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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Martin NR, Claypool AL, Diyaolu M, Chan KS, A'Neals E, Iyer K, Stewart CC, Egge M, Bernacki K, Hallinan M, Zuo L, Gupta U, Naru N, Scheinker D, Morris AM, Brandeau ML, Chao S. SCAN for Abuse: Electronic Health Record-Based Universal Child Abuse Screening. J Pediatr Surg 2024; 59:337-341. [PMID: 37953157 PMCID: PMC10842334 DOI: 10.1016/j.jpedsurg.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Identification of physical abuse at the point of care without a systematic approach remains inherently subjective and prone to judgement error. This study examines the implementation of an electronic health record (EHR)-based universal child injury screen (CIS) to improve detection rates of child abuse. METHODS CIS was implemented in the EHR admission documentation for all patients age 5 or younger at a single medical center, with the following questions. 1) "Is this patient an injured/trauma patient?" 2) "If this is a trauma/injured patient, where did the injury occur?" A "Yes" response to Question 1 would alert a team of child abuse pediatricians and social workers to determine if a patient required formal child abuse clinical evaluation. Patients who received positive CIS responses, formal child abuse work-up, and/or reports to Child Protective Services (CPS) were reviewed for analysis. CPS rates from historical controls (2017-2018) were compared to post-implementation rates (2019-2021). RESULTS Between 2019 and 2021, 14,150 patients were screened with CIS. 286 (2.0 %) patients screened received positive CIS responses. 166 (58.0 %) of these patients with positive CIS responses would not have otherwise been identified for child abuse evaluation by their treating teams. 18 (10.8 %) of the patients identified by the CIS and not by the treating team were later reported to CPS. Facility CPS reporting rates for physical abuse were 1.2 per 1000 admitted children age 5 or younger (pre-intervention) versus 4.2 per 1000 (post-intervention). CONCLUSIONS Introduction of CIS led to increased detection suspected child abuse among children age 5 or younger. LEVEL OF EVIDENCE Level II. TYPE OF STUDY Study of Diagnostic Test.
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Affiliation(s)
| | - Anneke L Claypool
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | | | - Katelyn S Chan
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Karan Iyer
- Lucile Packard Children's Hospital, Stanford, CA, USA
| | | | - Melissa Egge
- Lucile Packard Children's Hospital, Stanford, CA, USA
| | | | | | - Linda Zuo
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Urvi Gupta
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Navleen Naru
- Stanford University School of Medicine, Stanford, CA, USA
| | - David Scheinker
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA; Stanford University School of Medicine, Stanford, CA, USA
| | - Arden M Morris
- Stanford University School of Medicine, Stanford, CA, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Stephanie Chao
- Stanford University School of Medicine, Stanford, CA, USA
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Greene HM, Letson MM, Spencer SP, Dolan K, Foster J, Crichton KG. Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative. Pediatr Qual Saf 2023; 8:e644. [PMID: 37051404 PMCID: PMC10085517 DOI: 10.1097/pq9.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 02/17/2023] [Indexed: 04/14/2023] Open
Abstract
Abusive injuries can go unrecognized or improperly managed by medical providers. This study sought to standardize the nonaccidental trauma (NAT) workup and improve NAT evaluation completion for children <7 months with concerning injuries in the pediatric emergency department (PED) and inpatient settings at an urban, tertiary care children's hospital. Methods The quality improvement (QI) team created hospital guidelines for suspected NAT, including age-based recommendations (care bundle). The team embedded an order for NAT evaluation into the electronic health record (EHR). The QI team provided education on child abuse identification and evaluation across the hospital. Hospital providers received written guides focused on enhancing communication with families. Outcome measures included monthly NAT bundle use and cases between incomplete bundles in children with suspicious injuries. Chart review of incomplete bundles helped accurately identify patients who needed NAT bundles and improved accurate NAT bundle completion for appropriate patients. Results Appropriate NAT bundle completion increased from 31% during the baseline period in January 2019 to 100% in April 2020 and remained at 100% for the remainder of the study period, ending June 2021. The number of patients between missed bundles was 11 from August 2019 until March 2020, when it increased to 583. There were no missed bundles from March 2020 through June 2021. Conclusions Standardizing NAT evaluation and creating a NAT care bundle to facilitate the appropriate evaluation preceded an increase in appropriate bundle completion in patients <7 months old with possible NAT in the PED and inpatient units.
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Affiliation(s)
- H Michelle Greene
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Letson
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Sandra P Spencer
- Section of Emergency Medicine, Children's Hospital Colorado, and Department of Pediatrics University of Colorado School of Medicine, Aurora, Colorado
| | - Kevin Dolan
- Department of Quality Improvement, Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeanette Foster
- Department of Clinical Medical Social Work, The Ohio State University College of Social Work, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristin G Crichton
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
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Kellogg ND, Kissoon NN. Patient Safety Programs for Child Maltreatment: Does One Size Fit All? Pediatrics 2021; 148:peds.2021-051583. [PMID: 34426534 DOI: 10.1542/peds.2021-051583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nancy D Kellogg
- Division of Child Abuse, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Natalie N Kissoon
- Division of Child Abuse, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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