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

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.

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.

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).

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.