Harm range: Minimal temporary harm to death.
Prompt recognition of non-accidental trauma (NAT) is critical to improving outcomes for vulnerable children,1 but there are many challenges to detecting it. If not identified at the first encounter, these children “may have as much as a 50% chance of incurring further abuse and a 10% chance of dying”1. Children who experience NAT can present in any setting but are most often seen in the emergency department, typically for an alternative reason. Infants and children under 3 years old account for 27%2 of NAT cases, further compounding the difficulty in early identification.
Contributing factors may include:
- Challenges identifying the signs and symptoms, particularly when they vary or are non-specific
- Incomplete information or a believable false explanation from the caregiver
- Knowledge gap or unawareness of findings that warrant further investigation
- Fear of damaging relationships with families
- Difficulty recognizing patterns that span more than one encounter
- Uncertainty in the process and articulation of concerns
Patients with a delayed or missed diagnosis of non-accidental trauma may experience severe injuries from reoccurring abuse and are at a higher risk of death.
Recommendations
- Develop an EHR-integrated screening tool to assist in identifying factors that may warrant further evaluation.
- Utilize clinical decision support tools such as algorithms, order sets, and clinical practice guidelines to inform care and standardize practices.
- Provide staff training regarding key findings that may trigger NAT consideration and effective ways to engage the family.
- Consider ways to optimize the EHR system:
- Make it easy to see noted concerns or abnormalities relating to previous encounters.
- Utilize best practice alerts when specific signs or symptoms are documented.
- Use automation when appropriate for next steps.
- Implement engineering controls for appropriate diagnostic and laboratory testing related to specific evaluations.
- Ensure the multidisciplinary team maintains a broad perspective and differential diagnosis to detect potential subtle findings or nuances.
- Encourage the use of resources and specialty consults, especially when there is uncertainty.
- Establish an escalation process that includes clear communication through scripting.
Resources
References
- Boos, Stephen C. “Physical Child Abuse: Diagnostic Evaluation and Management.” UpToDate
- Boos, Stephen C. “Physical Child Abuse: Recognition.” UpToDate
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