Embed Size (px)
Citation preview
According to the National Child Abuse and Neglect Data System, >680 000 children were victims of maltreatment, and an estimated 1670 children died of abuse and neglect in 2015.1 Of the reported child fatalities, 43.9% of children suffered physical abuse, either exclusively or in combination with another maltreatment type, and 74.8% of all child fatalities secondary
to abuse or neglect in fiscal year 2015 were in children <3 years of age.1 Diagnosis of physical abuse in children remains a challenge in many practice settings because of provider bias, preconceptions, and failure to recognize the presentation as possible abuse.2, 3 As a result, these injuries may go undetected, leading to further injury before appropriate diagnosis.
Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency DepartmentLauren C. Riney, DO, Theresa M. Frey, MD, Emily T. Fain, MD, Elena M. Duma, MD, Berkeley L. Bennett, MD, MS, Eileen Murtagh Kurowski, MD, MS
BACKGROUND AND OBJECTIVES: Variability exists in the evaluation of nonaccidental trauma (NAT) in the pediatric emergency department because of misconceptions and individual bias of clinicians. Further maltreatment, injury, and death can ensue if these children are not evaluated appropriately. The implementation of guidelines for NAT evaluation has been successful in decreasing differences in care as influenced by race and ethnicity of the patient and their family. Our Specific, Measurable, Achievable, Realistic, and Timely aim was to increase the percent of patients evaluated in the emergency department for NAT who receive guideline-adherent evaluation from 47% to 80% by December 31, 2016.METHODS: The team determined key drivers for the project and tested them by using multiple plan-do-study-act cycles. Interventions included construction of a best practice guideline, provider education, integration of the guideline into workflow, and order set construction to support guideline recommendations. Data were compiled from electronic medical records to identify patients <3 years of age evaluated in the pediatric emergency department for suspected NAT based on chart review. Adherence to guideline recommendations for age-specific evaluation (<6, 6–12, and >12–36 months) was tracked over time on statistical process control charts to evaluate the impact of the interventions.RESULTS: A total of 640 encounters had provider concern for NAT and were included in the analysis. Adherence to age-specific guideline recommendations improved from a baseline of 47% to 69%.CONCLUSIONS: With our improvement methodology, we successfully increased guideline-adherent evaluation for patients with provider concern for NAT. Education and electronic support at the point of care were key drivers for initial implementation.
abstract
To cite: Riney LC, Frey TM, Fain ET, et al. Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department. Pediatrics. 2018;141(1):e20171994
Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
Drs Riney, Frey, and Fain assisted in manual chart review and analysis and drafted and revised the complete manuscript; Drs Duma and Bennett conceptualized and revised the nonaccidental trauma guideline, assisted in manual chart review and analysis, and critically reviewed the complete manuscript; Dr Murtagh Kurowski conceptualized and designed the study, developed the key drivers and quality improvement methodology, analyzed the data using quality statistics, and critically reviewed the complete manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
DOI: https:// doi. org/ 10. 1542/ peds. 2017 1994
Accepted for publication Sep 13, 2017
Address correspondence to Lauren C. Riney, DO, Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45229. Email: [email protected]
PEDIATRICS (ISSN Numbers: Print, 00314005; Online, 10984275).
Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
PEDIATRICS Volume 141, number 1, January 2018:e20171994 Quality RepoRt by guest on January 30, 2020www.aappublications.org/newsDownloaded from
An estimated 25% of children who are ultimately diagnosed with nonaccidental trauma (NAT) have a sentinel injury before their abuse diagnosis.4, 5 In a large retrospective chart review, researchers estimated that 80% of deaths from unrecognized abusive head trauma may have been prevented by earlier detection of NAT.4
At our institution, a cross-divisional team of pediatric emergency medicine and child abuse physicians convened to design and implement a guideline based on evidence and expert consensus for the evaluation of suspected NAT in a pediatric emergency department (PED). With this study, we aim to describe the strategy for implementation of a standardized approach to evaluation of suspected NAT in young children and evaluate the effect of this implementation strategy on practice variation among pediatric emergency providers. Our multidisciplinary team used improvement methodology to implement the guideline for the evaluation of suspected NAT in all children <3 years of age to decrease unwarranted provider practice variation by increasing the proportion of visits adherent to the guideline recommendations.
METhODS
Setting and Context
This quality improvement initiative was conducted at a large pediatric tertiary care center and its satellite community hospital, with an annual emergency department (ED) volume of ∼95 000 children across the 2 sites. This 600-inpatient bed pediatric institution has a level I trauma center responsible for 85% to 90% of pediatric admissions from a population base of 2 000 000 people.
This was a process improvement project designed to improve the process of performing a standardized evaluation for children
with suspected NAT. The project was evaluated by the Cincinnati Children’s Hospital Medical Center Institutional Review Board, which determined that it did not meet the definition of human subjects research.
Interventions
A team of PED attending physicians, child abuse pediatricians, and PED fellows met to discuss their theory and brainstorm key drivers to construct a key driver diagram to make explicit their theory for improvement (Fig 1). The drivers and interventions were iteratively revised and new ones were added as the team evaluated process failures using a modified failure mode and effects analysis, feedback from frontline staff, and information gained from plan-do-study-act cycles. The iterative refinement of the key driver diagram occurred throughout the study period. The team used multiple plan-do-study-act cycles to target key drivers of guideline-adherent evaluation of suspected NAT. Interventions included best practice NAT guideline development, provider education, integration of the guideline into provider workflow, order set construction to support guideline recommendations, and a communication strategy for providers to use with caregivers of patients undergoing NAT evaluation.
At our institution, a team of pediatric emergency medicine physicians and child abuse pediatricians convened to develop and implement a standardized NAT guideline for providers in a PED when evaluating children with suspected NAT (Fig 2 and Supplemental References). The guideline was based on current peer-reviewed literature as well as local expert consensus. The NAT guideline for evaluation of suspected NAT is divided into 3 separate age groups: <6, 6 to 12, and >12 to 36 months. Age groups were determined on the basis of risk of injury at different
age levels in described literature, acquisition of milestones as age progresses, and increased ability for young children to show specific signs of injury with increasing age.
Education of pediatric emergency providers occurred in August 2015 (medical students and pediatric residents), December 2015 (pediatric emergency medicine division fellows, faculty, and clinical staff), and January 2016 (emergency medicine residents). Education for the medical students, pediatric residents, and emergency medicine residents consisted of a case-based PowerPoint presentation discussing several pediatric patients with diagnoses of fractures concerning for NAT, abusive head injury, abusive abdominal injuries, and bruising patterns concerning for NAT. In addition, these conferences included education on age-based diagnostic evaluations for NAT and the introduction of the new NAT guideline. Education for the pediatric emergency medicine division consisted of a presentation of the new NAT guideline, a review of the literature summarizing the importance of standardizing evaluations for NAT, and a discussion of the literature that led to the development of the guideline.
A point-of-care order set was developed, with orders being divided into age groups corresponding to the segments in the guideline (Fig 3). The recommended workup is preselected in the order set; therefore, providers would have to deselect orders to opt out. Implementation of an electronic medical record (EMR) order set and reference guide for the standardized NAT guideline occurred in December 2015. The reference guide is an electronic version of the guideline with references attached for additional information, which can be accessed by any ED staff from a link embedded in the EMR.
Through our ED patient family experience team, an NAT communication strategy was
RINEy et al2 by guest on January 30, 2020www.aappublications.org/newsDownloaded from
developed for use when talking with families about the NAT evaluation and included the following: language to use when introducing and explaining the NAT evaluation, education on the different components of the NAT evaluation, and further references for providers evaluating patients with concern for NAT. This communication strategy was communicated to providers in the PED, radiology division, orthopedics division, and trauma division via PowerPoint presentations and is available in our EMR with the NAT guideline reference guide. A sample script for
introducing and explaining the NAT evaluation to families is included in the reference guide; its aim is to partner with families and inform them of the need for additional testing and social work consultation.
Study of the Interventions
Data were compiled from EMRs between January 2015 and March 2017 to identify eligible visits by patients <3 years of age evaluated in the PED for suspected NAT based on chart review. In an attempt to encompass all visits during which a patient was evaluated in our PED for NAT, charts were identified by using
any of the following criteria: (1) chief complaint, billing diagnosis code, or encounter diagnosis code for NAT (see Supplemental Information); (2) skeletal survey performed in a child <3 years of age; (3) diagnosis of skull fracture in a child <1 year of age; (4) diagnosis of subdural hematoma in a child <3 years of age; or (5) use of suspected NAT order set. We included all visits in which a skeletal survey was obtained because this evaluation is a way to screen for NAT at our institution (even without documentation of suspected NAT in the chart). Patients were excluded during chart review if there was no
PEDIATRICS Volume 141, number 1, January 2018 3
FIGURE 1Key driver diagram. SMART, Specific, Measurable, Achievable, Realistic, and Timely.
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
provider documentation of concern for NAT (and no skeletal survey performed) or if the patient was critically unstable in the ED (because it would not be feasible to conduct a complete NAT evaluation before admission to a critical care unit). Postmortem skeletal surveys are frequently requested by coroners in infant deaths to assess for NAT as a cause of death and were excluded. Additionally, we excluded siblings of patients found to be victims of NAT who are often referred to the PED for screening examinations by local child protective services agencies. The target population for this guideline was the index child with concern for abuse, so these sibling screening examinations were excluded. That sibling evaluations are dependent on multiple factors is supported by
literature, with most caseworkers and child abuse pediatricians agreeing that a medical evaluation for a sibling should be performed if visible injury is present in the index case or if the sibling is a twin or of a younger age (being higher risk for abuse); such medical evaluations are beyond the scope of this project.6
A standardized chart review process was completed by L.C.R., T.M.F., E.T.F., E.M.D., B.L.B., and E.M.K. Any uncertainty about documentation and/or adherence to the NAT evaluation guideline was reviewed with the entire authorship team in conjunction with a child abuse pediatrician (E.M.D. and B.L.B.).
Of note, any bruising present on the body was an indication for coagulation studies. Obtaining these
laboratory tests has clinical value as a screening mechanism for bleeding disorders. In the team’s experience, there is also forensic value because normal laboratory test results are reassuring for the prosecution that the child does not have easy bruising from minor trauma.
Measures
The primary process measure was the proportion of patients who presented to the ED and had an evaluation for suspected NAT that was adherent to all age-specific guideline recommendations. Testing that was labeled as “strongly consider” in the guideline was not used to determine adherence for our primary process measure. The denominator for this measure was any visit in which an evaluation was
RINEy et al4
FIGURE 2Guideline for evaluation of NAT. ALT, alanine transaminase; AST, aspartate aminotransferase; CBC, complete blood cell count; CT, computed tomography; ICH, intracerebral hemorrhage; PT, prothrombin time; PTT, partial thromboplastin time.
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
performed or there was concern for suspected NAT. The numerator for this measure was any visit in which the evaluation was adherent to all definitely recommended aspects of the age-specific guideline.
A p-chart was constructed to track the proportion of eligible encounters during which an evaluation for NAT was performed and that were adherent to age-specific guideline recommendations. The process measure was tracked over time on a statistical process control chart to evaluate the impact of the described interventions. The p-chart was analyzed by using the rules for interpretation of a Shewhart chart to identify special cause.7 In addition, we looked at the proportion of visits in which providers used the specific suspected NAT order set when
evaluating children for NAT and adherence to age-specific guideline recommendations when the order set was used.
RESULTS
We evaluated a total of 954 visits between January 2015 and March 2017. Of those, 314 were excluded from the analysis for the following reasons: 254 had no provider concern for NAT, 12 were clinically unstable, 42 were children of siblings with documented NAT, and 6 involved postmortem skeletal surveys looking for evidence of NAT as a cause of death. A total of 640 encounters had provider documentation of concern for NAT or skeletal surveys obtained indicating
concern for NAT and therefore were included in the analysis.
Adherence to age-specific guideline recommendations for NAT evaluation improved from a baseline of 47.1% to 68.5% (Fig 4). Special cause variation was demonstrated in November 2015, and performance at this new baseline has been sustained through March 2017. Annotations on the p-chart indicate when the team’s outlined interventions were implemented to make clear the team’s theory behind the improvement.
The baseline rate of EMR order set use was 4.4% before the initiation of this initiative. After our interventions were completed, order set use increased to 20.9% with 2 nonconsecutive points above the upper control limit (Fig 5).
PEDIATRICS Volume 141, number 1, January 2018 5
FIGURE 3NAT Electronic order set. BP, blood pressure; D/C, discharged; HR, heart rate; IV, intravenous; ROPA, rule out physical abuse; RR, respiratory rate; TPR, temperature, pulse, respiratory rate.
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
In Fig 6, we show the proportion of visits that were adherent to the NAT guideline when the order set was used compared with the proportion of visits that were adherent when the order set was not used. A higher proportion of visits were adherent to guideline recommendations when the order set was used (50% before the initiative, 100% after interventions were completed) compared with when the order set was not used (36.4%–75%) (Fig 6).
DISCUSSION
Summary and Interpretation
Variability exists in the evaluation of children for whom providers document suspicion of NAT. The unintended variation in the evaluation of these patients can lead to subsequent, more serious injuries, as shown by previous literature.
Improvement methodology was used to increase the proportion of visits in which children received standardized, evidence-based care for the evaluation of suspected NAT. Education and electronic support at the point of care were key drivers of this increase in guideline-adherent evaluation.
Earlier detection of subtle abusive injuries in infants and young chil dren can identify those at risk for future injury. Ravichandiran et al8 showed that 20% of pediatric patients with abusive fractures had a previous physician evaluation during which abuse was missed. Approximately 17% of missed abuse cases involved children who sustained repeat injuries before their eventual diagnosis. In a study of child abuse fatalities occurring in children <10 years old, one-third of patients had contact with a health care professional in the year before
their death, and almost 20% had a health care visit within a month before their death (excluding routine well-child care).9 With these findings, researchers underscore the necessity of optimizing a standardized process for the evaluation of suspected NAT to avoid missed opportunities for intervention.
Although the team has yet to achieve its stated goal of 80%, the improvement shown is significant. The degree of improvement, seen in measures of guideline implementation and adherence, is impacted by many factors: the acceptability and applicability of the guideline, the level of reliability of the interventions used by the team, and the context in which the interventions are applied. We are unaware of another study looking at adherence to an implemented guideline for all children 3 years or younger undergoing evaluation of
RINEy et al6
FIGURE 4Proportion of visits adherent to the NAT guideline, January 2015 through March 2017.
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 141, number 1, January 2018 7
FIGURE 5Proportion of visits with NAT order set used, January 2015 through March 2017.
FIGURE 6Proportion of visits with guidelineadherent care when order set used versus not, January 2015 through March 2017.
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
suspected NAT, so we do not have a direct comparison for the currently described work. The team used tools and techniques thought to function at the 10:1 performance level (1 failure out of 10 opportunities), including standard guideline and order set and awareness raising and training, but additional techniques (such as feedback regarding compliance with standards) and memory aids (such as displaying the preferred order set when certain chief complaints are presented) would likely be required to reach 90% adherence (10:1 performance).10 Additional work by the team will help identify if clinician bias, which has been shown to exist in suspicion of NAT and is the entry point for the described guideline, is impacting the improvement seen in this important project.
Physician bias can lead to underscreening and underdetection of NAT. In many studies, researchers have shown that minority and disadvantaged children from uneducated families are more likely to be screened for NAT.5, 11 In a large retrospective review, researchers showed that abusive head trauma was more likely to be unrecognized in young white children from intact families.4 Rangel et al5 showed that significant differences in rates of skeletal surveillance existed between African American children and white children <1 year of age being evaluated for head trauma. In a study in which interviews were conducted with medical providers at 3 general EDs, providers described challenges with identifying a child’s presentation as abuse and neglect, personal biases based on caregiver characteristics, and the challenges associated with reporting abuse and neglect amid a busy ED setting.3
Implementing standardized child abuse algorithms and guidelines in EDs can eliminate disparities in care. Rangel et al5 implemented a hospital policy for all infants with unwitnessed head injury to screen
for occult fractures and successfully eliminated disparities in care. Higginbotham et al2 implemented an algorithm for child abuse screening in children <1 year of age presenting with fractures. The algorithm required all children <12 months of age to have a skeletal survey, urinalysis, transaminase evaluation, and social work consult if the child presented with a skeletal fracture and was not in a motor vehicle crash. Although final determination of child abuse was still associated with socioeconomic status, screening for child abuse was no longer associated with socioeconomic status after implementation of this algorithm.2 Eliminating that association highlights the importance of standardized evaluation as described in this study for suspected NAT in a busy PED.
Strengths
In this quality improvement initiative, we used a standardized guideline for the evaluation of NAT that was based on evidence generated from peer-reviewed studies and expert consensus among physicians with pediatric emergency medicine and child abuse expertise. The clinical setting included a tertiary care pediatric hospital and its affiliated community-based pediatric hospital, both staffed by providers from the pediatric emergency medicine division. Education about the guideline was provided to pediatric emergency medicine attending physicians, clinical staff pediatricians, pediatric emergency medicine fellows, pediatric emergency medicine nurse practitioners, pediatric residents, emergency medicine residents, and medical students. The variety of clinical care settings as well as the variability in the background of the care providers speaks to the generalizability of this study.
Limitations
Limitations include the study being performed at 1 large pediatric institution and the difficulties that come with generalizability of a quality improvement process to other institutions. This is a limitation because of differences in the culture of improvement across institutions and the varying extent of resources present to support these types of interventions. In addition, data regarding postimplementation adherence to the guideline are only available for a 15-month time period. It is unclear whether increased adherence will be sustained in the future. Lastly, retrospective chart review has inherent problems with data collected possibly being inaccurate or incomplete.
The criteria used to identify cases of potential NAT were designed to maximize our capture of injuries concerning for NAT. We included pieces of the evaluation and social work consultation to help capture other injury patterns in which the provider was concerned for abuse. It is a limitation of the study that we were likely unable to capture all cases in which there may have been concern for abuse. Future work could focus on the evaluation of the provider decision to pursue an NAT evaluation, which was not the focus of this project.
CONCLUSIONS
Implementation of a quality improvement initiative has resulted in increased adherence to the evidence-based care guideline for evaluation of pediatric patients with concern for NAT. Multiple key drivers have sustained this initiative, including a readily available best practice guideline, multilevel provider education, integration of the guideline into provider workflow, and an EMR order set constructed to support guideline recommendations. The next steps for this initiative
RINEy et al8 by guest on January 30, 2020www.aappublications.org/newsDownloaded from
include analyzing outcome measures (such as sentinel injuries and return visits) and financial impact and cost analysis. Also, we hope to continue to increase adherence through individualized provider feedback and education as well as increasing the use of the EMR order set. Lastly, compliance to guideline-adherent evaluation at the provider level will be analyzed to further increase adherence and continue to improve care for children undergoing evaluation for suspected NAT.
ACkNOwLEDGMENTS
We thank Patricia Chambers and the ED patient family experience team for collaborating with us on this important quality improvement initiative.
AbbREvIATIONS
ED: emergency departmentEMR: electronic medical recordNAT: nonaccidental traumaPED: pediatric emergency
department
REFERENCES
1. US Department of Health and Human Services; Administration for Children and Families. Child maltreatment 2015. Available at: https:// www. acf. hhs. gov/ sites/ default/ files/ cb/ cm2015. pdf. Accessed April 1, 2017
2. Higginbotham N, Lawson KA, Gettig K, et al. Utility of a child abuse screening guideline in an urban pediatric emergency department. J Trauma Acute Care Surg. 2014;76(3): 871–877
3. Tiyyagura G, Gawel M, Koziel JR, Asnes A, Bechtel K. Barriers and facilitators to detecting child abuse and neglect in general emergency departments. Ann Emerg Med. 2015;66(5):447–454
4. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma [published correction appears in JAMA. 1999;282(1):29]. JAMA. 1999;281(7):621–626
5. Rangel EL, Cook BS, Bennett BL, Shebesta K, ying J, Falcone RA. Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. J Pediatr Surg. 2009;44(6):1229–1234, discussion 1234–1235
6. Vitale MA, Squires J, Zuckerbraun NS, Berger RP. Evaluation of the siblings of physically abused children: a comparison of child protective services caseworkers and child abuse physicians. Child Maltreat. 2010;15(2): 144–151
7. Provost LP, Murray SK. The Health Care Data Guide: Learning From Data for Improvement. San Francisco, CA: JosseyBass; 2011
8. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuserelated fractures. Pediatrics. 2010;125(1):60–66
9. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention? Pediatr Emerg Care. 2006;22(4): 211–214
10. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. Boston, MA: Institute for Healthcare Improvement; 2004
11. Flaherty EG, Sege R, Mattson CL, Binns HJ. Assessment of suspicion of abuse in the primary care setting. Ambul Pediatr. 2002;2(2): 120–126
PEDIATRICS Volume 141, number 1, January 2018 9 by guest on January 30, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2017-1994 originally published online December 6, 2017; 2018;141;Pediatrics
Bennett and Eileen Murtagh KurowskiLauren C. Riney, Theresa M. Frey, Emily T. Fain, Elena M. Duma, Berkeley L.
Emergency DepartmentStandardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric
ServicesUpdated Information &
http://pediatrics.aappublications.org/content/141/1/e20171994including high resolution figures, can be found at:
Referenceshttp://pediatrics.aappublications.org/content/141/1/e20171994#BIBLThis article cites 8 articles, 1 of which you can access for free at:
Subspecialty Collections
ubhttp://www.aappublications.org/cgi/collection/child_abuse_neglect_sChild Abuse and Neglectsubhttp://www.aappublications.org/cgi/collection/emergency_medicine_Emergency Medicinefollowing collection(s): This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or
Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2017-1994 originally published online December 6, 2017; 2018;141;Pediatrics
Bennett and Eileen Murtagh KurowskiLauren C. Riney, Theresa M. Frey, Emily T. Fain, Elena M. Duma, Berkeley L.
Emergency DepartmentStandardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric
http://pediatrics.aappublications.org/content/141/1/e20171994located on the World Wide Web at:
The online version of this article, along with updated information and services, is
http://pediatrics.aappublications.org/content/suppl/2017/12/04/peds.2017-1994.DCSupplementalData Supplement at:
1073-0397. ISSN:60007. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print
the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
by guest on January 30, 2020www.aappublications.org/newsDownloaded from
