Impact on Hospital Resources of Systematic Evaluation and Management of Suspected Nonaccidental Trauma in Patients Less Than 4 Years of Age

Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma

Introduction:

The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment.

Methods:

Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year.

Results:

After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months.

Conclusions:

Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.

Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

Purpose of Review

To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).

Recent Findings

Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.

Summary

Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.

Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse

BACKGROUND/PURPOSE

Accurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations.

METHODS

Electronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH.

RESULTS

Two hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated.

CONCLUSIONS

Children under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse.

LEVEL OF EVIDENCE

III (Diagnostic Test).

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.