Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse

Irit R. Rasooly; Khoi Dang; Ursula S. Nawab; Kathy N. Shaw; Joanne N. Wood

doi:10.1515/dx-2022-0008

Article

Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse

Irit R. Rasooly , Khoi Dang , Ursula S. Nawab , Kathy N. Shaw and Joanne N. Wood

Published/Copyright: April 27, 2022

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From the journal Diagnosis Volume 9 Issue 3

Abstract

Objectives

Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20–30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis.

Methods

We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process.

Results

The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR).

Conclusions

Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning.

Keywords: child physical abuse; diagnostic error; pediatrics

Corresponding author: Irit R. Rasooly, MD MSCE, Division of General Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA; Center for Pediatric Clinical Effectiveness & PolicyLab, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, 10th floor, Philadelphia, Pennsylvania, 19146 USA; and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, Pennsylvania, 19104 USA, E-mail: rasoolyi@chop.edu

Funding source: Society to Improve Diagnosis in Medicine

Award Identifier / Grant number: Fellowship in Diagnostic Excellence

Research funding: Dr. Rasooly’s effort was supported, in part, by the Society to Improve Diagnosis in Medicine fellowship in Diagnostic Excellence.
Author contribution: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Not applicable.
Ethical approval: The local Institutional Review Board deemed the study exempt from review.

References

1. National Academies of Sciences. Improving diagnosis in health care [internet]; 2015. Available from: https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-care [Accessed 23 Jun 2020].Search in Google Scholar

2. Jenny, C, Hymel, KP, Ritzen, A, Reinert, SE, Hay, TC. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621–6. https://doi.org/10.1001/jama.281.7.621.Search in Google Scholar PubMed

3. Berger, RP, Lindberg, DM. Early recognition of physical abuse: bridging the gap between knowledge and practice. J Pediatr 2019;204:16–23. https://doi.org/10.1016/j.jpeds.2018.07.081.Search in Google Scholar PubMed

4. Letson, MM, Cooper, JN, Deans, KJ, Scribano, PV, Makoroff, KL, Feldman, KW, et al.. Prior opportunities to identify abuse in children with abusive head trauma. Child Abuse Negl 2016;60:36–45. https://doi.org/10.1016/j.chiabu.2016.09.001.Search in Google Scholar PubMed

5. Sheets, LK, Leach, ME, Koszewski, IJ, Lessmeier, AM, Nugent, M, Simpson, P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013;131:701–7. https://doi.org/10.1542/peds.2012-2780.Search in Google Scholar PubMed

6. Thackeray, J, Minneci, PC, Cooper, JN, Groner, JI, Deans, KJ. Predictors of increasing injury severity across suspected recurrent episodes of non-accidental trauma: a retrospective cohort study. BMC Pediatr 2016;16:8. https://doi.org/10.1186/s12887-016-0540-y.Search in Google Scholar PubMed PubMed Central

7. Sieswerda-Hoogendoorn, T, Bilo, RA, van Duurling, LL, Karst, WA, Maaskant, JM, van Aalderen, WM, et al.. Abusive head trauma in young children in The Netherlands: evidence for multiple incidents of abuse. Acta Paediatr 2013;102:e497–501. https://doi.org/10.1111/apa.12377.Search in Google Scholar PubMed

8. Ravichandiran, N, Schuh, S, Bejuk, M, Al-Harthy, N, Shouldice, M, Au, H, et al.. Delayed identification of pediatric abuse-related fractures. Pediatrics 2010;125:60–6. https://doi.org/10.1542/peds.2008-3794.Search in Google Scholar PubMed

9. Rosenthal, B, Skrbin, J, Fromkin, J, Heineman, E, McGinn, T, Richichi, R, et al.. Integration of physical abuse clinical decision support at 2 general emergency departments. J Am Med Inf Assoc 2019;26:1020–9. https://doi.org/10.1093/jamia/ocz069.Search in Google Scholar PubMed PubMed Central

10. Rumball-Smith, J, Fromkin, J, Rosenthal, B, Shane, D, Skrbin, J, Bimber, T, et al.. Implementation of routine electronic health record-based child abuse screening in general emergency departments. Child Abuse Negl 2018;85:58–67. https://doi.org/10.1016/j.chiabu.2018.08.008.Search in Google Scholar PubMed

11. Suresh, S, Saladino, RA, Fromkin, J, Heineman, E, McGinn, T, Richichi, R, et al.. Integration of physical abuse clinical decision support into the electronic health record at a tertiary care children’s hospital. J Am Med Inf Assoc 2018;25:833–40. https://doi.org/10.1093/jamia/ocy025.Search in Google Scholar PubMed PubMed Central

12. Singh, H, Khanna, A, Spitzmueller, C, Meyer, AND. Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety. Diagnosis 2019;6:315–23. https://doi.org/10.1515/dx-2019-0012.Search in Google Scholar PubMed

13. Al-Mutairi, A, Meyer, AND, Thomas, EJ, Etchegaray, JM, Roy, KM, Davalos, MC, et al.. Accuracy of the Safer Dx instrument to identify diagnostic errors in primary care. J Gen Intern Med 2016;31:602–8. https://doi.org/10.1007/s11606-016-3601-x.Search in Google Scholar PubMed PubMed Central

14. Schiff, GD, Kim, S, Abrams, R, Cosby, K, Lambert, B, Elstein, AS, et al.. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. In: Henriksen, K, Battles, JB, Marks, ES, Lewin, DI, editors. Advances in patient safety: from research to implementation, (Advances in Patient Safety), vol. 2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2005. Concepts and Methodology [Internet]. Available from http://www.ncbi.nlm.nih.gov/books/NBK20492/ [Accessed 23 Oct 2019].Search in Google Scholar

15. Beasley, JW, Wetterneck, TB, Temte, J, Lapin, JA, Smith, P, Rivera-Rodriguez, AJ, et al.. Information chaos in primary care: implications for physician performance and patient safety. J Am Board Fam Med 2011;24:745–51. https://doi.org/10.3122/jabfm.2011.06.100255.Search in Google Scholar PubMed PubMed Central

16. Karunamuni, N, Imayama, I, Goonetilleke, D. Pathways to well-being: untangling the causal relationships among biopsychosocial variables. Soc Sci Med 2021;272:112846. https://doi.org/10.1016/j.socscimed.2020.112846.Search in Google Scholar PubMed

17. Institute of Medicine (U.S.) Balogh, E, Miller, BT, Ball, J, editors Improving diagnosis in health care. Washington, DC: The National Academies Press; 2015:444 p. (Quality chasm series).Search in Google Scholar

18. Trokel, M. Variation in the diagnosis of child abuse in severely injured infants. Pediatrics 2006;117:722–8. https://doi.org/10.1542/peds.2004-2731.Search in Google Scholar PubMed

19. Wood, JN, Feudtner, C, Medina, SP, Luan, X, Localio, R, Rubin, DM. Variation in occult injury screening for children with suspected abuse in selected US children’s hospitals. Pediatrics 2012;130:853–60. https://doi.org/10.1542/peds.2012-0244.Search in Google Scholar PubMed PubMed Central

20. Lane, WG, Dubowitz, H. What factors affect the identification and reporting of child abuse-related fractures? Clin Orthop 2007;461:219–25. https://doi.org/10.1097/blo.0b013e31805c0849.Search in Google Scholar

21. Lane, WG, Rubin, DM, Monteith, R, Christian, CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA 2002;288:1603–9. https://doi.org/10.1001/jama.288.13.1603.Search in Google Scholar PubMed

22. Wood, JN, Hall, M, Schilling, S, Keren, R, Mitra, N, Rubin, DM. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics 2010;126:408–14. https://doi.org/10.1542/peds.2010-0031.Search in Google Scholar PubMed

23. Wood, JN, Christian, CW, Adams, CM, Rubin, DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics 2009;123:e247–52. https://doi.org/10.1542/peds.2008-2467.Search in Google Scholar PubMed

24. Cort, NA, Cerulli, C, He, H. Investigating health disparities and disproportionality in child maltreatment reporting: 2002–2006. J Publ Health Manag Pract 2010;16:329–36. https://doi.org/10.1097/phh.0b013e3181c4d933.Search in Google Scholar PubMed PubMed Central

25. Henry, MK, Wood, JN, Metzger, KB, Kim, KH, Feudtner, C, Zonfrillo, MR. Relationship between insurance type and discharge disposition from the emergency department of young children diagnosed with physical abuse. J Pediatr 2016;177:302–7. https://doi.org/10.1016/j.jpeds.2016.06.021.Search in Google Scholar PubMed PubMed Central

26. Hymel, KP, Laskey, AL, Crowell, KR, Wang, M, Armijo-Garcia, V, Frazier, TN, et al.. Racial and ethnic disparities and bias in the evaluation and reporting of abusive head trauma. J Pediatr 2018;198:137–43. https://doi.org/10.1016/j.jpeds.2018.01.048.Search in Google Scholar PubMed PubMed Central

27. Laskey, AL, Stump, TE, Perkins, SM, Zimet, GD, Sherman, SJ, Downs, SM. Influence of race and socioeconomic status on the diagnosis of child abuse: a randomized study. J Pediatr 2012;160:1003–8. https://doi.org/10.1016/j.jpeds.2011.11.042.Search in Google Scholar PubMed

28. Lindberg, DM, Blood, EA, Campbell, KA, Laskey, AL, Berger, RP. Examining siblings to recognize abuse study group. Predictors of screening and injury in contacts of physically abused children. J Pediatr 2013;163:730–5. https://doi.org/10.1016/j.jpeds.2013.02.051.Search in Google Scholar PubMed

29. Stavas, N, Paine, C, Song, L, Shults, J, Wood, J. Impact of child abuse clinical pathways on skeletal survey performance in high-risk infants. Acad Pediatr 2020;20:39–45. https://doi.org/10.1016/j.acap.2019.02.012.Search in Google Scholar PubMed PubMed Central

30. Brennan, B, Henry, MK, Altaffer, A, Wood, JN. Prevalence of abuse and additional injury in young children with rib fractures as their presenting injury. Pediatr Emerg Care 2021;37:e1451–6. https://doi.org/10.1097/pec.0000000000002071.Search in Google Scholar

31. Wood, JN, Fakeye, O, Feudtner, C, Mondestin, V, Localio, R, Rubin, DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics 2014;134:45–53. https://doi.org/10.1542/peds.2013-3242.Search in Google Scholar PubMed PubMed Central

32. Lindberg, DM, Beaty, B, Juarez-Colunga, E, Wood, JN, Runyan, DK. Testing for abuse in children with sentinel injuries. Pediatrics 2015;136:831–8. https://doi.org/10.1542/peds.2015-1487.Search in Google Scholar PubMed

33. Rangel, EL, Cook, BS, Bennett, BL, Shebesta, K, Ying, J, Falcone, RA. Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. J Pediatr Surg 2009;44:1229–34. https://doi.org/10.1016/j.jpedsurg.2009.02.044.Search in Google Scholar PubMed

List of Abbreviations

Modified diagnostic error and evaluation research (DEER) taxonomy: electronic health record (EHR)

Received: 2022-01-18

Revised: 2022-02-22

Accepted: 2022-03-21

Published Online: 2022-04-27

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Articles in the same Issue

https://doi.org/10.1515/dx-2022-0008

Keywords for this article

child physical abuse; diagnostic error; pediatrics