Investigators from multiple institutions conducted a retrospective review to compare outcomes for pediatric trauma patients suffering from suspected nonaccidental trauma (sNAT) who were managed on a surgical service (SS) versus a nonsurgical service (NSS). The researchers reviewed trauma admissions to the Phoenix Children’s Hospital Trauma Center, an American College of Surgeons (ACS) verified level I pediatric trauma center, from 2009–2013. In 2011 the institution implemented a policy change that permitted admission of sNAT patients to a NSS. For the study, trauma admissions were identified by ICD-9 codes; children admitted for trauma from sNAT were identified by specific diagnostic codes, record of consult by the Child Protection Team, report of physical abuse, or if a skeletal survey was performed. Identified patients with sNAT were classified as admitted to a SS or NSS. The primary study outcome was care-related indicators (CRIs), which are specific events defined by the ACS to identify episodes of suboptimal care. CRIs include instances of missed injuries, readmissions, and other incidents that represent opportunities for quality improvement in patient care. Patient age and injury severity score (ISS) were also recorded. Rates of CRIs among children admitted to a SS or NSS were compared.
The investigators identified 671 patients admitted with sNAT: 365 were admitted to a SS (8% of SS trauma admissions) and 306 were admitted to a NSS (37% of NSS trauma admissions). Patient age and the presence of multisystem injuries did not differ between the 2 groups. While patients admitted to a SS had a statistically significant higher ISS, the difference was only 1 point, which is considered to be a clinically insignificant difference.1
Seventy percent of all CRIs occurred in patients admitted to a NSS. CRIs occurred more frequently with admission of sNAT patients to a NSS: 33 CRIs per 100 patients on a NSS versus 12 CRIs per 100 patients on an SS, P < .001. There was an increase in CRIs for sNAT patients from 18 per 100 patients to 26 per 100 patients after the 2011 policy change. The most common CRIs were direct admission, lack of consult, missed injury, and readmission.
The authors conclude that patients with sNAT benefit from admission to a SS. Since reviewing these data, the institution has reversed their 2011 policy and now requires that all patients with sNAT be admitted to the trauma service.
Dr Iqbal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
The medical community has recognized the vulnerability of pediatric trauma patients.2 Perhaps none are as vulnerable as victims of NAT. The current study highlights the suboptimal care (as defined by the ACS) of children with sNAT despite receiving care from...