Variation in Occult Injury Screening for Children With Suspected Abuse in Selected US Children’s Hospitals

Wood, Joanne N.; Feudtner, Chris; Medina, Sheyla P.; Luan, Xianqun; Localio, Russell; Rubin, David M.

doi:10.1542/peds.2012-0244

Cited by 68 publications

(70 citation statements)

References 47 publications

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“…In a study of 40 pediatric hospitals, only 68% of infants <1 year old with traumatic brain injury (cerebral contusion, laceration, and/ or intracranial hemorrhage [ICH]) were evaluated for occult fractures, with adjusted rates ranging from 44% to 86% across hospitals. 9 Even greater variation in rates of occult fracture evaluation in this population were observed in a study of primarily non-pediatric hospitals; rates of SS performance ranged from 26% to 98% after adjusting for case mix. 10 Previous studies have also shown that among infants with similar type and severity of traumatic brain injury, infants of minority race or without private insurance were more likely to undergo SS than infants of white race or with private insurance.…”

mentioning

confidence: 76%

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

Paine

Scribano²,

Localio

et al. 2016

Pediatrics

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BACKGROUND AND OBJECTIVE: As evidenced by the variation and disparities in evaluation, there is uncertainty in determining which young children with intracranial hemorrhage (ICH) should undergo evaluation with skeletal survey (SS) for additional injuries concerning for abuse. We aimed to develop guidelines for performing initial SS in children <24 months old presenting with ICH by combining available evidence from the literature with expert opinion.

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mentioning

confidence: 76%

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

Paine

Scribano²,

Localio

et al. 2016

Pediatrics

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“…The rate of occult fracture evaluation among children with an abuse diagnosis in our study cohort, which primarily included nonpediatric-focused hospitals, was lower than the rate of 83% reported in a study of 40 pediatric hospitals. 9 Further examination revealed that teaching status and greater experience with young, injured children, as measured by the annual hospital volume of patients ,2 years old with an injury diagnosis, were associated with increased odds of occult fracture evaluation.…”

Section: Discussionmentioning

confidence: 98%

“…A study in children ,2 years old diagnosed with abuse at 40 US children's hospitals found that, overall, the majority of children (83%) received an SS, but rates varied from 55% to 93% across hospitals. 9 Even greater variation in SS performance was observed among infants ,1 year old with non-motor vehicle crash (MVC)-related femur fractures or traumatic brain injuries (TBIs). Although national guidelines regarding SS performance in infants with non-MVC-related TBI and femur fractures do not exist, these specific injuries are associated with a high likelihood of abuse.…”

Section: What This Study Addsmentioning

confidence: 99%

“…Classification in the abuse group was determined by the presence of an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis code or external cause of injury code for physical abuse or assault. The high-risk injury group included infants with ICD-9-CM codes for serious injuries frequently attributed to abuse, specifically non-MVCrelated TBIs and femur fractures 9,12 (see Supplemental Table 4 for a listing of included ICD-9-CM codes). The TBI group included infants with intracranial hemorrhage, cerebral contusions, and/or lacerations.…”

Section: Study Populationmentioning

confidence: 99%

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Evaluation for Occult Fractures in Injured Children

et al. 2015

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OBJECTIVES: To examine variation across US hospitals in evaluation for occult fractures in (1) children ,2 years old diagnosed with physical abuse and (2) infants ,1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation. METHODS:We performed a retrospective study in children ,2 years old with a diagnosis of physical abuse and in infants ,1 year old with non-motor vehicle crash-related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child-and hospital-level factors associated with evaluation for occult fractures.RESULTS: Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P , .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P , .001).CONCLUSIONS: Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.WHAT'S KNOWN ON THIS SUBJECT: Screening for occult fractures is a key component of the medical evaluation for young victims of suspected physical abuse. Little is known about adherence to occult fracture evaluation guidelines in children with suspected abuse cared for at non-pediatric-focused hospitals.WHAT THIS STUDY ADDS: Occult fracture evaluations were performed in half of young children diagnosed with abuse or injuries concerning for abuse in a large cohort of hospitals. Evaluations were more common at hospitals caring for higher volumes of young, injured children.

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“…Contributing hospitals are located in 17 of the 20 major metropolitan areas and represent 85% of freestanding children' s hospitals in the United States. 17 For the purposes of external benchmarking, participating hospitals provide demographics, procedures, resource utilization data (eg, pharmaceuticals, imaging, and laboratory), and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses. Data are deidentified at the time of submission, but study identification numbers allow tracking of a patient across multiple visits to the same hospital.…”

Section: Settingmentioning

confidence: 99%

Management of Febrile Neonates in US Pediatric Emergency Departments

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Recommended management of febrile neonates (#28 days) includes blood, urine, and cerebrospinal fluid cultures with hospital admission for antibiotic therapy. No study has reported adherence to standard recommendations in the management of febrile neonates in US pediatric emergency departments. WHAT THIS STUDY ADDS:There is wide variation in adherence to recommended management of febrile neonates. High rates of serious infections in admitted patients but low return rates for missed infections in discharged patients suggest additional studies needed to understand variation from current recommendations. abstract BACKGROUND: Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates. METHODS:Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI. RESULTS:Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P , .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management.CONCLUSIONS: There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.

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Variation in Occult Injury Screening for Children With Suspected Abuse in Selected US Children’s Hospitals

Abstract: The observed variation in screening for occult fractures in young victims of physical abuse and infants who have injuries associated with a high likelihood of abuse underscores opportunities to improve the quality of care provided to this vulnerable population.

Cited by 68 publications

References 47 publications

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

Evaluation for Occult Fractures in Injured Children

Management of Febrile Neonates in US Pediatric Emergency Departments

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