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Assessing guideline adherence and child abuse evaluation in infants with fractures: a retrospective quality control
Liliane Raess1, Georg Staubli1,2, Michelle Seiler1
1Pediatric Emergency Department and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
Insights
Guideline adherence for infant fractures was low at 39%, with outpatient care showing particular deficits. Increased child protection team involvement highlights a positive but incomplete impact of the new guideline.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse and Neglect
- Healthcare Quality Improvement
Background:
- A guideline was implemented to standardize the assessment of infant fractures.
- The study aimed to evaluate adherence to this guideline and its impact on clinical management.
Purpose of the Study:
- To assess overall adherence to the infant fracture guideline.
- To evaluate changes in clinical management, including child protection team involvement and skeletal survey rates.
- To identify variations in adherence based on age and care setting (inpatient vs. outpatient).
Main Methods:
- Retrospective, single-centre quality control study.
- Inclusion of infants (<12 months) diagnosed with fractures between February 2021 and August 2022.
- Exclusion of children with prior bone disease or parental non-consent.
Main Results:
- Overall guideline adherence was 39%.
- Deviations often involved missing paediatrician or family doctor consultations.
- Inpatient care (53%) showed higher adherence than outpatient care (26%).
- Child protection team involvement doubled post-implementation (54%).
Conclusions:
- Poor overall adherence necessitates ongoing clinician training on child abuse differentials.
- While child protection team involvement increased, further improvement is needed.
- Outpatient care requires focused attention to improve guideline adherence.
Aims Of The Study:
To standardise the assessment of infants with fractures at University Children's Hospital Zurich, a guideline was implemented in February 2021. The aim of this study was to assess adherence to this guideline and to assess changes in management before and after guideline implementation. The primary outcome was the overall adherence rate to the guideline. Additionally, we evaluated specific omissions of guideline steps by clinicians and investigated differences in adherence for infants younger vs older than six months, as well as variations between in- and outpatient care. Secondary outcomes focused on changes in the frequency of involvement of the child protection team, skeletal survey rates and child abuse detection, comparing these rates before and after guideline implementation.
Methods:
We conducted a retrospective single-centre quality control study. We included infants younger than 12 months diagnosed with fractures at the emergency department between 1 February 2021 and 31 August 2022. We excluded children with prior bone disease diagnoses and those whose parents did not consent to their children's data being used for research.
Results:
A total of 61 emergency department visits of infants with fractures were included in the study. The overall adherence rate to the guideline was 39%. Notably, in 68% of cases where clinicians deviated from the guideline, the primary reason was a missing consultation of the paediatrician or family doctor. Adherence levels were consistent across age groups (under and over six months), but there was a notable discrepancy between inpatient (53%) and outpatient (26%) care settings. Child protection team involvement increased to 54%, twice the rate observed before guideline implementation.
Conclusions:
Overall adherence to the guideline was poor, emphasising the necessity for continuous training of clinicians to raise awareness regarding the differential diagnosis of child abuse. Despite the guideline's implementation leading to a doubled rate of child protection team involvement, there remains a need for improvement. Notably, outpatient care exhibited lower guideline adherence, signalling an area requiring focused attention.
