This retrospective study presents data that both support and refute its main conclusion that children with suspected non-accidental trauma receive better care when admitted to a surgical service. In my opinion, the authors focused too strongly on 1 side of the debate.
Source: Magoteaux S, Gilbert M, Langlais CS, et al. Should children with suspected nonaccidental trauma be admitted to a surgical service? J Am Coll Surg. 2016;222(5):838-843; doi:10.1016/j.jamcollsurg.2015.12.049. See AAP Grand Rounds commentary by Dr. Corey Iqbal (subscription required).
PICO Question: Among children hospitalized for suspected nonaccidental trauma, is their care better on a pediatric surgical service compared to a nonsurgical service?
Question type: Descriptive
Study design: Retrospective cohort
The study looked at 1 institution's experience with non-accidental trauma (NAT) admissions over a 5-year period. In the middle of the study period, the authors note that the institution's policy changed (apparently at the request of the pediatric surgical service) from requiring all suspected NAT patients to be admitted to a surgical service (SS) to allowing such admissions to also go to a non-surgical service (NSS). They found that NAT admissions to NSS were associated with a higher rate of "care-related indicators (CRIs)," which were developed based on guidance from the American College of Surgeons. Of note, the lowest rate of CRIs was in that middle period when the admissions policy changed, and the authors state that this improvement was likely "due to educational efforts (ie performance improvement and patient safety)" begun 2-3 years earlier. They don't mention details of these efforts, nor whether they were renewed or revised in the middle period, but do note an increase in CRIs after this midpoint, when admissions to NSS were allowed.
Now, this institution is monitoring CRIs for suspected NAT admissions following a return to the requirement for admission of such children to the SS. They also mention implementation of a standard algorithm for providing multi-disciplinary care for these patients. Of course, any change in CRIs will be difficult to attribute to either the admissions policy change versus the algorithm. I bet they wish they had come up with the algorithm at the time they made their admissions policy change to NSSs a few years earlier.
Children with suspected NAT represent a very vulnerable group, and any efforts to improve their care are to be applauded. However, I don't think the authors of this study proved their point about the key importance of admission service on outcomes. I suspect, like most patient safety initiatives, the cornerstone lies in development and implementation of management pathways, accompanied by educational programs for all providers. Other institutions providing care to NAT children should take note of this study's findings, but with an eye towards the bigger picture of management rather than a single component.
