Improving the Evaluation of Non-accidental Trauma Across Multiple Specialties at a Single Institution

Overview

Journal BMJ Open Qual

Publisher BMJ Publishing Group

Specialty Health Services

Date 2025 Jan 6

PMID 39762059

Authors

Lani Kroese

Courtney Port

William Hauda 2nd

Affiliations

Soon will be listed here.

Abstract

Background: Based on the presenting injury, patients undergoing abuse evaluation may be managed by different specialties. Our local child abuse specialist expressed concern over the variability in evaluation of patients presenting with injuries concerning for non-accidental trauma (NAT). The aim of this quality improvement project was to increase the percentage of patients for whom there is a concern for NAT who receive a guideline-adherent evaluation from 7.7% to 50% in 6 months' time.

Methods: A committee of physician stakeholders developed criteria for a complete NAT evaluation which were integrated into an order panel with built-in clinical guidance for test selection within our electronic medical record. Data on the completeness of NAT evaluation in paediatric patients 0-18 years of age were collected before and after the order panel release and analysed by admitting service, injury category and equity factors.

Results: This initiative increased the percentage of patients with a guideline-adherent evaluation from a mean of 7.7% to 25% within 6 months' time. The number of days between patients with complete evaluations decreased from 63 days to 35 days. Order panel utilisation increased to 55%, and the percentage of evaluation opportunities was more complete when the order panel was used (79% vs 92%).

Conclusions: Standardisation of NAT evaluations through creation of an order panel with a clinical decision tool resulted in more guideline-adherent evaluations. The potential reduction of bias in such evaluations remains an area of interest.

References

Choudhary A, Bradford R, Dias M, Moore G, Boal D . Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology. 2011; 262(1):216-23. DOI: 10.1148/radiol.11102390. View

Narang S, Fingarson A, Lukefahr J . Abusive Head Trauma in Infants and Children. Pediatrics. 2020; 145(4). DOI: 10.1542/peds.2020-0203. View

Wootton-Gorges S, Soares B, Alazraki A, Anupindi S, Blount J, Booth T . ACR Appropriateness Criteria Suspected Physical Abuse-Child. J Am Coll Radiol. 2017; 14(5S):S338-S349. DOI: 10.1016/j.jacr.2017.01.036. View

Rumball-Smith J, Fromkin J, Rosenthal B, Shane D, Skrbin J, Bimber T . Implementation of routine electronic health record-based child abuse screening in General Emergency Departments. Child Abuse Negl. 2018; 85:58-67. DOI: 10.1016/j.chiabu.2018.08.008. View

Wood J, Hall M, Schilling S, Keren R, Mitra N, Rubin D . Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics. 2010; 126(3):408-14. DOI: 10.1542/peds.2010-0031. View

Teeuw A, Kraan R, van Rijn R, Bossuyt P, Heymans H . Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases. Acta Paediatr. 2018; 108(2):300-313. DOI: 10.1111/apa.14495. View

Louwers E, Korfage I, Affourtit M, Scheewe D, van de Merwe M, Vooijs-Moulaert A . Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics. 2012; 130(3):457-64. DOI: 10.1542/peds.2011-3527. View

Higginbotham N, Lawson K, Gettig K, Roth J, Hopper E, Higginbotham E . Utility of a child abuse screening guideline in an urban pediatric emergency department. J Trauma Acute Care Surg. 2014; 76(3):871-7. DOI: 10.1097/TA.0000000000000135. View

Rojas M, Walker-Descartes I, Laraque-Arena D . An Experimental Study of Implicit Racial Bias in Recognition of Child Abuse. Am J Health Behav. 2017; 41(3):358-367. DOI: 10.5993/AJHB.41.3.15. View

10.

Crumm C, Brown E, Thomas-Smith S, Yu D, Metz J, Feldman K . Evaluation of an Emergency Department High-risk Bruising Screening Protocol. Pediatrics. 2021; 147(4). PMC: 8015159. DOI: 10.1542/peds.2020-002444. View

11.

Stavas N, Paine C, Song L, Shults J, Wood J . Impact of Child Abuse Clinical Pathways on Skeletal Survey Performance in High-Risk Infants. Acad Pediatr. 2019; 20(1):39-45. PMC: 7898241. DOI: 10.1016/j.acap.2019.02.012. View

12.

Riney L, Frey T, Fain E, Duma E, Bennett B, Kurowski E . Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department. Pediatrics. 2017; 141(1). DOI: 10.1542/peds.2017-1994. View

13.

Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K . Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009; 124(2):509-16. DOI: 10.1542/peds.2008-2348. View

14.

Marin J, Rodean J, Hall M, Alpern E, Aronson P, Chaudhari P . Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open. 2021; 4(1):e2033710. PMC: 7846940. DOI: 10.1001/jamanetworkopen.2020.33710. View

15.

Paroskie A, Carpenter S, Lowen D, Anderst J, DeBaun M, Sidonio Jr R . A two-center retrospective review of the hematologic evaluation and laboratory abnormalities in suspected victims of non-accidental injury. Child Abuse Negl. 2014; 38(11):1794-800. PMC: 4427034. DOI: 10.1016/j.chiabu.2014.05.012. View

16.

Dudas L, Petrohoy G, Esernio-Jenssen D, Lansenderfer C, Stirparo J, Dunstan M . Every child, every time: hospital-wide child abuse screening increases awareness and state reporting. Pediatr Surg Int. 2019; 35(7):773-778. DOI: 10.1007/s00383-019-04485-2. View

17.

Deans K, Thackeray J, Askegard-Giesmann J, Earley E, Groner J, Minneci P . Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013; 75(1):161-5. DOI: 10.1097/ta.0b013e3182984831. View

18.

Greene H, Letson M, Spencer S, Dolan K, Foster J, Crichton K . Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative. Pediatr Qual Saf. 2023; 8(2):e644. PMC: 10085517. DOI: 10.1097/pq9.0000000000000644. View

19.

Flaherty E, Perez-Rossello J, Levine M, Hennrikus W . Evaluating children with fractures for child physical abuse. Pediatrics. 2014; 133(2):e477-89. DOI: 10.1542/peds.2013-3793. View

20.

Ashraf I, Faivus Ackley D, Razawich K, Botash A, Schafer M, Pekarsky A . Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma. Pediatr Qual Saf. 2022; 7(3):e567. PMC: 9197371. DOI: 10.1097/pq9.0000000000000567. View