrates how micro-CT was used to contextualise the histological evidence in the Criminal Justice Proceedings of a fatal child abuse case. This was achieved by overlaying the aged fracture evidence from histopathology onto the visuals rendered from micro-CT imaging. The case was a suspected child abuse of a deceased 1-month old infant who was reported unresponsive by their parents. The child was taken to hospital where they were pronounced dead. Suspicion was raised and post-mortem imaging confirmed head trauma and rib fractures, and the case was escalated for a forensic investigation. This case report details how the micro-CT imaging was merged with the gold standard of histopathology for visualisation of trauma, and how the court presentation was planned alongside Senior Investigating Officers and various medical experts. The presentation was used in court by the histopathologist to present the evidence. The resulting presentation provided additional clarity to jury members regarding the location, severity, frequency, and timings of the injuries. From the perspective of the investigating police force, the resulting presentation was crucial in ensuring understanding of the medico-legal evidence of how the infant died. The prosecuting lawyer noted that combining the histological and micro-CT evidence in this way allowed the evidence to be presented in a sensitive, clear, and impactful manner.

Racial and ethnic disparities in diagnostic imaging for child physical abuse

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.

Deep learning-based prediction of rib fracture presence in frontal radiographs of children under two years of age: a proof-of-concept study

OBJECTIVE

In this proof-of-concept study, we aimed to develop deep-learning-based classifiers to identify rib fractures on frontal chest radiographs in children under 2 years of age.

METHODS

This retrospective study included 1311 frontal chest radiographs (radiographs with rib fractures, n = 653) from 1231 unique patients (median age: 4 m). Patients with more than one radiograph were included only in the training set. A binary classification was performed to identify the presence or absence of rib fractures using transfer learning and Resnet-50 and DenseNet-121 architectures. The area under the receiver operating characteristic curve (AUC-ROC) was reported. Gradient-weighted class activation mapping was used to highlight the region most relevant to the deep learning models' predictions.

RESULTS

On the validation set, the ResNet-50 and DenseNet-121 models obtained an AUC-ROC of 0.89 and 0.88, respectively. On the test set, the ResNet-50 model demonstrated an AUC-ROC of 0.84 with a sensitivity of 81% and specificity of 70%. The DenseNet-50 model obtained an AUC of 0.82 with 72% sensitivity and 79% specificity.

CONCLUSION

In this proof-of-concept study, a deep learning-based approach enabled the automatic detection of rib fractures in chest radiographs of young children with performances comparable to pediatric radiologists. Further evaluation of this approach on large multi-institutional data sets is needed to assess the generalizability of our results.

ADVANCES IN KNOWLEDGE

In this proof-of-concept study, a deep learning-based approach performed well in identifying chest radiographs with rib fractures. These findings provide further impetus to develop deep learning algorithms for identifying rib fractures in children, especially those with suspected physical abuse or non-accidental trauma.

Application of the Whole Optimization of Emergency Nursing Model United and Its Influence on Patients' Stress Response and Nursing Satisfaction

Objective

To investigate the use of an integrated emergency nursing model with a multidisciplinary team (MDT) teaching method for practice of nursing towards multiple trauma in the emergency department and its influence on patients' stress response and nursing satisfaction.

Methods

The research subjects were 120 multiple trauma patients hospitalized to our hospital's emergency department between January 2019 and January 2020, who were evenly divided into groups A (n = 60) and B (n = 60) based on the sequence of admission. For patients in group A, on the basis of whole optimization of the emergency nursing model, the MDT teaching and training were given to the nursing staff in group A. Patients in group B had their emergency nursing model completely optimized. The assessment scores of nursing staff were compared. The patients' C-reactive protein (CRP) levels in peripheral circulation, first-aid time indices, treatment effect, risk of complications & nursing contentment were all investigated.

Results

Nursing personnel in group A had considerably higher achievement scores than staff nurses in group B (P < 0.001). CRP levels in group A were considerably lower following therapy (P < 0.05) than those in group B. The time it took for group A to receive first assistance was considerably less than that for group B (P < 0.001). Group A had a considerably superior treatment effect than group B (P < 0.05). Complications occurred at a lower rate in group A (P < 0.05) than in group B. Group A nurses were more satisfied than group B nurses (P < 0.05).

Conclusion

The entire optimization of the emergency nursing model combined with the MDT way of teaching can abbreviate the rescue process, reduce stress, improve treatment effect & reduce the possibility of complications in multiple trauma patients in the emergency department, and patients seem to be more comfortable with this nursing model. As a result, it should become more well known.

Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse

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.

Child Abuse Imaging and Findings in the Time of COVID-19

OBJECTIVE

To assess the impact of the COVID-19 pandemic on physical abuse in young children, we compared the following before and during the pandemic: (1) skeletal survey volume, (2) percent of skeletal surveys revealing clinically unsuspected (occult) fractures, and (3) clinical severity of presentation. We hypothesized that during the pandemic, children with minor abusive injuries would be less likely to present for care, but severely injured children would present at a comparable rate to prepandemic times. We expected that during the pandemic, the volume of skeletal surveys would decrease but the percentage revealing occult fractures would increase and that injury severity would increase.

METHODS

We conducted a retrospective study of children younger than 2 years undergoing skeletal surveys because of concern for physical abuse at a tertiary children's hospital. Subjects were identified by querying a radiology database during the March 15, 2019-October 15, 2019 (pre-COVID-19) period and the March 15, 2020-October 15, 2020 (COVID-19) period, followed by chart review to refine our population and abstract clinical and imaging data.

RESULTS

Pre-COVID-19, 160 skeletal surveys were performed meeting the inclusion criteria, compared with 125 during COVID-19, representing a 22% decrease. No change was observed in identification of occult fractures (6.9% pre-COVID vs 6.4% COVID, P = 0.87). Clinical severity of presentation did not change, and child protective services involvement/referral decreased during COVID.

CONCLUSIONS

Despite a >20% decrease in skeletal survey performance early in the pandemic, the percent of skeletal surveys revealing occult fractures did not increase. Our results suggest that decreases in medical evaluations for abuse did not stem from decreased presentation of less severely injured children.

Rib fractures in infancy, case-series and register case-control study from Sweden

OBJECTIVES

To assess cases with rib fractures in infants under observation for or with an abuse diagnosis, and to compare risk factors with that in infants with fractures but no abuse diagnosis.

METHODS

Design was case-series and register case-control of infants (aged <1 year) with rib fractures. Data was clinical records for the case-series (n = 26) and from national health registers for the case-controls (n = 28 and n = 31). Outcome measures were maternal and perinatal characteristics, reasons for appointment, examination, diagnoses, blood tests, and radiologic findings.

RESULTS

The case-series had a median age of 70 days. A majority were detected through a skeletal survey for abuse investigation. Sixteen were boys, three were preterm and six were small-for-gestational age. Three carers had noticed popping sound from the chest; no infants showed signs of pain at physical examination. Mean number of fractures was 4.2, and 24 had callus. Bone mineralisation was scarcely reported. Metabolic panel was not uniformly analysed. The register case-control had a median age of 76 days, sharing risk factors such as maternal overweight/obesity, male sex, prematurity, and being small-for-gestational age. Cases more often had subdural haemorrhage, retinal haemorrhage, or long-bone fractures, controls more often had neonatal morbidity, respiratory infection, or a fall accident. Detection of fracture at time of a major surgery (n = 6) and rickets/vitamin D deficiency (n = 5) appeared in both groups, but was delayed among the cases.

CONCLUSIONS

Rib fractures in young infants, diagnosed as abuse, are usually asymptomatic and healing. A substantial proportion had metabolic risk factors, suggesting false positive cases.

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

OBJECTIVES

Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age.

METHODS

A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.

RESULTS

Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.

CONCLUSION

Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).