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Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative
H Michelle Greene1,2, Megan M Letson2, Sandra P Spencer3
1Division 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.
Insights
Standardizing nonaccidental trauma (NAT) evaluations with a care bundle significantly improved completion rates in young children with concerning injuries. This quality improvement initiative ensured timely and appropriate assessments in pediatric settings.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse Pediatrics
- Quality Improvement Science
Background:
- Abusive injuries in children are often missed or inadequately managed by healthcare providers.
- Standardized protocols are needed to improve the identification and evaluation of nonaccidental trauma (NAT) in young children.
- Existing evaluation processes for suspected NAT may lack consistency, leading to potential gaps in care.
Purpose of the Study:
- To standardize the nonaccidental trauma (NAT) workup for children under 7 months old presenting with concerning injuries.
- To improve the completion rate of NAT evaluations in pediatric emergency departments and inpatient settings.
- To implement a care bundle approach for evaluating suspected child abuse in a pediatric hospital.
Main Methods:
- A quality improvement team developed hospital guidelines and an age-based care bundle for suspected NAT.
- An electronic health record (EHR) order for NAT evaluation was embedded into clinical workflows.
- Education on child abuse identification and evaluation was provided to hospital staff, along with communication guides for families.
Main Results:
- Appropriate NAT bundle completion increased from 31% (baseline) to 100% by April 2020, sustained through June 2021.
- The number of patients with missed NAT bundles decreased significantly after implementation.
- The standardized approach led to consistent and complete NAT evaluations for eligible pediatric patients.
Conclusions:
- Standardizing NAT evaluations through a dedicated care bundle effectively increased appropriate evaluation completion in young children.
- The implemented quality improvement initiative successfully addressed gaps in NAT evaluation processes.
- This approach enhances the detection and management of abusive injuries in pediatric care settings.
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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