Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma.

Introduction: The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment. Methods: Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year. Results: After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months. Conclusions: Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.

Making the Most of Clinical Encounters: Prevention of Child Abuse and Maltreatment.

Child abuse is a public health concern with great costs to children, families, and society. Prevention of child abuse and maltreatment is an important clinical skill. Providers can take advantage of the opportunity to offer prevention interventions in the health care setting. Identification of risk factors and signs and symptoms of abuse, referral to local resources, parenting education, and application of the public health prevention framework should be integrated into clinical encounters. Identification of sentinel injuries enables tertiary interventions to save lives. Primary interventions during early childhood using effective parenting programs has been shown to reduce child maltreatment.