- Email: [email protected]
Should Children with Suspected Nonaccidental Injury Be Admitted to a Surgical Service?
Should Children with Suspected Nonaccidental Injury Be Admitted to a Surgical Service? Summer Magoteaux, BSN, Megan Gilbert, MSN, CPNP-AC, Crystal S Langlais, Pamela Garcia-Filion, PhD, MPH, David M Notrica, MD, FACS
MPH,
In many hospitals, children with suspected nonaccidental trauma (sNAT) are admitted to nonsurgical services (NSS). Although the surgical service (SS) initially admitted sNAT patients at our American College of Surgeons (ACS)-verified level 1 pediatric trauma center (vPTC), a change in hospital policy allowed admission to NSS. The objective of this study was to determine if the rate of care-related indicators (CRIs) varies by admission to an SS vs an NSS in the sNAT patient population. STUDY DESIGN: We conducted a retrospective review of patients admitted to an ACS vPTC with a final diagnosis of sNAT between January 2009 and December 2013. The primary study outcome was the presence of a CRI. Surgical service and NSS admissions were compared on age, Injury Severity Score, and Abbreviated Injury Scale to account for population differences among admissions by service and type of CRIs, using chi-square or Fisher’s exact and Mann-Whitney tests. Rates of CRIs over time were also evaluated. RESULTS: During the study period, 5,340 total patients were admittedd671 (13%) with sNAT. Nonsurgical services admitted 306 patients (46%) of these patients, but 71% (n ¼ 102) of the CRIs occurred in patients admitted to an NSS. The rate of CRIs per 100 patients was 33 for NSS compared with 12 for SS (p < 0.001). The overall rate of CRIs for sNAT increased from 18 to 26 (p ¼ 0.07) per 100 patients after the policy change. CONCLUSIONS: Nonaccidental trauma patients admitted to an NSS were shown to have more CRIs than those admitted to an SS. This study supports an ACS requirement of admission of sNAT to an SS. (J Am Coll Surg 2016;222:838e843. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
The American College of Surgeons (ACS) provides guidelines on the requisite resources for optimal care of injured children in the reference book, Resources for Optimal Care of the Injured Patient.1 An important aspect of the
guidelines mandates admission of multiply injured or seriously injured patients to a surgical service (SS) for care management by a credentialed trauma care provider.1 Children who are injured as a result of nonaccidental trauma (NAT) often present with an unknown mechanism of injury. The unknown, incomplete, or false history provided often delays identification of multisystem or serious injury, and may prevent appropriate determination of criteria for initial SS admission. Once admitted, these patients are often retrospectively found to have met criteria for initial SS admission.2,3 The frequency of adverse events during admission is unknown in this population. Furthermore, there have been no studies to examine whether admission to an SS decreases the incidence of adverse events in the NAT patient population.4-7 American College of Surgeons-verified pediatric trauma centers (vPTC) are required to review patient care for performance improvement and patient safety opportunities. To facilitate this effort, the ACS guidelines explicitly
CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Presented at the 2nd Annual Western Pediatric Trauma Conference, San Diego, CA, July 2014. Received September 21, 2015; Revised November 29, 2015; Accepted December 28, 2015. From the Trauma Center (Magoteaux, Gilbert, Langlais, Garcia-Filion, Notrica) and Barrow Neurological Institute (Garcia-Filion), Phoenix Children’s Hospital; the Department of Child Health, University of Arizona, College of Medicine-Phoenix (Garcia-Filion, Notrica); and the Department of General Surgery, Mayo Clinic (Notrica), Phoenix, AZ. Correspondence address: David M Notrica, MD, FACS, Level 1 Pediatric Trauma Center, Phoenix Children’s Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016. email: [email protected]
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.12.049 ISSN 1072-7515/16
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Abbreviations and Acronyms
ACS CRI GCS IQR ISS NAT NSS sNAT SS vPTC
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
American College of Surgeons care-related indicators Glasgow Coma Scale interquartile range Injury Severity Score nonaccidental trauma nonsurgical service suspected nonaccidental trauma surgical service verified pediatric trauma center
address the use of audit filters or care-related indicators (CRIs), which may indicate adverse suboptimal care for process improvement opportunities.1 In 2011, the pediatric surgical service questioned the added benefit of SS admission of suspected nonaccidental trauma (sNAT) patients, and a policy change allowed admission to a nonsurgical service (NSS). In evaluating this policy change, the performance improvement and patient safety process examined the frequency of CRIs in patients with sNAT to determine whether the rate of CRIs varied based on admission to an SS or an NSS, and examined changes over time.
Admitting Service for Nonaccidental Trauma
839
5,340 PaƟents in Trauma Registry
671 (12.6%) sNAT
365 (54%) admiƩed to SS
306 (46%) admiƩed to NSS
40 paƟents (11%) with 43 CRIs
76 paƟents (25%) with 102 CRIs
12 CRIs per 100 paƟents on SS
33 CRIs per 100 paƟents on NSS
Figure 1. CONSORT diagram of subject enrollment. CRI, carerelated indicator; NSS, nonsurgical service; sNAT, suspected nonaccidental trauma; SS, surgical service.
METHODS Study design The program evaluation used a retrospective review of patients admitted for evaluation of NAT to a level 1 vPTC between January 2009 and December 2013. Patients were identified from the institution’s trauma registry (Fig. 1).1 By ACS guidelines, patients are entered in the trauma registry if they are either diagnosed with an ICD-9 between 800 and 959 (excluding certain diagnostic codes within this range) or present with a trauma-related mechanism (with or without injury diagnosis) and have an SS consult.1 The sNAT population was derived from the trauma registry based on specific population identifiers including: E-Code E988.x, E967.x, Child Protection Team consult recorded, report of physical abuse, or a skeletal survey (88.31) was performed. The primary study outcome was the presence of a CRI. The study did not involve human subject research, but was instead considered a quality improvement evaluation. Data collection The admitting service was classified as an SS if the patient was admitted to orthopaedic surgery, neurosurgery, or the trauma service (pediatric surgeons). The trauma service did not consult on neurosurgery or orthopaedic surgery
patients unless requested. Patients were classified as NSS if admitted to general pediatric hospitalist or critical care specialist. In accordance with the ACS guidelines, CRIs are standardly defined in the Resources for Optimal Care of the Injured Patient1 and further expanded at the discretion of the vPTC. The CRIs that are routinely collected at our trauma center (defined in detail below) include delay in diagnosis or missed injury, lack of consult, lack of follow-up, National Trauma Data Bank-defined complications, readmissions, death with opportunity for improvement, error in communication, inappropriate airway management, Glasgow Coma Scale (GCS) < 8 without an intracranial pressure monitor, under-triage, and direct admissions. The type and number of CRIs per patient and admitting service (SS vs NSS) were collected. Aggregate data were also queried from the trauma registry on age and Injury Severity Score (ISS) distributions by admitting service. Care-related indicator definitions Delay in diagnosis or missed injury is an injury identified in a patient more than 24 hours post-admission. Lack of consult is defined as a patient not receiving a consult
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from a specialty that is appropriate for the patient’s care. Lack of follow-up occurs when follow-up with appropriate disciplines is not requested or included in discharge planning or instructions. Complications include a transfer to the ICU from the floor, reintubation, mainstream intubation, pressure ulcer, and nasogastric tube placement in a patient with a basilar skull fracture. Readmission is a CRI when patients are readmitted secondary to findings related to their initial hospitalization within 30 days of discharge. Death is a CRI when it is deemed preventable or with opportunity for improvement (per ACS Committee on Trauma guidelines1). Error in communication includes error in discharge, incomplete documentation by treating physician, miscommunication between multidisciplinary teams, lack of protocol compliance, and delay in consulting subspecialists. Inappropriate airway management occurs when patients with a GCS score < 8 do not receive airway adjuncts. A GCS < 8 without an intracranial pressure monitor is defined as when a patient with a GCS < 8 fails to have an intracranial pressure monitor placed within 24 hours of admission. Under-triage occurs when a patient meets pre-defined level 1 or level 2 trauma activation criteria, but the patient is not triaged as such. Direct admissions are CRIs if patients present with traumatic injury within 24 hours of injury time (excluding isolated orthopaedic or ophthalmic injury), but are not evaluated in the emergency department before admission. Data analysis The data were analyzed to examine the frequency of CRIs among sNAT patients admitted to an SS compared with those admitted to a NSS. Additionally, the purpose of this analysis was to evaluate if provider type is important in guiding optimal care, managing, and ultimately improving outcomes for this vulnerable pediatric population. Data were analyzed using Stata 13.1. Patients admitted to SS and NSS were compared on age, ISS, and Abbreviated Injury Scale to evaluate for population differences among patients by service and type of CRIs, using chi-square or Fisher’s exact and Mann-Whitney tests, as appropriate. Statistical significance was defined as an alpha of 0.05, with a 2-sided alternative hypothesis. Data were not normally distributed and therefore are presented as median and interquartile range (IQR). Total CRIs per admitting services were converted to a rate per 100 sNAT admissions in order to account for multiple CRIs per patient. Rates were compared overall and stratified by year of admission.
J Am Coll Surg
RESULTS During the study period, 5,340 total patients were entered into the trauma registry. Suspected nonaccidental trauma patients made up 8% (n ¼ 365 of 4,504) of SS trauma admissions and 37% (n ¼ 306 of 836) of NSS trauma admissions, resulting in a study population composed of 671 patients (13% of all admissions) (Fig. 1). The median age of sNAT patients admitted to an SS (8 mo; IQR 3, 20 mo) was similar to that of patients in an NSS (8 mo; IQR 3, 16 mo) (p ¼ 0.608). There were 136 total patients with an ISS >15 and 39 with ISS > 25. There was a statistically significant 1 point difference in ISS between SS admits (median 9; IQR 5, 16) and NSS admits (median 8; IQR 4, 10) (p < 0.001). In SS, 55% (202 of 365) of patients had multisystem injury (Abbreviated Injury Scale score 1 in at least 2 regions); the 48% (146 of 306) of patients admitted to an NSS had multisystem injury. Care-related indicators A total of 145 CRIs were identified in 116 patients (Fig. 1). The most common CRIs were direct admission (23%, n ¼ 34), lack of consult (14%, n ¼ 20), missed injury (13%, n ¼ 19), and readmission (13%, n ¼ 19). Seventy percent (n ¼ 102) of the CRIs occurred in patients admitted to an NSS. Table 1 delineates the frequency and rate of CRIs by admitting service. Table 2 shows the injuries that were missed by admitting service. The sNAT patients admitted to an NSS experienced a higher rate of CRIs (per 100 patients) throughout the study period compared with those admitted to an SS (33 CRIs per 100 patients [NSS] vs 12 CRIs per 100 patients [SS]; p < 0.001). Secular trends in care-related indicators Rate of CRIs by year and admitting service are shown in Figure 2. The overall rate of CRIs increased from 18 per 100 patients for 2009 through 2010 to 26 for 2012 through 2013 (p ¼ 0.07), after the 2011 policy change.
DISCUSSION Our analysis demonstrated that the rate of CRIs is higher for sNAT patients admitted to an NSS vs an SS, and an overall trend toward increased rates of CRIs was temporally related to a change in policy that resulted in more sNATs admitted to an NSS. These data suggest that provider type is important in guiding optimal care, managing, and ultimately improving outcomes for this vulnerable population. Ideal management of sNAT patients begins with an early thorough assessment for
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Table 1.
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841
Care-Related Indicators by Admitting Service
Care-related indicator
NSS (n ¼ 306) CRI/100 CRI, n admissions
Direct admission Lack of consultation Missed injury Readmission Complication Under-triage Error in communication Death Lack of follow-up GCS < 8 without ICP monitor Inappropriate airway management Totals Mean CRI/100 admissions
28 15 14 10 10 6 6 6 6 1 0 102
SS (n ¼ 365) CRI/100 CRI, n admissions
9.15 4.90 4.58 3.27 3.27 1.96 1.96 1.96 1.96 0.33 0.00
6 5 5 9 8 5 2 1 0 1 1 43
Total CRIs Frequency CRI, n of CRI, %
1.64 1.37 1.37 2.47 2.19 1.37 0.55 0.27 0.00 0.27 0.27
33.3
34 20 19 19 18 11 8 7 6 2 1 145
22.9 13.5 12.8 12.8 12.16 7.4 5.4 4.7 4.1 1.4 0.7
11.8
p Value
<0.001 0.007 0.013 0.533 0.390 0.570 0.151 0.051 0.009 1.000 1.000 <0.001
21.6
CRI, care-related indicator; GCS, Glasgow Comma Scale; ICP, intracranial pressure; NSS, nonsurgical service; SS, surgical service.
abuse identification followed by appropriate care and follow-up.2,3 The discrepancy in the rate of CRIs between services may help to highlight the relationship of the admitting service to quality of care measures in the sNAT population. Opportunities for improvement regarding patient management are reflected by CRI occurrence, the most common of which, in our study, were direct admission, missed injury, lack of consult, readmission, and complication. All but readmission were statistically higher among NSS admits compared with SS admits. Less common, but equally concerning, is the presence of CRIs related to lack of follow-up, errors in communication, and death. Patients admitted to an SS experienced only 12 CRIs per
100 admissions compared with 33 CRIs per 100 admissions among patients admitted to an NSS. Comparison between SS and NSS admissions on ISS show a 1 point higher severity among SS admissions, suggesting the difference cannot be attributed to greater acuity in the NSS admits. Missed injury in the sNAT patient is associated with additional risks compared with those for other trauma patients. Although almost none of the missed injuries required surgery, they did require treatment and followup. Additionally, some aspects of missed injury in 90 SS
80
Missed injury
Femur fracture Rib fracture(s) Skull fracture Foot fracture Tibia/fibula fracture C2 laminar fractures Radius fracture Humerus fracture Bruising to frenulum Bruising of sternum Bruising to spine Cervical esophagus perforation Missed child abuse NSS, nonsurgical service; SS, surgical service.
Injuries by service, n NSS SS
e 4 1 1 2 1 1 1 1 1 1 1 2
NSS
70
Missed Injuries by Admitting Service
4 e 1 e e e e e e e e e e
CRIs per 100 paƟents
Table 2.
Total
60 50 40 30 20 10 0 2009
2010
2011
2012
2013
Year
Figure 2. Rate (per 100 nonaccidental trauma patients) of carerelated indicators (CRIs) by admitting service. The red (top) dotted line is the mean rate for nonsurgical service (NSS) admissions, the gray (middle) dotted line is the mean rate for all patients, and the blue (lowest) dotted line is the mean rate for surgical service (SS) admissions.
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Admitting Service for Nonaccidental Trauma
sNAT pose unique risks, including concluding the mechanism was accidental, return of the patient to an unsafe environment, and decreased support for the legal case against the perpetrator. The second reason is particularly compelling because abuse is a repetitive process with minor NAT often precluding more severe and even fatal outcomes.8-13 Missed signs of abuse are often sentinel injuries preceding escalating injury or death, making failure to diagnose even a minor injury far more serious if it results in the return of a child to an unsafe environment.8-11 In our analysis, patients admitted to an NSS were also more likely to experience lack of appropriate follow-up and communication errors compared with their SS admission counterparts. Lack of follow-up is particularly concerning for patients evaluated and returned to their original environment because missed follow-up appointments can provide another opportunity for child protection agencies to intervene.14 Additionally, because many of these children are discharged from the hospital in the custody of someone other than their initial caregivers, it is imperative that follow-up be arranged before hospital discharge to ensure the patient receives the necessary services. Communication between the treating medical providers, caregivers, social work, law enforcement, child welfare agencies, and child abuse specialists is essential to ensuring appropriate patient management and follow-up. Although hospitalists, critical care specialists, and forensic pediatrics are part of the trauma committee membership, and they participate in the meetings regularly, coordination of care for an individual patient is time-consuming. For patients admitted to the SS, care is coordinated by a dedicated team of trauma nurse practitioners, who round daily on inpatients, coordinate care between multiple specialties, and help implement guidelines related to best practice, all of which helps to ensure that care-related incidents do not occur.15 Although the Child Protection Team evaluates for evidence of child maltreatment, they do not make treatment recommendations, leaving some NSS patients in the care of specialists with infrequent exposure to the sNAT victim. This study demonstrates that admission to an SS, in conjunction with the trauma team resources, was associated with fewer CRIs in NAT patients at our institution. The trauma nurse practitioners are likely critical in the role of avoiding CRIs. Analysis of the data over time demonstrates the impact of admitting service on patient care. Although the CRIs were more frequent among patients admitted to NSS admissions compared those admitted to an SS during every year of the study, there was an initial decrease in
J Am Coll Surg
overall CRIs, followed by an increase in frequency in the later study years. We speculate that the initial decrease in CRIs among NSS admissions was due to educational efforts (ie performance improvement and patient safety) started in mid-2008 as our institution prepared to become an ACS-verified level 1 pediatric trauma center. In mid2011, our institution’s policy changed to no longer requiring admission of sNAT patients to an SS. As such, sNAT admissions to NSS spiked, and we speculate the sharp increase in total CRIs starting in 2012 is a direct result of the change in admitting service. Any retrospective study has limitations, even those done specifically to evaluate the impact of a significant policy change. Other unmeasured changes may have affected the data. In this study, the injury severity of patients across admitting services, as measured by the ISS, varied slightly (median 9 vs 8), which was statistically significant. Although this presents the potential of bias in the underlying population, a 1-point difference in ISS is not clinically important. We acknowledge that the 2 populations may not be identical, but believe that the temporal changes in rate over the study years suggest that some of the CRI differences are due to the admitting service and not a difference in population. The age distribution between the admitting services was similar, minimizing the differences in complexity when treating young, preverbal children. The higher number of direct admissions to an NSS may have contributed to the higher rates of missed injuries, but does not excuse it. The standardized system for patient intake through the emergency department, as well as triage guidelines, facilitates an early and thorough evaluation before admission for all injured patients. Although our trauma program is an ACSvPTC, it may not be possible to generalize this information to adult trauma centers, or even pediatric trauma centers with fewer resources dedicated to victims of NAT. In April 2014, the hospital policy at our institution was modified to again require admission of sNAT patients to the trauma service. Data are actively being collected to evaluate the effectiveness of this practice and the rate of CRIs. A standard algorithm for assessment of these patients has been put into place to improve thorough sNAT evaluations from a multi-disciplinary approach.
CONCLUSIONS Nonaccidental trauma patients admitted to an NSS were shown to have more CRIs than those admitted to an SS, including higher rates of missed injuries, errors in communication, and lack of appropriate follow-up. In a free-standing level 1 pediatric trauma center, admission of patients with sNAT to an SS appears to be associated
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with improved patient care. The requirements set forth by the ACS should specifically mandate sNAT patients be admitted to an SS in order to ensure the best possible outcomes for this vulnerable population. Author Contributions Study conception and design: Magoteaux, Gilbert, Langlais, Garcia-Filion, Notrica Acquisition of data: Magoteaux, Gilbert Analysis and interpretation of data: Magoteaux, Langlais, Garcia-Filion, Notrica Drafting of manuscript: Magoteaux, Gilbert, Langlais, Garcia-Filion, Notrica Critical revision: Magoteaux, Gilbert, Langlais, GarciaFilion, Notrica REFERENCES 1. Hospital organization and the trauma program. In: Resources for Optimal Care of the Injured Patient. 5th ed. Chicago, IL: American College of Surgeons; 31e35. 2. Larimer EL, Fallon SC, Westfall J, et al. The importance of surgeon involvement in the evaluation of nonaccidental trauma patients. J Pediatr Surg 2013;48: 1357e1362. 3. Kempe CH, Silverman FN, Steele FB, et al. The battered-child syndrome. JAMA 1962;181:17e24. 4. Leventhal JM, Martin KD, Gaither JR. Using US data to estimate the incidence of serious physical abuse in children. Pediatrics 2012;129:458e464.
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5. Lane WG, Lotwin I, Dubowitz H, et al. Outcomes for children hospitalized with abusive versus noninflicted abdominal trauma. Pediatrics 2011;127:e1400ee1405. 6. Roaten JB, Partrick DA, Nydam TL, et al. Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center. J Pediatr Surg 2006;41:2013e2015. 7. DiScala C, Sege R, Li G, Reece RM. Child abuse and unintentional injuries: a 10-year retrospective. Arch Pediatr Adolesc Med 2000;154:16e22. 8. Tilak GS, Pollock AN. Missed opportunities in fatal child abuse. Pediatr Emerg Care 2013;29:685e687. 9. Oral R, Yagmur F, Nashelsky M, et al. Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse. Pediatr Emerg Care 2008;24: 816e821. 10. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention? Pediatr Emerg Care 2006;22:211e214. 11. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621e626. 12. Spivey MI, Schnitzer PG, Kruse RL, et al. Association of injury visits in children and child maltreatment reports. J Emerg Med 2009;36:207e214. 13. Keshavarz R, Kawashima R, Low C. Child abuse and neglect presentations to a pediatric emergency department. J Emerg Med 2002;23:341e345. 14. Oral R, Blum KL, Johnson C. Fractures in young children: Are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse? Pediatr Emerg Care 2003;19:148e153. 15. Haan JM, Dutton RP, Willis M, et al. Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner. J Trauma 2007;63:339e343.
MPH,
In many hospitals, children with suspected nonaccidental trauma (sNAT) are admitted to nonsurgical services (NSS). Although the surgical service (SS) initially admitted sNAT patients at our American College of Surgeons (ACS)-verified level 1 pediatric trauma center (vPTC), a change in hospital policy allowed admission to NSS. The objective of this study was to determine if the rate of care-related indicators (CRIs) varies by admission to an SS vs an NSS in the sNAT patient population. STUDY DESIGN: We conducted a retrospective review of patients admitted to an ACS vPTC with a final diagnosis of sNAT between January 2009 and December 2013. The primary study outcome was the presence of a CRI. Surgical service and NSS admissions were compared on age, Injury Severity Score, and Abbreviated Injury Scale to account for population differences among admissions by service and type of CRIs, using chi-square or Fisher’s exact and Mann-Whitney tests. Rates of CRIs over time were also evaluated. RESULTS: During the study period, 5,340 total patients were admittedd671 (13%) with sNAT. Nonsurgical services admitted 306 patients (46%) of these patients, but 71% (n ¼ 102) of the CRIs occurred in patients admitted to an NSS. The rate of CRIs per 100 patients was 33 for NSS compared with 12 for SS (p < 0.001). The overall rate of CRIs for sNAT increased from 18 to 26 (p ¼ 0.07) per 100 patients after the policy change. CONCLUSIONS: Nonaccidental trauma patients admitted to an NSS were shown to have more CRIs than those admitted to an SS. This study supports an ACS requirement of admission of sNAT to an SS. (J Am Coll Surg 2016;222:838e843. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
The American College of Surgeons (ACS) provides guidelines on the requisite resources for optimal care of injured children in the reference book, Resources for Optimal Care of the Injured Patient.1 An important aspect of the
guidelines mandates admission of multiply injured or seriously injured patients to a surgical service (SS) for care management by a credentialed trauma care provider.1 Children who are injured as a result of nonaccidental trauma (NAT) often present with an unknown mechanism of injury. The unknown, incomplete, or false history provided often delays identification of multisystem or serious injury, and may prevent appropriate determination of criteria for initial SS admission. Once admitted, these patients are often retrospectively found to have met criteria for initial SS admission.2,3 The frequency of adverse events during admission is unknown in this population. Furthermore, there have been no studies to examine whether admission to an SS decreases the incidence of adverse events in the NAT patient population.4-7 American College of Surgeons-verified pediatric trauma centers (vPTC) are required to review patient care for performance improvement and patient safety opportunities. To facilitate this effort, the ACS guidelines explicitly
CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Presented at the 2nd Annual Western Pediatric Trauma Conference, San Diego, CA, July 2014. Received September 21, 2015; Revised November 29, 2015; Accepted December 28, 2015. From the Trauma Center (Magoteaux, Gilbert, Langlais, Garcia-Filion, Notrica) and Barrow Neurological Institute (Garcia-Filion), Phoenix Children’s Hospital; the Department of Child Health, University of Arizona, College of Medicine-Phoenix (Garcia-Filion, Notrica); and the Department of General Surgery, Mayo Clinic (Notrica), Phoenix, AZ. Correspondence address: David M Notrica, MD, FACS, Level 1 Pediatric Trauma Center, Phoenix Children’s Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016. email: [email protected]
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
838
http://dx.doi.org/10.1016/j.jamcollsurg.2015.12.049 ISSN 1072-7515/16
Vol. 222, No. 5, May 2016
Magoteaux et al
Abbreviations and Acronyms
ACS CRI GCS IQR ISS NAT NSS sNAT SS vPTC
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
American College of Surgeons care-related indicators Glasgow Coma Scale interquartile range Injury Severity Score nonaccidental trauma nonsurgical service suspected nonaccidental trauma surgical service verified pediatric trauma center
address the use of audit filters or care-related indicators (CRIs), which may indicate adverse suboptimal care for process improvement opportunities.1 In 2011, the pediatric surgical service questioned the added benefit of SS admission of suspected nonaccidental trauma (sNAT) patients, and a policy change allowed admission to a nonsurgical service (NSS). In evaluating this policy change, the performance improvement and patient safety process examined the frequency of CRIs in patients with sNAT to determine whether the rate of CRIs varied based on admission to an SS or an NSS, and examined changes over time.
Admitting Service for Nonaccidental Trauma
839
5,340 PaƟents in Trauma Registry
671 (12.6%) sNAT
365 (54%) admiƩed to SS
306 (46%) admiƩed to NSS
40 paƟents (11%) with 43 CRIs
76 paƟents (25%) with 102 CRIs
12 CRIs per 100 paƟents on SS
33 CRIs per 100 paƟents on NSS
Figure 1. CONSORT diagram of subject enrollment. CRI, carerelated indicator; NSS, nonsurgical service; sNAT, suspected nonaccidental trauma; SS, surgical service.
METHODS Study design The program evaluation used a retrospective review of patients admitted for evaluation of NAT to a level 1 vPTC between January 2009 and December 2013. Patients were identified from the institution’s trauma registry (Fig. 1).1 By ACS guidelines, patients are entered in the trauma registry if they are either diagnosed with an ICD-9 between 800 and 959 (excluding certain diagnostic codes within this range) or present with a trauma-related mechanism (with or without injury diagnosis) and have an SS consult.1 The sNAT population was derived from the trauma registry based on specific population identifiers including: E-Code E988.x, E967.x, Child Protection Team consult recorded, report of physical abuse, or a skeletal survey (88.31) was performed. The primary study outcome was the presence of a CRI. The study did not involve human subject research, but was instead considered a quality improvement evaluation. Data collection The admitting service was classified as an SS if the patient was admitted to orthopaedic surgery, neurosurgery, or the trauma service (pediatric surgeons). The trauma service did not consult on neurosurgery or orthopaedic surgery
patients unless requested. Patients were classified as NSS if admitted to general pediatric hospitalist or critical care specialist. In accordance with the ACS guidelines, CRIs are standardly defined in the Resources for Optimal Care of the Injured Patient1 and further expanded at the discretion of the vPTC. The CRIs that are routinely collected at our trauma center (defined in detail below) include delay in diagnosis or missed injury, lack of consult, lack of follow-up, National Trauma Data Bank-defined complications, readmissions, death with opportunity for improvement, error in communication, inappropriate airway management, Glasgow Coma Scale (GCS) < 8 without an intracranial pressure monitor, under-triage, and direct admissions. The type and number of CRIs per patient and admitting service (SS vs NSS) were collected. Aggregate data were also queried from the trauma registry on age and Injury Severity Score (ISS) distributions by admitting service. Care-related indicator definitions Delay in diagnosis or missed injury is an injury identified in a patient more than 24 hours post-admission. Lack of consult is defined as a patient not receiving a consult
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from a specialty that is appropriate for the patient’s care. Lack of follow-up occurs when follow-up with appropriate disciplines is not requested or included in discharge planning or instructions. Complications include a transfer to the ICU from the floor, reintubation, mainstream intubation, pressure ulcer, and nasogastric tube placement in a patient with a basilar skull fracture. Readmission is a CRI when patients are readmitted secondary to findings related to their initial hospitalization within 30 days of discharge. Death is a CRI when it is deemed preventable or with opportunity for improvement (per ACS Committee on Trauma guidelines1). Error in communication includes error in discharge, incomplete documentation by treating physician, miscommunication between multidisciplinary teams, lack of protocol compliance, and delay in consulting subspecialists. Inappropriate airway management occurs when patients with a GCS score < 8 do not receive airway adjuncts. A GCS < 8 without an intracranial pressure monitor is defined as when a patient with a GCS < 8 fails to have an intracranial pressure monitor placed within 24 hours of admission. Under-triage occurs when a patient meets pre-defined level 1 or level 2 trauma activation criteria, but the patient is not triaged as such. Direct admissions are CRIs if patients present with traumatic injury within 24 hours of injury time (excluding isolated orthopaedic or ophthalmic injury), but are not evaluated in the emergency department before admission. Data analysis The data were analyzed to examine the frequency of CRIs among sNAT patients admitted to an SS compared with those admitted to a NSS. Additionally, the purpose of this analysis was to evaluate if provider type is important in guiding optimal care, managing, and ultimately improving outcomes for this vulnerable pediatric population. Data were analyzed using Stata 13.1. Patients admitted to SS and NSS were compared on age, ISS, and Abbreviated Injury Scale to evaluate for population differences among patients by service and type of CRIs, using chi-square or Fisher’s exact and Mann-Whitney tests, as appropriate. Statistical significance was defined as an alpha of 0.05, with a 2-sided alternative hypothesis. Data were not normally distributed and therefore are presented as median and interquartile range (IQR). Total CRIs per admitting services were converted to a rate per 100 sNAT admissions in order to account for multiple CRIs per patient. Rates were compared overall and stratified by year of admission.
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RESULTS During the study period, 5,340 total patients were entered into the trauma registry. Suspected nonaccidental trauma patients made up 8% (n ¼ 365 of 4,504) of SS trauma admissions and 37% (n ¼ 306 of 836) of NSS trauma admissions, resulting in a study population composed of 671 patients (13% of all admissions) (Fig. 1). The median age of sNAT patients admitted to an SS (8 mo; IQR 3, 20 mo) was similar to that of patients in an NSS (8 mo; IQR 3, 16 mo) (p ¼ 0.608). There were 136 total patients with an ISS >15 and 39 with ISS > 25. There was a statistically significant 1 point difference in ISS between SS admits (median 9; IQR 5, 16) and NSS admits (median 8; IQR 4, 10) (p < 0.001). In SS, 55% (202 of 365) of patients had multisystem injury (Abbreviated Injury Scale score 1 in at least 2 regions); the 48% (146 of 306) of patients admitted to an NSS had multisystem injury. Care-related indicators A total of 145 CRIs were identified in 116 patients (Fig. 1). The most common CRIs were direct admission (23%, n ¼ 34), lack of consult (14%, n ¼ 20), missed injury (13%, n ¼ 19), and readmission (13%, n ¼ 19). Seventy percent (n ¼ 102) of the CRIs occurred in patients admitted to an NSS. Table 1 delineates the frequency and rate of CRIs by admitting service. Table 2 shows the injuries that were missed by admitting service. The sNAT patients admitted to an NSS experienced a higher rate of CRIs (per 100 patients) throughout the study period compared with those admitted to an SS (33 CRIs per 100 patients [NSS] vs 12 CRIs per 100 patients [SS]; p < 0.001). Secular trends in care-related indicators Rate of CRIs by year and admitting service are shown in Figure 2. The overall rate of CRIs increased from 18 per 100 patients for 2009 through 2010 to 26 for 2012 through 2013 (p ¼ 0.07), after the 2011 policy change.
DISCUSSION Our analysis demonstrated that the rate of CRIs is higher for sNAT patients admitted to an NSS vs an SS, and an overall trend toward increased rates of CRIs was temporally related to a change in policy that resulted in more sNATs admitted to an NSS. These data suggest that provider type is important in guiding optimal care, managing, and ultimately improving outcomes for this vulnerable population. Ideal management of sNAT patients begins with an early thorough assessment for
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Table 1.
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Care-Related Indicators by Admitting Service
Care-related indicator
NSS (n ¼ 306) CRI/100 CRI, n admissions
Direct admission Lack of consultation Missed injury Readmission Complication Under-triage Error in communication Death Lack of follow-up GCS < 8 without ICP monitor Inappropriate airway management Totals Mean CRI/100 admissions
28 15 14 10 10 6 6 6 6 1 0 102
SS (n ¼ 365) CRI/100 CRI, n admissions
9.15 4.90 4.58 3.27 3.27 1.96 1.96 1.96 1.96 0.33 0.00
6 5 5 9 8 5 2 1 0 1 1 43
Total CRIs Frequency CRI, n of CRI, %
1.64 1.37 1.37 2.47 2.19 1.37 0.55 0.27 0.00 0.27 0.27
33.3
34 20 19 19 18 11 8 7 6 2 1 145
22.9 13.5 12.8 12.8 12.16 7.4 5.4 4.7 4.1 1.4 0.7
11.8
p Value
<0.001 0.007 0.013 0.533 0.390 0.570 0.151 0.051 0.009 1.000 1.000 <0.001
21.6
CRI, care-related indicator; GCS, Glasgow Comma Scale; ICP, intracranial pressure; NSS, nonsurgical service; SS, surgical service.
abuse identification followed by appropriate care and follow-up.2,3 The discrepancy in the rate of CRIs between services may help to highlight the relationship of the admitting service to quality of care measures in the sNAT population. Opportunities for improvement regarding patient management are reflected by CRI occurrence, the most common of which, in our study, were direct admission, missed injury, lack of consult, readmission, and complication. All but readmission were statistically higher among NSS admits compared with SS admits. Less common, but equally concerning, is the presence of CRIs related to lack of follow-up, errors in communication, and death. Patients admitted to an SS experienced only 12 CRIs per
100 admissions compared with 33 CRIs per 100 admissions among patients admitted to an NSS. Comparison between SS and NSS admissions on ISS show a 1 point higher severity among SS admissions, suggesting the difference cannot be attributed to greater acuity in the NSS admits. Missed injury in the sNAT patient is associated with additional risks compared with those for other trauma patients. Although almost none of the missed injuries required surgery, they did require treatment and followup. Additionally, some aspects of missed injury in 90 SS
80
Missed injury
Femur fracture Rib fracture(s) Skull fracture Foot fracture Tibia/fibula fracture C2 laminar fractures Radius fracture Humerus fracture Bruising to frenulum Bruising of sternum Bruising to spine Cervical esophagus perforation Missed child abuse NSS, nonsurgical service; SS, surgical service.
Injuries by service, n NSS SS
e 4 1 1 2 1 1 1 1 1 1 1 2
NSS
70
Missed Injuries by Admitting Service
4 e 1 e e e e e e e e e e
CRIs per 100 paƟents
Table 2.
Total
60 50 40 30 20 10 0 2009
2010
2011
2012
2013
Year
Figure 2. Rate (per 100 nonaccidental trauma patients) of carerelated indicators (CRIs) by admitting service. The red (top) dotted line is the mean rate for nonsurgical service (NSS) admissions, the gray (middle) dotted line is the mean rate for all patients, and the blue (lowest) dotted line is the mean rate for surgical service (SS) admissions.
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sNAT pose unique risks, including concluding the mechanism was accidental, return of the patient to an unsafe environment, and decreased support for the legal case against the perpetrator. The second reason is particularly compelling because abuse is a repetitive process with minor NAT often precluding more severe and even fatal outcomes.8-13 Missed signs of abuse are often sentinel injuries preceding escalating injury or death, making failure to diagnose even a minor injury far more serious if it results in the return of a child to an unsafe environment.8-11 In our analysis, patients admitted to an NSS were also more likely to experience lack of appropriate follow-up and communication errors compared with their SS admission counterparts. Lack of follow-up is particularly concerning for patients evaluated and returned to their original environment because missed follow-up appointments can provide another opportunity for child protection agencies to intervene.14 Additionally, because many of these children are discharged from the hospital in the custody of someone other than their initial caregivers, it is imperative that follow-up be arranged before hospital discharge to ensure the patient receives the necessary services. Communication between the treating medical providers, caregivers, social work, law enforcement, child welfare agencies, and child abuse specialists is essential to ensuring appropriate patient management and follow-up. Although hospitalists, critical care specialists, and forensic pediatrics are part of the trauma committee membership, and they participate in the meetings regularly, coordination of care for an individual patient is time-consuming. For patients admitted to the SS, care is coordinated by a dedicated team of trauma nurse practitioners, who round daily on inpatients, coordinate care between multiple specialties, and help implement guidelines related to best practice, all of which helps to ensure that care-related incidents do not occur.15 Although the Child Protection Team evaluates for evidence of child maltreatment, they do not make treatment recommendations, leaving some NSS patients in the care of specialists with infrequent exposure to the sNAT victim. This study demonstrates that admission to an SS, in conjunction with the trauma team resources, was associated with fewer CRIs in NAT patients at our institution. The trauma nurse practitioners are likely critical in the role of avoiding CRIs. Analysis of the data over time demonstrates the impact of admitting service on patient care. Although the CRIs were more frequent among patients admitted to NSS admissions compared those admitted to an SS during every year of the study, there was an initial decrease in
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overall CRIs, followed by an increase in frequency in the later study years. We speculate that the initial decrease in CRIs among NSS admissions was due to educational efforts (ie performance improvement and patient safety) started in mid-2008 as our institution prepared to become an ACS-verified level 1 pediatric trauma center. In mid2011, our institution’s policy changed to no longer requiring admission of sNAT patients to an SS. As such, sNAT admissions to NSS spiked, and we speculate the sharp increase in total CRIs starting in 2012 is a direct result of the change in admitting service. Any retrospective study has limitations, even those done specifically to evaluate the impact of a significant policy change. Other unmeasured changes may have affected the data. In this study, the injury severity of patients across admitting services, as measured by the ISS, varied slightly (median 9 vs 8), which was statistically significant. Although this presents the potential of bias in the underlying population, a 1-point difference in ISS is not clinically important. We acknowledge that the 2 populations may not be identical, but believe that the temporal changes in rate over the study years suggest that some of the CRI differences are due to the admitting service and not a difference in population. The age distribution between the admitting services was similar, minimizing the differences in complexity when treating young, preverbal children. The higher number of direct admissions to an NSS may have contributed to the higher rates of missed injuries, but does not excuse it. The standardized system for patient intake through the emergency department, as well as triage guidelines, facilitates an early and thorough evaluation before admission for all injured patients. Although our trauma program is an ACSvPTC, it may not be possible to generalize this information to adult trauma centers, or even pediatric trauma centers with fewer resources dedicated to victims of NAT. In April 2014, the hospital policy at our institution was modified to again require admission of sNAT patients to the trauma service. Data are actively being collected to evaluate the effectiveness of this practice and the rate of CRIs. A standard algorithm for assessment of these patients has been put into place to improve thorough sNAT evaluations from a multi-disciplinary approach.
CONCLUSIONS Nonaccidental trauma patients admitted to an NSS were shown to have more CRIs than those admitted to an SS, including higher rates of missed injuries, errors in communication, and lack of appropriate follow-up. In a free-standing level 1 pediatric trauma center, admission of patients with sNAT to an SS appears to be associated
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with improved patient care. The requirements set forth by the ACS should specifically mandate sNAT patients be admitted to an SS in order to ensure the best possible outcomes for this vulnerable population. Author Contributions Study conception and design: Magoteaux, Gilbert, Langlais, Garcia-Filion, Notrica Acquisition of data: Magoteaux, Gilbert Analysis and interpretation of data: Magoteaux, Langlais, Garcia-Filion, Notrica Drafting of manuscript: Magoteaux, Gilbert, Langlais, Garcia-Filion, Notrica Critical revision: Magoteaux, Gilbert, Langlais, GarciaFilion, Notrica REFERENCES 1. Hospital organization and the trauma program. In: Resources for Optimal Care of the Injured Patient. 5th ed. Chicago, IL: American College of Surgeons; 31e35. 2. Larimer EL, Fallon SC, Westfall J, et al. The importance of surgeon involvement in the evaluation of nonaccidental trauma patients. J Pediatr Surg 2013;48: 1357e1362. 3. Kempe CH, Silverman FN, Steele FB, et al. The battered-child syndrome. JAMA 1962;181:17e24. 4. Leventhal JM, Martin KD, Gaither JR. Using US data to estimate the incidence of serious physical abuse in children. Pediatrics 2012;129:458e464.
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5. Lane WG, Lotwin I, Dubowitz H, et al. Outcomes for children hospitalized with abusive versus noninflicted abdominal trauma. Pediatrics 2011;127:e1400ee1405. 6. Roaten JB, Partrick DA, Nydam TL, et al. Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center. J Pediatr Surg 2006;41:2013e2015. 7. DiScala C, Sege R, Li G, Reece RM. Child abuse and unintentional injuries: a 10-year retrospective. Arch Pediatr Adolesc Med 2000;154:16e22. 8. Tilak GS, Pollock AN. Missed opportunities in fatal child abuse. Pediatr Emerg Care 2013;29:685e687. 9. Oral R, Yagmur F, Nashelsky M, et al. Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse. Pediatr Emerg Care 2008;24: 816e821. 10. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention? Pediatr Emerg Care 2006;22:211e214. 11. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621e626. 12. Spivey MI, Schnitzer PG, Kruse RL, et al. Association of injury visits in children and child maltreatment reports. J Emerg Med 2009;36:207e214. 13. Keshavarz R, Kawashima R, Low C. Child abuse and neglect presentations to a pediatric emergency department. J Emerg Med 2002;23:341e345. 14. Oral R, Blum KL, Johnson C. Fractures in young children: Are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse? Pediatr Emerg Care 2003;19:148e153. 15. Haan JM, Dutton RP, Willis M, et al. Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner. J Trauma 2007;63:339e343.