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Quality Improvement Initiative to Improve Abuse Screening Among Infants With Extremity Fractures

Deutsch, Stephanie Anne MD, MS*; Henry, M. Katherine MD, MSCE; Lin, Winnie MD; Valentine, Karen J. MStat§; Valente, Christopher MD; Callahan, James M. MD¶,#; Lavelle, Jane MD¶,#; Scribano, Philip V. DO, MSCE†,#; Wood, Joanne N. MD, MSHP†,#,**

Section Editor(s): Rutman, Lori E. MD, MPH; Associate Editor

doi: 10.1097/PEC.0000000000001671
Original Research-QI

Objectives The aim of this study was to evaluate the effectiveness of clinical pathway implementation and quality improvement (QI) interventions to increase the percentage of infants with extremity fractures undergoing evaluation for suspected physical abuse, including skeletal survey (SS), and consultation with social work, and/or Child Protection Team.

Methods Charts were retrospectively reviewed to establish percentage of infants less than 12 months old with extremity fractures undergoing an SS and consultation during the prepathway (January 1, 2012 to December 31, 2013) and postpathway (January 1, 2014 to June 30, 2015) periods. Using an Ishikawa framework, key process drivers were identified and additional QI interventions (clinical decision support and provider education) were developed and implemented. Impact of QI interventions on study metrics during active QI (July 1, 2015 to June 30, 2016) and post-QI periods (July 1, 2016 to December 31, 2016) was monitored using statistical process control charts. Logistic regression assessed predictors of obtaining an SS, consultation use, and occult fracture detection.

Results Skeletal survey use pre- and postpathway averaged 40%, surpassing 60% on average during active QI and post-QI periods. Consultation performance averaged 46% pre- and postpathway, increasing to nearly 67% during active QI; consultation performance decreased during post-QI to 60%. A lack of trauma history and presence of femur or humerus fracture were associated with increased SS use and consultation (both P < 0.001). Overall 20% of SS revealed occult fractures.

From the *Division of General Pediatrics, Alfred I. DuPont Hospital for Children/Nemours, Wilmington, DE

Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA

Department of General Pediatrics, University of Chicago, Chicago, IL

§Intermountain Healthcare, Salt Lake City, UT

Reading Hospital, Reading

Division of Emergency Medicine, The Children's Hospital of Philadelphia

#Perelman School of Medicine at the University of Pennsylvania

**PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA.

Disclosure: The authors declare no conflict of interest.

Reprints: Stephanie Anne Deutsch, Division of General Pediatrics, Alfred I. DuPont Hospital for Children/Nemours, 3D224, 1900 Rockland Road, Wilmington, DE 19803 (e-mail: Stephanie.deutsch@nemours).

Dr Wood received salary funding from the National Institute of Child Health and Human Development grant (1K23HD071967). Dr Deutsch received project funding from the Ray E. Helfer Society Career Development Grant.

Financial disclosure: The Children's Hospital of Philadelphia has received payment for expert testimony after subpoenas in cases for suspected child abuse for Drs Wood, Scribano, Henry, and Deutsch.

The remaining authors have no financial relationships relevant to this article to disclose.

Online date: December 26, 2018

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