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Standardization of the Child Physical Abuse Evaluation in a Pediatric Emergency Department
Karen Yaphockun1,2, Danielle Hatt1,2, Shalon Nienow1,3
1Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California.
Insights
Implementing a new guideline significantly improved skeletal surveys and lab testing for suspected nonaccidental trauma (NAT) in young children. This initiative ensured equitable care across all racial and ethnic groups.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse Pediatrics
- Healthcare Quality Improvement
Background:
- Child abuse is a leading cause of death in young children.
- Standardized guidelines for evaluating suspected nonaccidental trauma (NAT) were lacking in the pediatric emergency department.
- Current recommendations include skeletal surveys, laboratory testing, and cranial imaging for specific age groups.
Purpose of the Study:
- To implement and evaluate a standardized guideline for NAT evaluation in a pediatric emergency department.
- To increase the rate of skeletal surveys and required laboratory testing in children aged 24 months or younger with suspected NAT.
- To assess the impact of the guideline on testing rates across different racial and ethnic groups.
Main Methods:
- A multidisciplinary team developed an age-based NAT guideline and an electronic health record order set.
- Interventions included implicit bias education, abuse recognition training, and physician-specific feedback.
- Statistical process control charts were used to monitor changes in skeletal survey and laboratory testing rates over time.
Main Results:
- Skeletal surveys ordered/planned increased from 74% to 91% for patients aged 24 months or younger with suspected NAT.
- Required laboratory testing completion increased from 13% to 71% within the same patient population.
- No significant differences in testing rates were observed when stratified by race/ethnicity.
Conclusions:
- The implementation of a standardized ED guideline, order set, and educational interventions significantly improved adherence to recommended NAT work-up.
- The initiative successfully increased diagnostic testing rates for suspected NAT in young children.
- Equitable care was maintained, with no disparities in testing based on race or ethnicity.
Background:
Child abuse is the third leading cause of death in children aged 4 years and younger. In children aged 24 months or younger with suspected nonaccidental trauma (NAT), a skeletal survey (SS) to evaluate for occult fracture is recommended. Laboratory testing and cranial imaging are recommended in specific ages and scenarios. Before this initiative, there was no standardized guideline for NAT evaluation in our pediatric emergency department (ED).
Methods:
A team of ED nurses and physicians and child abuse pediatricians reviewed data and identified barriers to obtaining laboratory testing, SS, and head computed tomography in cases of suspected NAT. Interventions included education on implicit bias and abuse recognition, creation of an age-based NAT guideline, the launch of an electronic health record order-set, and physician specific feedback. Primary aims were to increase the proportion of patients aged 24 months or younger with suspected NAT with (1) a SS ordered or planned in the ED from 74% to greater than 95% and (2) required laboratory testing completed from 13% to greater than 60% in 7 months. Results were stratified by race/ethnicity. We used statistical process control charts to examine changes in measures over time.
Results:
From October 2020 to September 2021, the proportion of patients aged 24 months or younger in the ED with SS ordered/planned increased from 74% to 91%, and those with required laboratory testing increased from 13% to 71%. There were no differences in testing stratified by race/ethnicity.
Conclusion:
We improved adherence to the recommended medical work-up for suspected NAT in patients aged 24 months or younger across racial and ethnic groups by implementation of an ED guideline with accompanying order-set, education, and individualized physician feedback.
