Background: Child abuse and neglect occur in approximately 9.2 of every 1000 children, with the highest rates in children less than 1 year. In 2018, 1770 children died as a result of abuse and neglect, with the youngest at significantly increased risk of mortality. Despite the American Academy of Pediatrics’ (AAP) comprehensive recommendations for the evaluation of suspected non-accidental trauma (NAT), great variability and delayed identification in NAT remains a challenge. Implementation of a guideline for NAT evaluation has been shown to successfully remove biases and misconceptions surrounding child abuse and decrease disparities in care. Objective: Increase the percent of children presenting with injuries concerning for NAT who undergo complete diagnostic evaluation from 33% to 95%. Methods: A multidisciplinary interdepartmental team developed a clinical practice guideline (CPG) and order set for the initial evaluation of suspected NAT in children at our tertiary care level 1 trauma center which was implemented in August 2019. A key driver diagram delineated the factors impacting the primary aim of the project (Figure 1). Complete diagnostic evaluation for suspected NAT was defined by obtaining the clinically indicated AAP recommended studies, including skeletal surveys, head CTs, transaminases, and coagulation studies. The team identified ICD-10 codes consistent with traumatic injuries in children <1 year, and these encounters were reviewed to determine if the types of injury required consideration of NAT. Data collected from January to July 2019 was used to calculate the baseline percentage of a complete comprehensive diagnostic evaluation for suspected NAT and data was followed prospectively after interventions occurred. Educational conferences, integration of the CPG into provider workflow, and order set construction were used to optimize compliance with the CPG. A statistical p-chart was used to analyze the percentage of completed evaluations over time. Nelson’s rules were used to determine special cause variation. Each data point represents a consecutive cohort of 10 patients. Results: Chart review of 265 consecutive encounters with suspected NAT between January 2019 to March 2020 was performed to analyze completion of evaluations. Pre-implementation baseline demonstrated a mean of 33.33% (40/120) for a complete initial diagnostic evaluation of NAT. Following our interventions, special cause variation was demonstrated as a single point outside the control limits on 8/14/19 and a shift beginning 9/10/2019 to a mean of 61.32% (65/106) over the past 8 months (Figure 2). Conclusions: The CPG and order set improved awareness and adherence to evidence-based diagnostic evaluation of injuries concerning NAT. In addition to providing education on the specific indicated studies of the clinical practice guideline which are inadequately completed, future interventions will be geared towards incorporating the CPG into the emergency department workflow.
Improved screening of non-accidental trauma in the emergency department
Key driver diagram
Comprehensive initial work up of suspected non-accidental trauma in the emergency department
control chart with the percentage of completed work up for each data point representing a consecutive cohort of ten emergency department encounters