Discrepancies in Physician and Coroner Findings in Cases of Fatal Suspected Physical Child Abuse.

OBJECTIVES: As mandated reporters of suspected abuse, physicians must consider abuse when a child dies unexpectedly. Subsequently, a coroner or medical examiner determines the manner of death (MOD) and cause of death (COD). Accurate diagnoses and determinations are important for social safety and justice. This study described discrepancies between physicians' and coroners' findings in cases of fatal suspected physical child abuse. METHODS: This study was a single-institution, retrospective review. All children 6 years or younger who died in a pediatric emergency department from October 2006 to January 2013 with a coroner report were included in this study. Coroner reports, MODs, and CODs were reviewed. Skeletal survey results were compared with coroners' findings. RESULTS: One hundred twenty-nine children were included. The MODs included the following: undetermined, 63 (49%); accident, 32 (25%); natural, 31 (24%); and homicide, 3 (2%). Thirty-three (26%) of the 129 patients had abuse suspected at the time of death in the emergency department; in this subset, MODs were as follows: undetermined, 16 (48%); accident, 8 (24%); natural, 6 (18%); and homicide, 3 (9%). Sudden infant death syndrome or sudden unexpected death was the most common COD in all children (68, 55%). Skeletal surveys were positive in 12 children with 29 fractures identified; 8 (28%) of the 29 fractures were corroborated on autopsy findings. Of the 12 children with positive skeletal survey findings, only 1 was ruled a homicide. CONCLUSIONS: We found discrepancies between coroner determination of homicide and abuse suspected by physicians, especially among children with fractures. Improved communication between agencies in cases of fatal child abuse is needed.

Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department.

BACKGROUND: Emergency Department (ED) patients who leave without being seen (LWBS) are associated with adverse safety and medico-legal consequences. While LWBS risk has been previously tied to demographic and acuity related factors, there is limited research examining crowding-related risk in the pediatric setting. The primary objective of this study was to determine the association between LWBS risk and crowding, using the National Emergency Department Overcrowding Score (NEDOCS) and occupancy rate as crowding metrics. METHODS: We performed a retrospective observational study on electronic health record (EHR) data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period. NEDOCS and occupancy rate were calculated for 15-min windows and matched to patient arrival time. We leveraged multiple logistic regression analyses to demonstrate the relationship between patientlevel LWBS risk and each crowding metric, controlling for characteristics drawn from the pre-arrival state. We performed a chi-squared test to determine whether a difference existed between the receiver operating characteristic (ROC) curves in the two models. Finally, we executed a dominance analysis using McFadden's pseudo-R 2 to determine the relative importance of each crowding metric in the models. RESULTS: A total of 54,890 patient encounters were studied, 1.22% of whom LWBS. The odds ratio for LWBS risk was 1.30 (95% CI 1.27-1.33) per 10-point increase in NEDOCS and 1.23 (95% CI 1.21-1.25). per 10% increase in occupancy rate. Area under the curve (AUC) was 86.9% for the NEDOCS model and 86.7% for the occupancy rate model. There was no statistically significant difference between the AUCs of the two models (p-value 0.27). Dominance analysis revealed that in each model, the most important variable studied was its respective crowding metric; NEDOCS accounted for 55.6% and occupancy rate accounted for 53.9% of predicted variance in LWBS. CONCLUSION: Not only was ED overcrowding positively and significantly associated with individual LWBS risk, but it was the single most important factor that determined a patient's likelihood of LWBS in the pediatric ED. Because occupancy rate and NEDOCS are available in real time, each could serve as a monitor for individual LWBS risk in the pediatric ED.