Skeletal Surveys in Suspected Non-accidental Trauma: Examining the Yield and Current Clinical Practices at a Regional Referral Center in West Virginia

Introduction Non-accidental trauma (NAT) is a leading cause of pediatric injury and death. When NAT is suspected in children under the age of 24 months, the American Academy of Pediatrics (AAP) recommends using skeletal surveys (SS) to identify acute, healing, or old fractures and to repeat the SS approximately two weeks after initial imaging as acute fractures can sometimes not be seen on initial imaging. In this study, we determined the yield of initial and follow-up SS obtained for suspected NAT in children under the age of 24 months at a regional referral hospital. Methods We reviewed charts of children younger than 24 months who received SS imaging, due to physical abuse suspicion, at our hospital system between 2017 and 2022. We used convenient sampling to examine all SS occurring at the Charleston Area Medical Center Healthcare System. Results A total of 61 of the 126 initial SS showed fractures. Only 9% of children received follow-up SS. Repeat SS performed approximately two weeks after positive initial SS showed signs of healing, including new fractures not reported on the initial scan. Follow-up SS performed within eight weeks after initial negative scans continued to be negative. Lastly, consults from child abuse pediatricians were found to be underutilized as only 48% of patients received consultations. Conclusion Follow-up SS and child abuse pediatrician consults were found to be underutilized. Follow-up SS and consulting child abuse specialists should not be overlooked, irrespective of positive or negative initial SS, to provide optimal management of NAT.

Hospital-Based Case Management Model for Child Protection Teams in Taiwan: An Action Research Approach

BACKGROUND

Hospital-based child protection teams play an important role in the multidisciplinary assessment, treatment, care, and rehabilitation of abused children and their families. However, the process by which these teams are built and promoted has not been explored adequately in the literature.

PURPOSE

This study was developed to examine the process used to promote child protection team case management and to evaluate the related results.

METHODS

An action research model was adopted in this study. The participants and the investigator were members of a child protection team at a medical center in southern Taiwan. Qualitative and quantitative assessments were used to identify problems related to organizational structure, intervention procedures, and evaluation effectiveness. Thereafter, the study program was implemented, and the results were evaluated. Content analysis of the qualitative data, including transcribed interviews with external benchmark members and members of the hospital's team and text entries from the investigator's reflective journal, was conducted. Quantitative data, including monitoring indicators for team case management, were analyzed using descriptive statistics.

RESULTS

Three important concepts emerged related to changes in the promotion of case management by hospital child protection teams. These included formulation of a team operation model through visits to benchmark hospitals, establishment of the case management and monitoring mechanism based on team consensus, and expansion of collaboration with external agencies through the establishment of a child and adolescent protection medical regional integration center. The results of the promotion process were affected by factors that included member willingness, teamwork, hospital support, and national policy.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Use of the hospital child protection team case management model developed in this study was shown to facilitate the provision of consultation services, integrate the opinions and resources of experts from various fields, and allow the timely provision of acute care, follow-up family environment support, and social resources required by children and their family members. These measures help prevent the reoccurrence of child abuse and enable children to grow up healthily and free from violence.

Nationwide Management of Trauma in Child Abuse: Exploring the Racial, Ethnic, and Socioeconomic Disparities

OBJECTIVE

Child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with interventions for child abuse on a national scale.

METHODS

Retrospective analysis of 2017-2018 ACS-TQIP. All children presenting with suspected/confirmed child abuse and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcomes were abuse investigations initiated among those with abuse reports, and change-of-caregiver at discharge among survivors with an investigation initiated. Multivariable regression analyses were performed.

RESULTS

7,774 child abuse victims with an abuse report were identified. Mean age was 5±5yrs, 4,221(54%) patients were White, 2,297(30%) Black, 1,543(20%) Hispanic, and 5,298(68%) had government-insurance. Most common mechanism was blunt(63%),followed by burns(10%),and penetrating(10%). Median ISS was 5[1-12]. Most common form of abuse was physical(92%), followed by neglect(6%),sexual(3%),and psychological(0.1%). Most common perpetrator of abuse was care provider/teacher(49.5%),followed by member of immediate family(30.5%),or member of the extended/step/foster family(20.0%). 6,377(82%) abuse investigations were initiated for those with abuse reports. Of these, 1,967(33%) resulted in change-of-caregiver. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change-of-caregiver after investigations, while privately-insured children were less likely to experience both (Table 3).

CONCLUSION

Significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of child abuse. Further studies are strongly warranted to understand contributing factors and possible strategies to address them.

LEVEL OF EVIDENCE

III Therapeutic/Care Management.

Implementation of the Dutch expertise centre for child abuse: descriptive data from the first 4 years

OBJECTIVE

Combined paediatric and forensic medical expertise to interpret physical findings is not available in Dutch healthcare facilities. The Dutch Expertise Centre for Child Abuse (DECCA) was founded in the conviction that this combination is essential in assessing potential physical child abuse. DECCA is a collaboration between the three paediatric hospitals and the Netherlands Forensic Institute. DECCA works with Bayes' theorem and uses likelihood ratios in their conclusions.

DESIGN

We present the implementation process of DECCA and cross-sectional data of the first 4 years.

PARTICIPANTS

Between 14 December 2014 and 31 December 2018, a total of 761 advisory requests were referred, all of which were included in this study. An advisee evaluation over the year 2015 was performed using a self-constructed survey to gain insight in the first experiences with DECCA.

RESULTS

761 cases were included, 381 (50.1%) boys and 361 (47.4%) girls (19 cases (2.5%) sex undisclosed). Median age was 1.5 years (range 1 day to 20 years). Paediatricians (53.1%) and child safeguarding doctors (21.9%) most frequently contacted DECCA. The two most common reasons for referral were presence of injury/skin lesions (n=592) and clinical history inconsistent with findings (n=145). The most common injuries were bruises (264) and non-skull fractures (166). Outcome of DECCA evaluation was almost certainly no or improbable child abuse in 35.7%; child abuse likely or almost certain in 24.3%, and unclear in 12%. The advisee evaluations (response rate 50%) showed that 93% experienced added value and that 100% were (very) satisfied with the advice.

CONCLUSION

Data show growing interest in the expertise of DECCA through the years. DECCA seems to be a valuable addition to Dutch child protection, since advisee value the service and outcome of DECCA evaluations. In almost half of the cases, DECCA concluded that child abuse could not be substantiated.

Non-accidental trauma increases length of stay and mortality in pediatric trauma

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.

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

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.

Non-accidental trauma: A national survey on management

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.