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Published on: August 17, 2017
Identifying Child Abuse in Patients With Femur Fractures Through Pathway Compliance: A Pilot Study
Kylie Scallon1, Shirley Wiggins2, Kaeli K Samson3
1Trauma, Children's Nebraska, Omaha, USA.
Insights
Implementing a clinical pathway for pediatric femur fractures improved child abuse identification. However, consistent adherence to the full pathway is crucial for successful diagnosis and intervention in suspected non-accidental trauma cases.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse Pediatrics
- Trauma Surgery
Background:
- Child abuse is a major cause of child morbidity and mortality, necessitating accurate identification through thorough history and physical examinations.
- Standardized screening tools and clinical pathways can aid in identifying pediatric patients with injuries secondary to abuse.
- There is variability in recommendations regarding the upper age limit for routine pediatric abuse evaluations.
Purpose of the Study:
- To describe the outcomes of implementing an evidence-based clinical pathway for suspected non-accidental trauma in pediatric patients aged five and under with femur fractures.
- To characterize the population of pediatric patients with femur fractures and analyze the findings associated with the clinical pathway.
Main Methods:
- A retrospective study was conducted on patients meeting National Trauma Data Standard registry criteria and presenting with a femur fracture at a single institution.
- Variables analyzed included demographics, injury characteristics, hospital course, and outcomes, excluding patients with metabolic bone disease.
Main Results:
- Of 200 eligible patients, 32 had confirmed or suspected child abuse.
- While all 32 underwent skeletal surveys, only 71.9% received the complete workup as per the clinical pathway.
- A confirmed child abuse diagnosis was established in 65.6% of these cases.
Conclusions:
- Clinical pathways standardize assessments and interventions but rely on individual judgment for implementation.
- Children with suspected abuse are a vulnerable population, and clinical pathways can aid diagnosis to prevent further harm.
- Successful implementation of clinical pathways for suspected child abuse requires consistent adherence to every step.
Abstract:
Background Child abuse is a significant cause of morbidity and mortality in children. A thorough history and physical exam is critical to identifying abuse. Standardized screening tools as well as clinical pathways can assist with identifying patients who may have an injury secondary to abuse. There are varied recommendations for the upper age in which to routinely evaluate pediatric patients for child abuse. Objectives The primary objective of this study was to describe the outcomes of the implementation of an evidence-based clinical pathway for suspected non-accidental trauma for all pediatric patients aged five years and under presenting with a femur fracture. This pathway includes orders for imaging, labs, and consults. In addition, the characteristics of this population and the findings were described. Methods A retrospective study of patients at a single institution who met the National Trauma Data Standard registry inclusion criteria and had a femur fracture was performed. Variables analyzed included age, demographics, mechanism and location of injury, admission status and service, injury severity, hospital characteristics, and discharge status. Patients with a metabolic bone disease were excluded. Results There were 200 patients who met the inclusion criteria. Thirty-two patients had a diagnosis of confirmed or suspected child abuse. While all 32 patients had a skeletal survey performed, only 23 (71.9%) had the complete workup per the clinical pathway, and 21 (65.6%) had a diagnosis of confirmed child abuse. Conclusion Clinical pathways are established to provide the standardization of clinical assessments and interventions; however, this process relies on a single individual to make a judgment determining whether or not to implement the pathway. Children presenting to an emergency department with confirmed or suspected child abuse are a vulnerable population. A child abuse diagnosis is a clinical judgment; however, clinical pathways aid in the diagnosis in hopes to stop any further abuse. For a pathway to be successful, each step needs to be addressed.
