Pediatric Trauma Screening For Non-Accidental Trauma: Pediatric Trauma Series...

Good evening, everybody, and thanks for joining us, those who've been able to join us, uh, tonight. Um, this is the 3rd part of our series, uh, from Cincinnati Children's and with our sponsor, uh, from Children's Institute. Uh, this session will be on, uh, trauma or abuse screening and how do we standardize, how do we get better. Um, I'm fortunate to have been able to recruit a couple and a Real leaders in this, in this field to help us tonight have this discussion and share some of their experiences. Um, we'll start first with, uh, with Tony Escobar, who's the, uh, pediatric surgeon from Mary Bridge Children's Hospital, the chief of staff there, um, and has, has shared some of this work at the Pediatric Trauma Society, um, and has certainly been interested and advocate in this work. Um, and our other is Chris, Kristen Crichton. Who's that nationwide, uh, Children's child abuse expert pediatrician, um, who's also presented at the Pediatric Trauma Society and doing some really great things, um, in the state of Ohio to help us collaboratively improve our, our work around screening. So I think we'll have a great, uh, evening for you. We'll try to have some PowerPoints and some discussions. Please feel free to send some messages via text or via the, uh, the communication, uh. On the Zoom platform, um, and we'll try to answer those as we go. Um, so with that, I'm gonna hand it over to Tony to get us started. Thank you, Rich. Um, I really appreciate you giving me this opportunity. Um, and having Kristen has been a, a real pleasure and I've learned so much so far. Um, so I just wanna make sure you can see the slides. Looks good. Great. So, um, Rich asked me to discuss, um, our experience in the development of a systematic protocol to identify victims of NAT. And so my talk, um, is going to focus on, uh, 3 different studies that we've had the opportunity to publish. Um, the only disclosure I have is that we did have some intramural funding for, um, the 1st 2 studies to be able to be completed. And the objectives are listed here, and I'm gonna go into a little bit of the background behind those, um, right now. So, As you might have seen on the video that just introduced the talks, uh, trauma is the number one killer for children, and 48% of, uh, child fatalities each year are a result of physical abuse. Um, one statistic that I found from the US Department of Health and Human Services revealed that approximately 12% of these fatalities involve families that had had some sort of CPS intervention in the last 5 years prior to the fatality. And the majority of these children were less than 4 years of age. There's a significant cost to society and, um, in at least one level 1 trauma center, only about a little over half of the kids being evaluated for NAT were seen by a pediatric surgeon. That's by no means to suggest that every single NAT patient needs to be evaluated by a pediatric surgeon. It's more of a um hallmark of how NAT is being managed across the system, even if those resources are available. And identification of risk factors and systematic screening programs may help avoid escalation injuries. But what are escalation injuries? So there are some classic studies that show that NAT is not necessarily even considered when a young child is being evaluated in an ER for an injury. And there's a classic study that Kristen's gonna discuss a little bit more in depth, um, by Carol Jenny and her group, um, that revealed approximately 30% of children with abusive head trauma, position, and NAT was not originally considered or recognized. And um from uh Columbus, from Kate Dean's group, um they demonstrated that patients with recurrent NAT had a significantly higher mortality than during their first presentation. Um, and there was also concerns of missed abdominal injury from UK registries. So at Mary Bridge, um, we became interested in looking at NAT and how we screen for those patients when we had a Sentinel event. And I think a lot of hospitals have had this experience. And so, following the Sentinel, um, event, An ad hoc committee, um, initially led by one of my colleagues, Doctor Elizabeth Paulson, uh, and I got together and we got stakeholders from different, um, services and got together to see how could we improve, um, our screening for NAT. And so we subsequently, uh, incorporated this little ad hoc committee under the trauma Committee because we felt that the trauma committee and trauma presence gave us an across the system. Um, view of patients, starting in the ER, moving through the PICU, going through med surge, and, um, and because trauma is in the name of non-accidenal trauma, um. We all agreed that this is where it should live. We subsequently were able to obtain funding um to look at how we were doing before we implemented this and then how did we do after we implemented the standardized screen. And so as we went through, we adapted and then modified and developed um a screening algorithm that we actually found from Pittsburgh um and applied it for, to Mary Bridge. Um, and then in 2014, we went live with a standardized approach for screening for NAT. The screening tools based on three red flags, a historical component, uh, physical exam component, and then radiographic findings components. Um, and these were adapted and modified as literature came out and as I kind of continued my journey and learning more about NAT through the pediatric trauma Society. For history, the high level, uh, bullet points are, uh, families that present with no history of the injury or event or an inconsistent history, especially with the patient's developmental status. Changing history, somebody's being told something, one provider is told something, another provider is told something else, the staffs told something else, um, and delay in seeking care. And you can see some of the other, uh, historical red flags. We're gonna talk a little bit more about, um, the validity of these, uh, historical red flags as we talk more about the pediatric trauma Society work, um, that subsequently followed. In terms of physical exam findings, um, some very big, uh, catch-all, uh, findings that, uh, should point you in the direction of NAT include, um, bruising, especially in particular patterns which we will discuss as well. Um, there is something called the 10-4, uh, pattern group that Mary Clyde Pierce's group, um, uh, has reported and we're gonna discuss that. Um, there are still certain bruising patterns that are very much pathonomonic for, um, non-accidental trauma. Uh, torn frenulum was a classic example of something that has, uh, been associated with NAT for a very long time, but we're going to discuss whether or not that still holds true. Um. And in regards to radiographic findings, there are certain skeletal injuries that are very suggestive of non-accidenal trauma, especially depending on the patient's, um, development. As well as, um, rib fractures in infants, uh, without a history of a significant major trauma event like a motor vehicle collision or something along those lines, um, and undiagnosed healing fractures. Certain, uh, traumatic brain injuries are suggestive of abusive head trauma in the right setting. So, we first started off trying to see where we were when we started. Um, and so we did a retrospective review looking at how good were we at screening patients for NAT before we implemented our tool. Um, and as you can see here, the demographics of that particular cohort. What we found was that we had an inconsistent or missing history um in our patients that presented with NAT in about 89% of the cases. Um, additionally, there was unwitnessed injuries in 79% of the cases and as you can see, these numbers don't add up to our total cohort. That's because oftentimes the stories would change and that's what we had available in our retrospective review in the chart. Um, interestingly though, almost 40% of patients had a prior ED visit and 60% of those were less than a year of age. So if you think about it, a less than 1 year old with multiple ED visits is a concerning finding. Now, interestingly, 41 up to 73%, and this is a range of patients were missing social history data. That meant that we were not recording it in the chart, and something as important as NAT and how social history impacts that, that was a very telling finding for us. Bruising was found in almost 2/3 of our patients. Um, and you can see that the, uh, The, the breakdown of those patterns there. I'd like to draw your attention to the final bullet point, which is our perineal bruising or injury. This was a small number of patients. However, what we did find was the majority were less than 4 years of age and there was a significantly increased risk of mortality if we had this finding on um physical examination as well as increased morbidity. Radiographically, we had 60% of our patients less than a year of age that had fractures, as well as a fraction of those that did have undiagnosed healing fractures in other sites. Um, and of the patients that had subdural or subarachnoid hemorrhages found, the vast majority were less than a year of age. Also, a third of our patients had rib fractures, and those were significantly injured, um, and associated with other undiagnosed healing fractures. And I'll draw your attention to that half of them had an injury severity score, which is somehow, is how we measure the severity of the injured patient of greater than or equal to 16, which is severe. 9 patients died in this in retrospective cohort, and I've been asked at meetings, if we'd had this particular screening guideline, would we have been able to intervene sooner? Would we have been able to prevent this? Um, unfortunately, this is a retrospective study, so the answer is I don't know the answer to that. However, there is some telling data, and that is if you look. 2/3 of those patients had had a prior ED visit, so theoretically a time that we could have intervened. CPS history. 5 of the patients did have a prior contact with CPS. And in terms of domestic violence, this was something that was disturbing to me when we found was that although 3 patients did have a history of domestic violence recorded in the chart. The majority actually did not have data at all, which means we didn't record it and most likely didn't ask it. So now we're gonna move on to the prospective data. Oh, pardon me. One more slide. The, this just is to give a little bit of a sense of how injured our NAT patients are by looking at their severe ISS comparing it to our overall accidental trauma patients in our registry. So there's a significantly increased number of severely injured patients when they come in with NAT as a mechanism. There were concerns. So, we're talking about implementing a standardized uh NAT screening and some of the questions that arose, rightly so, were, what does that mean in terms of ED lengths of stay? What does that mean for the number of admissions? What does that mean for the number of HET CTs that we're gonna be doing? Um, are we gonna start getting unnecessary studies? Um, and so, uh, we were very fortunate in that we had partnered with all the different departments to, um, To implement and then study this. So, we did implement this on January 1st, 2014 and we were very interested in looking at our utilization of resources. As you can see here, the demographics were very similar. Before and after The implementation of our tool. And we didn't see a significant increase in the number of NATs that we actually did, uh, diagnose. We did see an increase in referral in our pediatric surgeons. And there was no significant difference between our severe or ISS. However, we did have a, although we did have a roughly similar mortality, we started to see some changes. We had less prior ED visits. We had less CPS history and at least 2 spots where we couldn't find documentation. And there was 1 episode of domestic violence in the home, but now we were down to 2 times when it wasn't asked as opposed to before when the majority of the times it wasn't asked. The use of HET CT actually did not change. So, we were still following our PCA guidelines. We're combining that with our NAT guidelines, um, and we did not see a significant increase in number of use of HET CT or the diagnosis of subdural subarachnoids. Our ED length of stay, and I think this is a really important slide to point out, is that they did not change. So, this was before and after implementation of our screening tool. The number of admissions went down, and that was very interesting. Um, and so we posit that because we were doing a more standardized screening in the ER and we were having a safer disposition planned from the get-go, that we were seeing less medical holds. Now I'm gonna move on to the final part of my talk, which is the pediatric trauma Society, um, review article that I was very fortunate to be a part of. About 2 to 3 years ago, um, the Pediatric trauma Society identified screening for NAT as a key objective for the development of a guideline. And so I was lucky to co-chair this with uh Mark Auerbach uh from Yale, uh, who's a Ped EM physician, and we got together a multidisciplinary, multi-institutional, international group to review the literature and try to come up with high-quality recommendations for NAT screening. And what we found was, um, we were hoping to use, uh, the approach of a systematic review and then create grade criteria guidelines. Um, and what we found was that the literature wasn't quite up to where we needed it to be, to go down that route. Nevertheless, there was a significant amount of high-quality literature that we could evaluate and so we turned the project around into a more generalized review article with the concept that this could Be something that an general ED physician, a traumatologist, somebody could essentially rip out our one big table and put up on the board so that it could be looked at every time a patient comes in that should prompt a red flag and what should prompt a child abuse workup. And so, it was broken down into 7 categories. We had bruising, we had, um, abusive head trauma, fractures, burns, abdominal injuries, um, oral injuries, etc. And then based on the high quality literature, we were able to make recommendations about when to pull the trigger on a child abuse workup. Um, the first was bruising, and some of the best literature is, uh, exists on this and is currently, um, To the last of my knowledge is being worked on to be validated, and Kristen could probably make a comment on this as well. So, we use the 10-4 um clinical prediction rule, uh, which was developed by Mary Clyde Pierce, as I mentioned earlier. And the idea is that you have torso, ears, and neck bruising that are highly suspicious for NAT in children less than 4 years of age, or any bruising in an infantant less than 4 months of age. The sensitivity and specificity are listed there. And if there is bruising found in this group or characteristic patterns of bruising such as whip marks or cigarette burns, then we do recommend um a child abuse workup. And this is just an example of what that looks like, um, of what low-risk and high-risk areas are. Anybody who has a toddler knows, you're gonna see bruises on the shins and on the knees and elbows all the time. Um, but areas of the diaper area and on the chest and back and the buttocks are highly suspicious. In regards to burns, there are two, large systematic reviews, um, looking at, um, burns, most recently from Parkland, um, that found that these associations with non-accidenal trauma. And interestingly, in the most recent review, up to 25% of children that were admitted to the burn center had been abused. Um, and so, there are characteristic patterns to intentional burns. Um, they are listed there. There's also characteristic high risk ages, um, where a significant number of kids less than, pardon me. Of the patients that presented with intentional burns, greater than 95% were aged less than 5 years. So, based on that, the characteristics of the burns as well as the age, we do recommend a child abuse workup. Now, less than 5 is a big spectrum and we recognize that. But this is geared more towards the general ED that may not have the experience or the child abuse experts to be able to intervene and say yes or no on the risk of uh factor or risk assessment for NAT. And this is an example of a of a uh skull burn, uh, in which the patient was dipped into a scalding uh tub. In regards to intracerebral injury or um abusive head trauma. So, the two clinical prediction rules that have the, the largest amount of evidence behind them are the PD Burne uh clinical prediction rule as well as the, um, we call the PREDAHT, uh, clinical prediction rule. Um, and both of these have associated other findings. Some are very specific to having been admitted to the PICU and having these findings, but nevertheless, we generalize these concepts. Um, and so if there is. Uh, a, a traumatic brain injury associated with an additional feature that you can see here, then the sensitivity and specificity is as listed, and then we do recommend a, uh, NAT workup. Additionally, um, the Pred AHT rule has a slightly lower sensitivity and specificity, and it does have these, um, associated injuries, but nevertheless, if it is, it trips positive on that, we also recommend a non-extendal trauma workup. And it's just an example of an abusive head trauma that I've taken care of. Abdominal injury. This is where the literature starts to not be quite as robust, um, but of the existing literature, um, it's consistent that hollow viscous injuries, specifically duodenal injuries in age less than 4, are highly suggestive of, um, abuse. And so if a patient presents in this particular age group. Or if there is an associated hollow viscous injury and solid organ injury in this age group, then we do recommend a non-external trauma workup. This is less common, but the mortality is significantly higher if it's present. One thing I do want to point out, and that is that you can have abusive abdominal injury without external signs such as bruising. And so, we do recommend screening or the general consensus is to screen for um elevated liver function tests. Um, and I can refer you to the reference in, in terms of that. And if those are elevated, then further axial imaging is recommended to evaluate for intraabdominal injury. Um, and these are just examples of, uh, bruising that's associated with, um, non-accidenal trauma, um, as well as a, uh, ruptured duodenum. In terms of skeletal injury, the key take-home message of skeletal injury is it's developmentally um appropriate, is the history developmentally appropriate for the injury that you've seen. High risk, um, long bone injuries include, uh, proximal and mid uh humeral fractures, uh, femur fractures, um, and especially rib fractures in infants that are in without a preceding history of a, uh, major trauma. In this particular case, if the patterns are inconsistent with the degree of mobility, then we do recommend child abuse workup. Additionally, the American Academy of Pediatrics recommends a skeletal survey to screen for occult fractures in any child less than 2 with suspected non-accidenal trauma. Um, and, uh, it is recommended that a pediatric radiologist read those. And this is just an example of a bucket handle fracture that's his, um, classically been associated in smaller children with NAT uh due to the twisting motion that occurs, uh, in this particular kind of injury. And this is an example of posterior rib fractures, um, where there were sets of fractures here and then here you can see, I think, quite well, the posterior rib fracture. And that's from a squeezing type of, um, mechanism for, uh, infants. Frenulum tears are very interesting, and of course I'll be happy to hear Kristen's uh opinion on this, but classically, this was always taught to be associated with non-accidenal trauma. However, um, once you get into, uh, uh, children that are mobile, the incidence of lip injuries, uh, oral injuries, renum injuries are equivalent between accidental trauma and non-accidenal trauma mechanisms. So, in and of themselves, there's not sufficient evidence to recommend a child abuse workup. However, if you do have an infant with an oral injury, then it should at least raise the red flag. And if there is another finding, then absolutely, it is recommended to proceed with the workup. And this is an example of some of the um older literature uh associated with a torn frenum or frenulum uh in an infant. Finally, historical factors. Um, historical factors are the least well studied of all of the categories that I just discussed. Um, usually you find that the historical factors that I discussed earlier in conjunction with a finding of suspicious. For non-accidal trauma is going to be what prompts the child abuse workup. Um, there are several studies that look at, and Kristen's gonna discuss, um, standardized implementation, um, of NAT, uh, screening guidelines, um, but there's still a lot of work to be done in this particular category. So, in conclusion, from our uh Mary Bridge studies, we found that the majority of patients less than a year of age um had had prior ED visits in our retrospective study. And in the absence of a standardized process, we did not obtain a thorough social history. We found that perineal bruising, though rare, was associated with mortality, and we had nearly 1/3 of patients who had undiagnosed healing fractures. Um, I'm not gonna talk about this aspect of our study, but we did feel that anecdotally, there was more comfort discussing NAT workup with parents, um, from both physicians and staff, uh, once we standardize the language. And then finally, our implementation of our NAT screening guideline did not lead to increased utilization of resources and in fact, we felt that they were better utilized. Um, and that ultimately led to the work I did with the Pediatric Trauma Society with the recommendations that we just discussed. And these are the, uh, people that I need to acknowledge, uh, for all their hard work and the references, uh, to the studies I just discussed. Thank you. All right, thanks, Tony. That was, that was really great and uh a nice start to our discussion. Um, I have a couple of questions kind of for our, for our audience more than, more than me or, or at a children's hospital, but what if you don't have a pediatric radiologist? Um, and you're saying I need to do this child abuse workup and I don't have that or I don't have you or Kristen at my hospital to help evaluate these patients. So I've had the uh wonderful opportunity to go speak around our region, um, Olympia, other places to talk about this work, and that is the number one question I get. Um, so, My answer is that as a level 2 pediatric trauma center, as a level 1, we're the resource for our region. And so, um, and I certainly, we certainly capture probably a smaller area, uh, in Southern Washington, um, than perhaps in some of the uh greater Ohio areas. Um, but we recommend that, um, if there's really, if there's concern. We, we ask them to send them to us and we do the evaluation. Um, we also try to establish their, with their resources because in our, uh, state, every, um, the child abuse resources are, uh, county dependent. So we try to make sure that they're set up with the appropriate referrals, uh, in regards to CPS and then child abuse follow-up. Um, but we do ask them to come to us. I'm not suggesting that every hospital has to do that, um, but that's how we handle it. Great, no, I, it, it is a real challenge for hospitals that we talked to as well and, and those out there who are seeing kids and as you know, seeing the majority of kids before, before we do, and, and that's why of helping to figure out how to help them screen and know who to screen and also be connected to their regional trauma. Lines open so we can have some more of this discussion, but I think Kristen's gonna cover um some of this as well as far as kind of, you know, how do you, you have these great screening tools, but how do you actually get people to use them, um, and how do you talk to families when you're not used to having that discussion without sounding accusatory. So Kristen, whenever you're ready, looks like you're starting your screen share. I think so. Can you see it? I do. All right. So as Kristen's getting set up, if, if folks in the audience, I know some folks had a little trouble getting in right at the beginning, but, um, this is recorded, so it'll be out there, um, for you, but also feel free to type in questions, uh, that we can try to answer as we go through. Go ahead. All right, so thank you so much for having me in, and as you just mentioned, um, Tony did a great job kind of talking about the injuries that we're worried about and why we're worried about them and, um. I think that laid out very clearly the recommendations, but what we know is that there are a lot of barriers to detecting child abuse, um, and so we wanna kind of try and figure out what those are and how we can conquer them. Um, so, despite clear recommendations from the American Academy of Pediatrics and federal and local laws that mandate that all of us as healthcare providers report suspected child abuse, we know, um, through lots and lots of studies in the literature that providers do not consistently recognize, um, recognize injuries that are concerning for child abuse, and then do the appropriate work. For these injuries that are concerning. Um, and this is true across healthcare providers. I'm not pointing fingers at any, um, any one discipline, um, and it's also true in a variety of medical settings, both EDs, urgent cares, primary care offices. This is, um, this is a true struggle, um, for, for all of us in this profession. Um, in the national study of primary care providers, um, specifically pediatricians, um, Doctor Flaherty and colleagues found that PCPs often fail to report injuries concerning for child abuse, uh, to child protective services for a number of reasons. Um, one of them is the familiarity with the family, you know, a lot of times, uh, pediatricians know their, their families very well. They may have been the pediatrician to mom, and, and now they're, you know, treating her kids, and so they, they know the family, they don't want to imagine that this is something that could happen in this family. Um, and, and they don't want to do something that they may view as punitive, um, like report to Children's Services, um, or they think, you know, I can, I know that this isn't, this isn't that bad, um, this child is safe with this family. Another barrier is perceived lack of value to the family from involvement with CPS. So I hear a lot, well, Children's Services isn't gonna do anything, so why would I report this? Or they're just gonna screen it out, um, or, or, um, I don't wanna do that to this family. I don't wanna have that involve. of children's services with this family and we have to remember our mandate, um, whether we think Children's Services will respond or not should not at all influence whether we make the report. If we have a concern, if we've identified a suspicion, we have to report and it is up to Children's Services how to respond, um. And I think it's also important to not view um a CPS report as punitive. This, this is something that may help this family and certainly can help protect a child from further injury. So, kind of separating, um, our, our thought process of I'm getting them in trouble by reporting to Children's Services versus I'm protecting a child, um, which is what we have to remember. And then the other thing that PCPs identify is use of their own alternative management plan. Well, This happened this one time. I'm worried that there was an abusive injury, but I'll just, I'll just have close follow-up with the family and I'll manage it. I don't need to get, to get children's services, um, as another um reason that PCPs don't report. Um, and another study looking at pediatric nurses, um, and, and their hesitation to report, they, they stated they recognize that detection of non-acal trauma was really important and it's a priority, but it can be really hard because a lot of the cases aren't clear cut, you know, not all the kids come in with a slap mark on them. It, it can be much grayer than that, um, especially in small. Um, infants where, where the injuries can be not very severe or not very specific, um, and, and it may be hard to pull the trigger on making that report. Um, in a study, um, a Dutch study of emergency department physicians, um, barriers identified there were lack of time. Obviously, Um, if, if it's up to the physician to make a report versus here in my great big AD where we have a team of social workers that make a report, taking time away from seeing patients to make a report to Children's Services can take a very long time, and it's normal to be on hold with my County Children's Services for 30 to 45 minutes. So I understand that that's a barrier, plus lack of time to talk to the families to fully understand the history and why they're here, and is this injury concerning or isn't it? Um, another barrier is fear of inaccurate suspicion, so I don't wanna get them in trouble if I'm not sure if it's abuse or not. Again, that, that kind of gray area. Um, insufficient communication skill, like I don't know how to talk to families about it, so I just don't, um, and then I don't report. And then turnover of ED staff, you know, if, um, we have a lot of new and different providers, um, this may be an educational issue, so not understanding what injuries are concerning for abuse. In a more recent study looking at American emergency department providers, um, and their identified barriers to recognition of non-external trauma, um, Tiga and colleagues identified Desire to believe the caregiver. I mean, as, as pediatricians, especially, we're trained to, to trust parents. Parents are a proxy for their kids, but parents want the best for their kids. They wouldn't seek care for their child if they hurt their child on purpose. These are all kinds of things that I hear that are kind of these, these barriers in terms of wanting to trust and believe families, which I understand, um, but we also have to put together the Um, subjective of what the family is telling us and the objective of what we're seeing and what we know to be true in terms of, of a child's developmental ability, or, um, would that fall cause this injury, um, which leads into the knowledge deficit, um, and failure to recognize concerning injuries if Uh, providers aren't exposed to children, um, with abusive injuries, they may not, they may not know, or, um, in, in our youngest infants, like Tony was talking about, it may be very small, um, injuries that are concerning for, for abuse, a bruise on a 4 month old, a frenulum tear on a 2 month old, those are gonna be concerning. They don't require medical intervention, they're gonna heal by themselves, but they need to be reported if they have, um, if they raise concern for abuse. And then personal bias in this, um, In this paper, there's a quote that I thought was really interesting, which is, um, I'm gonna be worried about the child who comes in with a mom who, you know, looks like a drug addict, but I'm not gonna be worried if they come in with a mom who looks put together, and it's really important to understand that child abuse can happen in all socioeconomic statuses. So even the most put together families, um, can, can have kids with, with injuries, um, that are concerning for, for abuse. Um, from this study, barriers, um, barriers that were identified in terms of reporting, um, non-accidal trauma to children's services included again, time and effort required to report. It is, um, It is a time-consuming process. Children's Services ask a lot of questions and you need to get a lot of, of details like parents' address and things like that, that um are not necessarily part of the medical history, um, but things that Children's Services requires. Again, this is where social workers are very helpful, but if you're in a place where you don't have a lot of them, um, this can be, um, a certain, certainly a barrier. Um, and then negative consequences to the provider of making a report. Well, if I report, then I'm gonna have to go testify. And I don't wanna deal with that, which I understand as someone who testifies a lot, it's not the most fun thing to do, but that shouldn't be a reason we don't do the right thing for the child. So just so it's not all bad news, from the same paper, some of the identified facilitators to detecting non-external trauma included real-time discussion with the medical team. So, physicians talking to nurses, talking to triage staff, talking to um other providers that may have seen more interaction between the family and the child, um, can help kind of get a better understanding of, of should we be worried? Are you worried? Am I worried? Let's check in and, and see if we're concerned, if we see any red flags with this family. Um, understanding the importance of reporting to Children's Services in the setting of suspicion. So understanding our mandated reporting laws, these are both gonna contribute to, um, to providers going ahead and pulling the trigger on making that report. And we know that all of these, um, all of these barriers are tied to bias, um, and we know that, that we are all biased in our, um, non-acal trauma evaluation, uh, even though we try very, very hard not to be. Um, Tony mentioned the Carol Jenny paper from 1999 looking at missed cases of abusive head trauma. In the children where abusive head trauma was missed, they were significantly more likely to be white, um, and they were significantly more likely to be children in dual parent homes. Um, so if we're under diagnosing, These white children are overdiagnosing in minority children, that's not necessarily clear, but there is a discrepancy there, um, and then, and it is, um, likely based on race and socioeconomic status. Wendy Lane and colleagues found minority children had higher rates of evaluation for abuse and higher reports of suspected abuse, and that's separate from, um, that's above and beyond the, any racial disparity that was seen in actual abuse. Um, and we know that physical abuse is considered more often in children with low socioeconomic status, and that's been, that's been demonstrated in numerous studies. And, um, we also know that decisions about discharging children home from the emergency department with a diagnosis of abuse also depends on socioeconomic status. So all these studies really demonstrate a differential, um, decision-making in the evaluation and disposition of children with suspected abuse. And just so, um, I'm clear that I don't think that child abuse pediatricians are above this, this is a study just from last year. Heather Keenan and colleagues looked at 746 consult notes from 32 child abuse pediatricians around the country. Um, CAPS or child abuse pediatricians. The CAPS rated the perceived family socioeconomic status, so kind of on a scale from 00 to 100, just how, what they thought the family socioeconomic status was, and the perceived social risk to the child. And the social risk included um some kind of obvious risk factors, um, like, um, single, single parent, young mom, um, unrelated caregiver in the, unrelated adult male caregiver in the home, also known as mom's boyfriend. Um, who's often, um, the culprit. But then some other kind of non, non-social flags, um, like, uh, late prenatal care or, um, behind on immunizations, kind of other things that may really factor into our decisions about whether or not we're worried about this child. Um, the, the social risk also included, um, positive social factors, so, um, both parents are professionals or the family goes to church every week. Um, and, and so, um, what they found was that the cap perception of a child's socioeconomic status was strongly linked to the perception, um, of, of risk, even when other social cues were accounted for. So, if, if child abuse pediatricians are, are assuming that this child is in a low socioeconomic status, that separate from Everything else contributes to their estimation of the risk of abuse, which is really concerning because we know that poverty in and of itself does not specifically um predict abuse and the risk of abuse. So we need to be making sure we're looking at the child and at the, the circumstances of each case individually. And what we know from all these studies and with all this bias is that when we, we have these, these biases, we have these barriers, these lead to inadequate evaluations for non-accidenal trauma. Um, in several studies where we kind of use the completion of a skeletal survey as a measure, um, of, of whether or not we're evaluating these kids for, for NAT, um, the first study, Dan Lindberg and colleagues in 2015 found that only 20% of infants under 6 months old who had a bruise had a skeletal survey done. By the AAP guidelines, pretty much all of those children should have had a skeletal survey done, and we're at 20%. That's shockingly low. Um, Joanne Wood and colleagues in another study found that 68% of children less than a year old with a diagnosis of traumatic brain injury, so a high, high, um, severity injury, um, had a skeletal survey done. And again, we could argue that a lot of those kids probably should have, have had the skeletals done. Um, skeletal surveys were done in 83% of children, um, with a diagnosis of child physical abuse. So one of the studies that, that I've worked on that um Rich kind of alluded to here in Ohio, um, was kind of looking at how we can, how can we do a better job. Um, and so through grant funding from the Ohio Attorney General's Office, um, the six children's hospitals in Ohio have formed a Quality Improvement collaborative, um, named TRAIN or Timely Recognition of Abusive injuries. Um, and we've looked at, at our completion of skeletal surveys. And, and I'm sad to report that our baseline from several years ago was not much better than what's published. Um, we're around 40% of, of kids less than 6 months with a bruise getting skeletal surveys, but we're working to, to improve that. And I'm gonna talk a little bit at the end of the talk about what we're doing to try and improve and deal with our, our barriers that we've identified. But one of the studies that's come out of the training collaborative, um, was this one that I, I presented at PTS um in November. Uh, we looked at 367 infants who are less than 6 months old with an ICD-9 code for bruising to see which, if any, demographic factors predicted completion of a skeletal survey. So we know that we have bias, and we know that we failed to get scalable surveys in a lot of these kids. So how do we put that together and understand what, what are these biases that are contributing to our decision to do the evaluation for child abuse? Um, so again, less than 40% of infants less than 6 months old with bruising had a skeletal survey completed, so that's not good. Um, and of these infants, significantly more infants with public insurance, so using public, using insurance as a proxy for socioeconomic status, um, significantly more kids with low socioeconomic status had skeletal surveys than those covered by private insurance. And interestingly, in, in this study, no racial difference was seen. It's important to note that in Ohio, in our catchment area, we skew Um, very white, so it's hard to see racial differences, um, in these studies. But it helps us to know that we, we are biased and, and the completion of these um evaluations is likely um biased by, by socioeconomic status. And we also know that it is so important to do these workups because in non-accidenal trauma, diagnosis is treatment. Um, even though a lot of these injuries are really clinically insignificant, like I said, a frenulum tear is gonna heal, a bruise on a 4 month old is gonna get better, um, but we have to detect and recognize that these clinically insignificant injuries are really essential for protecting children. Um, posterior rib fractures, classic metaphyseal fractures, pattern bruises, they'll all get better without us doing anything. But for every injury that we identify, that's more information that we can give to children's services, and that is how we protect these kids. Um, I think it's been in the news, um, a couple, and it was in the New York Times recently and also in the Chicago Tribune that various children's services agencies are using algorithms now, um, to make decisions on placement. Um, and one of the things, um, in Ohio, uh, much like in Washington, sounds like in Ohio, Children's Services, Um, agencies are county-based, so we have 88 counties in Ohio, so we have 88 different children's services agencies, and some of them use these algorithms, and they'll count the injuries. They'll ask me how many rib fractures are there. Each of those counts as a separate injury, which, OK, how many bruises are there? Each of those counts. No. Sometimes intracranial hemorrhage counts as the same kind of injury as a bruise, which is interesting, but it's important to know how Children's Services is making these decisions because that can impact what we're doing to evaluate and how we communicate with them, um, our concern for abuse for these kids. So, for every injury we evaluate evaluate or we identify, um, we're more likely to help protect these kids. So routine screening for Nat, just like um Tony talked about using routine, a routine approach, um, you know, I'm gonna advocate for the exact same thing. The approach should be based on the injuries identified. Um, the determination to do a workup should have minimal. Reliance on risk factors we're working with patients, not populations. Um, risk factors are helpful if they're positive, but they're, um, not helpful if they aren't there because an absence of a risk factor does not exclude abuse. Um, we wanna avoid basing decisions on subjective impressions of the caregivers. One of the things that I get called, um, called in the middle of the night from the ED and. They'll tell me about this 4 month old, they'll tell me about the bruises, and then they'll say, but they seem so nice. Don't you think this could be a bleeding disorder? Well, you know, we'll evaluate for a bleeding disorder, but child abuse is more common than every bleeding disorder. So let's evaluate for that as well, um, and, and try and be as objective as we can. One of the other barriers that comes up talking to caregivers, it is hard to talk to caregivers about concerns for abuse. Um, I try and advocate for having an open and honest communication, um, with families about maltreatment concerns and if a report needs to be made to Children's Services. Um, we don't wanna operate covertly. Families will, families catch on, they know what we're doing. We do wanna consider the patient's safety first if we're concerned that Um, you know, the alleged perpetrator is present in the emergency department, they're gonna snatch the child up and run away. Well, we need to kind of deal with that and make sure that we're keeping the child safe. We may need to delay telling the family if the Children's Services response isn't immediate, um, if the evidence of abuse is vague, or if the child may be going home with a potential perpetrator. I, um, I tell our, our residents when I'm talking to them, to, these recommendations aren't personal. When a, when a 24 day old comes in with a fever, we don't hem and haw about whether or not we need to do the LP and do the workup for the febrile newborn. We just say, this is our recommendation, and it's not, we're, we're Try and really be matter of fact. We're concerned that someone has hurt your child. It is not up to us as medical providers to identify who hurt the child. That's why we have Children's Services and law enforcement. It's just up to us as medical providers to identify that there is a concern. The workup is not really optional. We're not really saying, hey, would you like to do a skeletal survey? It's really, this is what's indicated, and this is what's in this child's best interest is to get these studies done to identify any other injuries. We can introduce that as part of the differential, you know, your child fell, but this is more, this is more injury than we would expect from a fall. So one of the things we wanna do is make sure we're looking for um any other um injuries and any other medical causes that might be contributing to these injuries. Again, try and keep a matter of fact tone. Um, our next step, when we see these injuries, our next step is to do this, um, and really just keep it as routine as possible. Um, and then improving detection of non-external trauma really hinges on improving education on recognizing injuries, um, that are concerning, um, in our youngest, most vulnerable patients. Developing institutional guidelines, just like Tony discussed, um, the guidelines, um, that they had at Mary Bridge seem really improved, um, their detection and, um, It seems like didn't contribute negatively to things like, like length of stay, which is one of the, the, um, concerns that always comes up. Um, and then the other thing that we've done with the train collaborative is using quality improvement techniques to identify what barriers exist at our institution, um, and at the other institutions that we're working with. So this is the standard approach, um, the components of the evaluation for non-acciental trauma. With all kids, we recommend a full physical examination. Um, and photo documentation of cutaneous findings. Well, to get a full physical examination, we need to undress the babies. Turns out that's a huge barrier in our ED. Our ED does not like to undress babies. They get cold. That's what they tell us, they get cold. We don't want the babies to be cold. I don't want the babies to be cold either, but I don't want the babies to have missed abuse, and we have blankets. So, talking to Everyone involved and with um the care of these children and identifying exactly what a barrier is. I don't know that I would have guessed that undressing the babies was gonna be such a barrier, but it has been. Um. The next, one of the, the next kind of basic thing is a skeletal survey. And just like Tony said, this needs to follow um the American College of Radiologists and AAP guidelines, um, which means it's not a babygram. We don't put the, the baby on a plate and take one picture. This is about 24. Or separate X-rays, um, the, the RAD techs need to be familiar with the imaging needed, and we need to have radiologists who are comfortable reading these films, preferably pediatric radiologists. Um, one of the things that we identified when we reached out to our community hospitals is that they don't even have the radiologists in-house. They're using, um, radiologists at a kind of central location here in Columbus, even though they're an hour outside of the city. Um, to, to read their, their films. None of them are pediatric radiologists, and they're probably missing things. So, again, with those hospitals, one of the things that we advocated is, if you can't get someone that's comfortable reading these films, go ahead and send the kids to us. Um, psychosocial assessment. Again, just like Tony was talking about, it's really important to try and understand, um, what's going on in this family, what are the stressors, um, and, in our hospital, we have social work available 24/7, that's not true for most places. Um, so understanding what the social work availability is, um, if they aren't available, is there other support? Um, who's responsible for making the report to Children's Services when there's this concern, and, and what can we do to facilitate getting that report made? Again, if we need If we need to help, um, being the large tertiary care center that we are, we're happy to help. That's where the consult to the child abuse pediatrician comes in. So, for my team, someone is on call all of the time. It's currently me, um, and we are on call for the whole catchment area of the hospital. So I'll get calls from 2.5 hours away, and I'm, I'm happy to do that because I'd rather the adult hospital in Marietta, Ohio. Um, get, get good advice from someone that, that knows, um, that knows how to deal with these issues rather than them trying to kind of guess and figure out themselves. Um, so those are kind of some of the barriers that we've identified and I think that it sounds like they're pretty similar to, to other places, um, but I just kinda wanted to go over kind of how we broke down the workup and, and looked at what, um, what may be keeping us from getting each of those things done. This is just a slide cause, because one of the things that comes up all the time is what is the skeletal survey? Here's a slide for what the skeletal survey is. It is a lot of x-rays, um, but it's important to get them all done. So, um, in conclusion, lots of kids are raised in environments where they're repeatedly exposed to potential harm. We don't want to miss any opportunity to protect children. It may require improved education, um, for providers and recognizing these concerning injuries. We know unconscious bias exists for all of us, and we try and try and be more conscious about it because that's how we know that we'll avoid, um, avoid missing abuse, um, and using, um, institutional guidelines and, and QI. Um, a QI approach can really help improve detecting these injuries. So, thank you. With that, I will. Thanks, thanks, Kristen, and, and thanks again, Tony. So, let's kind of just end with some discussion among all of us maybe. So, I'm gonna throw out a couple ideas and questions that have come up. Um, uh, you know, certainly, Kristen and, and Tony both covered this to some degree, kind of this understanding our own biases and, and how do we get past this? Well, you know, that's my neighbor or that's, you know, someone. That I've worked with or someone that works in the hospital um that comes in with an injured child and have these conversations. So you, you've touched on it a little, but either one of you want to emphasize kind of, I think the importance of that standardized approach to help alleviate some of those challenges. Well, I would say from, from our end, from um our hospital, everything that Kristen just discussed, we've had that as an experience um as we've tried to implement these, um, having the conversation of, we're not saying that you abused your child. We're concerned that your child has been injured intentionally, and it is our job to be able to screen that and we protect, and this, we do this for every child that comes through. Um, and trying to get that script in the turnover, oh my gosh, the turnover, um, new staff, new docs, new, you know, that are, um, maybe fresh out of fellowship or something along those lines. And it's really, it's a difficult conversation to have if they're not used to it. And sometimes the easier path is to avoid it altogether. Um, so we've certainly had, uh, those experiences. So we've really tried hard to standardize, standardize that across, and then also standardize our language around that. We've definitely had difficult patients, uh, I mean, certainly difficult patients, but also difficult situations with families. We had years ago, we had, um, uh, uh, someone that we know well because they're part of our prosecutorial team. Um, so that was dicey, and we just try to approach as, as routinely as possible, just like Tony said, you know, if we see this, then we do this. We cannot treat people differentially. Um, and it makes people mad, and that's OK, and, you know, we're, we really listen to families as much as we can but try to explain that this is what we do for everybody, um, and, and, you know, if you get patient relations involved, that's OK too. Um, but for the most part, families generally understand, um, and, and are pretty cooperative with the workup. For us too, Rich, oh, I'm sorry, go ahead, Kristen. Oh, go ahead, go ahead. So yeah, what, and we also, you know, we, we try to utilize our QI and our PI, um, quite a bit in this situation. So we have the NAT subcommittee. It still formally reports up through the trauma committee, and, um, as we've gotten more mature with the process, we've started to do more peer review. Um, and if we need to, we, we go down the peer review route. Um, we look for, um, maybe some of those physicians that, um, consistently don't seem to be applying the screen. Um, and how do we intervene, um, and, and get them part of the process, you know, part of the solution. And so, um, we, we've definitely used our PI and QI process to that effect. One of the other things that we've done, Tony, I know you mentioned that you had a Sentinel event. We, we had a Sentinel, um, event here at the hospital was when I, I did residency and fellowship at Nationwide, so I'm a lifer. But, um, it was when I was in residency, so it was a while ago, but we, um, had a 4 year old that came in with, with injuries that ended up, um, Kind of being out of proportion to the history, but the family was all sticking to the story. She got discharged and within 6 hours came back and had and died of, of subsequent injuries that were abusive, and it turned out that all of her injuries were abusive. So, as a result of that, um, our trauma team, um, as well as Jonathan Thackeray, um, a Abuse pediatrician who's now at Dayton Children's um did a deep dive to kind of come up with a way to avoid, avoid missing abuse, and we now have an automatic consult to our team for any child under the age of 5 that's admitted to the hospital and so that's kind of our team taking on that load which. I was a fellow when this started, so I was, I was a brand new fellow, so it was kind of like, yeah, sure, we'll see all the patients, um, isn't attending now I just have different thoughts about that, but, um, it's, it's really, it so kind of measures you like it has not increased our length of stay. It has not increased the number of head CTs or skeletal surveys we're doing, but what it has done is increased, um, availability and access of our team, just kind of visibility of our team. We now get calls like, oh. This kid got admitted and maybe it should have triggered your consult, maybe not, so it's something that's really just kind of helped, um, culturally with identification of, of concerns um for, for abuse. So this, of course, misses all of the children that Go home from the ED because it's only applied to kids that are admitted, but it's something that we've done just as, as the child assessment team is what we call ourselves, but so the child abuse pediatricians to kind of help take some of that burden of detection off of the ED and um and. You know, put it on us and have a second set of eyes just go through these charts. If we are not concerned for abuse, there is no bill, there is no note, the family has no idea. Um, so if it's a 4 year old jumping off of a couch that ends up with a supracondylar fracture, fine. Um, but if it's a 4 month old with, with an injury that's concerning, then we see those kids. That's great. I think I wanna, there's another question from the crowd, but I'll, I'll get to that. I just wanna emphasize what both of you have said. I mean this communication of families about this is what we always do and, and we're not being accusatory and we're not picking out on you. Only works if we all have a standard screening. And so I think just to further emphasize universal screening for these folks at risks like you both have talked about, like Tony's paper, um, you know, summarizes that that's really the key in getting those steps implemented so that you can have these non-biased discussions that we really do do this only with our all the time. The question from the crowd, it says one barrier that we have is child protective services seems to screen lower, have less concern if we Report something but say we don't have concerns, but what about those gray areas? Um, it seems they're in their experience, child protective service only investigates if there's deemed a real concern and how you, how do you handle that communication. So one of the things that I put in my notes is that we can't exclude non-accidenal trauma, which is my way of being really wishy-washy, which I, I get Children's Services doesn't like, but I also can't be definitive, and I don't wanna overstate an injury. Um, I think once you Put in the documentation that that's on the list and it has to be thought of, um, that pushes them a little bit. Um, the other thing, um, that we do if we think Children's Services needs to screen something in and they're not is I will often reach out and, and just say. Do you have questions for me or can I talk to a supervisor, um, just to make sure that, um, there, it's being staffed with the supervisor, the supervisor level, and they understand why we made the report in the first place because we don't make a report when we have no concern. There's obviously some concern. Yeah, I would echo that. We, um, we got aggressive, I guess, um, in that the, we, we actually use a consult note or an admission note that, uh, has NAT screen on the top. It's the title. So, the fact that I've already put a note in our and that the surgeons are now involved means that the concern was enough to warrant the CPS referral. And so, um, it's almost a non-starter conversation, um. Certainly where we get into uh some debate is if all the members of the team don't agree. So, you know, we always have hospitalists involved. We always have the ER involved, um, because there's a lot of pediatric specific stuff that's not gonna be my role to be able to sort out. And that can be tricky. And so we've developed a huddle or the technique to, we have to have a conversation amongst all of us, including the social worker. If it's the ER it's the bedside nurse, uh, or Um, to try to sort out a disposition, um, and try to come to some sort of consensus. So thanks Tony. I think that's important. I think that also kind of emphasizes something we've been working on is trying to make sure at a place with residents and fellows and lots of other people, um, that we're all giving a consistent message so we don't have one resident, um, coming in and saying I don't know why they're doing all this workup. You know, this seems pretty typical to me, um, and that goes back to keeping consistent. Another question that I've had come up, um, to me from, from our hospital sometimes and, and from patients is, well, you guys in pediatrics and pediatric surgeons are always talking about radiation and now you're telling me to do another head CT and a skeletal survey, and you're also talking about cost. And who's going to pay for this? We've had families, you know, call back and argue once it's been safely proven that their child doesn't have any injuries and say, Well, I got this bill for this skeletal survey and this head CT. We're running out of time, but kind of I know it's a big question, but quick answers from thoughts. In terms of radiation, the, um, benefits outweigh the risk in terms of identifying abuse. Um, your, your risk is far higher of dying from repeated abuse than from brain cancer from your head CT. So that's kind of my, my message. And at a children's hospital, we're using the lowest dose radiation possible, so that's another reason we kind of advocate to have the kids come here. Um, as far as cost, Our hospital has done a lot and I don't fully understand that we eat a lot of the cost, um, of the workup. Yeah, I would just say the same thing. If I'm ruling out an, you know, appendicitis, I'm gonna get an ultrasound. And if that ultrasound's negative, great. But that doesn't mean we're gonna eat the cost of the ultrasound. The diagnosis of NAT is a diagnosis, uh, in my mind. Um, and so we're ruling out a medical issue just as we would appendicitis. Great, and I, I, I agree. I mean, I think those are challenging discussions sometimes, but it's exactly what you guys both said. It's, we're doing, and, and as you both alluded to throughout, we're doing all this to protect the child, not to accuse or blame a family member, um, as, as you said, and, and sometimes the abuse is not by either family member, and we're helping them identify that. Something bad happened to their child that they want to protect their child, they should want to protect their child from also. Um, so just in closing, first, thank you both, uh, for your time. This was great. I think it's really valuable to everyone, um, on the line and those of you who are now watching this record it later. Um, I hope this was useful. I want to emphasize the standard and consistent. And universal screening following there's lots of information out there, a lot of it you've heard, uh, tonight, uh, about how to, how to set up standardize what should be screened for. We need to use that, that screening we had racial and. SES disparities in our screening, we put in standardized processes and we got rid of that. It's, it's doable. It's hard sometimes, but it's doable. And the other thing that I think you heard tonight is partner with your regional pediatric trauma center, your regional experts. You may or may not have to always transfer everybody there, but have those lines of communication, have the understanding. We've, at Children's Hospitals that and trauma centers, that's what we're here for, to have thought through some of these process. Processes and be able to help and collaborate with you on how do you, who should you screen, how should you screen, when should you refer? I mean, it is a big deal to transfer kid long distances um for something without having that discussion with your referring folks. So I, I would just encourage those of you who aren't at children's centers to, to reach out to your pediatric trauma center and, and ask for advice or ask for help and those that you are at children's centers, be receptive to that. So with that, if you guys have any last-minute, uh, closing comments. No, just thank you. Thank you for having us. All right, thank you all and, and thanks everybody for attending. Thank you. Thanks.