Evaluation Of Abuse Research Articles

Screening for pediatric abusive head trauma: Are three variables enough?

BackgroundThe PediBIRN 4-variable clinical decision rule (CDR) detects abusive head trauma (AHT) with 96% sensitivity in pediatric intensive care (PICU) settings. Preliminary analysis of its performance in Pediatric Emergency Department settings found that elimination of its fourth predictor variable enhanced screening accuracy. ObjectiveTo compare the AHT screening performances of the “PediBIRN-4” CDR vs. the simplified 3-variable CDR in PICU settings. Participants and settings973 acutely head-injured children <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. MethodsRetrospective, secondary analysis of the combined, prospective PediBIRN data sets. AHT definitional criteria and physicians' diagnoses were applied iteratively to sort patients into abusive vs. other head trauma cohorts. Outcome measures of CDR performance included sensitivity, specificity, predictive values, likelihood ratios, ROC AUC, and the correlation between each CDR's patient-specific estimates of AHT probability and the overall positive yield of patients' completed abuse evaluations. ResultsApplied accurately and consistently, both CDR's would have performed with sensitivity ≥93% and negative predictive value ≥91%. Eliminating the PediBIRN-4's fourth predictor variable resulted in significantly higher specificity (↑′d ≥19%), positive predictive value (↑′d ≥8%), and ROC AUC (↑′d ≥5%), but a 3% reduction in sensitivity. Both CDRs provided patient-specific estimates of abuse probability very strongly correlated with the positive yield of patients' completed abuse evaluations (Pearson's r = 0.95 and 0.91, p = .13). ConclusionThe PediBIRN 3-variable CDR performed with greater AHT screening accuracy than the 4-variable CDR. Both are good predictors of the results of patients' subsequent completed abuse evaluations.

Domestic Violence Current Legal Status: Psychiatric Evaluation of Victims and Offenders.

Domestic Violence Current Legal Status: Psychiatric Evaluation of Victims and Offenders.

A Standardized Peer Review Program Improves Assessment and Documentation of Child Sexual Abuse.

Introduction:The objective was to assess the impact of interventions associated with ongoing expert peer review on the quality of child abuse medical providers’ written and photograph documentation in child sexual abuse cases.Methods:Pediatricians participated in a HIPAA compliant blind peer review process on a web platform developed to provide the American Board of Pediatrics maintenance of certification. Participants submit sequential photograph and written documentation of child sexual abuse examinations over 1 year. Documentation includes genital examination descriptions and interpretation of findings. Reviewers evaluate the photographic quality and written documentation of examination findings utilizing a numerical rating system. Each case cycle is reviewed by one of four experts in child abuse who received training in a uniform evaluation process. Reviewers follow each case throughout three cycles of documentation, selecting from several interventions that have been customized to address the quality issues noted. The third and final cycle includes summary comments from the reviewer.Results:Forty-one participants completed the program at the time these data were collected. A paired t test analysis of the combined scores of the three measures, such as Image Quality, Quality of Written Documentation, and Accuracy of Exam Interpretation, showed a statistically significant improvement (P < 0.001) between the first and last sets. In addition, each of the individual measures was statistically significant between the first and last case sets with a P value of <0.05 for each.Conclusion:Peer review with interventions customized to address quality issues improved the quality of the assessment and documentation of child sexual abuse evaluations.

Child Abuse Screening in the Emergency Department Before and After Implementation of a Formal Screening Tool

Background: &#x0D; Child abuse and neglect is a leading cause of mortality and morbidity in children. Victims of abuse often present to emergency departments due to these injuries. Early identification of suspected child abuse by emergency department staff allows the opportunity for intervention prior to a devastating injury. Signs of child abuse can be subtle and may not always be identified. Recent efforts have worked to improve suspected child abuse identification by implementation of validated screening protocols. Specifically, the IU Health Riley Emergency Department has recently implemented a new child abuse screening tool (effective on 15Apr2021). The Covid-19 pandemic has further exacerbated this issue, creating social isolation and additional socioeconomic stressors that contribute to child abuse. &#x0D; Method: &#x0D; A retrospective chart review was conducted to analyze patients identified for child abuse evaluation in the Riley emergency department. Patients prior to the implementation of the screening tool were identified by those undergoing a social work evaluation for child abuse. For patients presenting after implementation of the screening tool, all patients with a positive screen were reviewed. Charts were then reviewed for baseline demographics, diagnostic testing performed, and injuries identified. All data was recorded in an electronic Redcap database. &#x0D; Results: &#x0D; Implementation of a formal screening tool increased the number of patients identified for a child abuse evaluation (1.34% vs 3.17%) and those evaluated who had an injury also increased (1.15% vs 1.81%). More patients received a head CT scan after implementation of the screening tool (0.89% vs 1.07%), while the percentage of patients with an abnormal head CT decreased (62% vs 45%). &#x0D; Conclusions: &#x0D; Implementation of a formal screening tool for child abuse in the emergency department successfully improved identification of patients that should be further evaluated for child abuse. These results may be used to support implementation of the tool in additional emergency departments.

Complex Skull Fracture in a Toddler.

Complex Skull Fracture in a Toddler.

External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused

BackgroundAcute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. PurposeThe purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. Material and methodsEighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. ResultsInfants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC. ConclusionA substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Improving Physical Abuse Documentation and Photography through a Remote Peer Review Intervention.

In each cycle, participants submitted de-identified medical reports and photographs for review by a child abuse pediatrics expert. Experts evaluated 3 cycles of 5 cases using a novel rubric and assigned quality interventions for the participants based on their scores. 15 of 16 participants improved scores between cycles 1 and 3 (78% versus 89%, P < 0.001). All participants rated the program as helpful and would recommend it to a colleague. A quality improvement project administered via the internet improves the quality and uniformity of written and photographic documentation in child physical abuse evaluations.

Psychometric evaluation of the Substance Abuse Subtle Screening Inventory-3 with Northern Plains American Indians.

The efficacy of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) was assessed among northern plains American Indians (AIs). The current study examined the efficacy of the SASSI-3 for identification of substance abuse in AIs. Northern plains AIs from 7 reservations participated in the study. The participants were either a clinical sample receiving substance abuse (SA) or mental health diagnoses from behavioral health clinicians and receiving outpatient treatment services or a community sample that had no substance abuse or mental health diagnoses and were not currently in treatment (no diagnosis). The internal consistency for Face Valid Alcohol (FVA), Face Valid Other Drugs, and Symptoms (SYM) subscales were excellent, and the consistency for the other subscales was moderate, ranging from .21 to 73. The results of the study suggest that the SASSI-3 has good positive predictive power (PPP) and negative predictive power (NPP), particularly when the criterion group substance abuse is larger in the sample. Additionally, the PPP and NPP varied depending on the decision rules. For the analysis that included individuals with just SA, the clinical group scored significantly higher than the no diagnosis group on all measures of the SASSI-3, except for Defensiveness. When the SA group included all individuals with the diagnosis (regardless of the comorbid diagnosis), the clinical group scored significantly higher than the no diagnosis group for all the SASSI-3 subscales. A discriminant examination of the standardized function coefficients indicated that the FVA and SYM subtests contributed the most to the function. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Relationships Between Anxiety, Perceived Vulnerability to Disease, and Smartphone Use During Coronavirus Disease 2019 Pandemic in a Sample of Italian College Students.

Introduction: As of March 2020, coronavirus disease 2019 (COVID-19) has been declared a “pandemic” by the WHO. This has led to the need for governments around the world to implement restrictive containment and isolation measures to stem the spread of the virus; these measures have included social distancing, isolation, and quarantine. The fear of contagion has been indicated as one of the causes of stress, anxiety, depression, and insomnia in the general population. With respect to the response of young people to the pandemic, the category of University students deserves further attention. The sudden change in “University” habits (i.e., poor interaction with teachers and colleagues, disturbing learning environment, and difficulty in adapting to online learning), the consequent loss of a social network, and the economic problems in their families have seriously affected the psychophysical well-being of University students. The aim of this study was to explore, in a sample of Italian University students, the relationships among anxiety, perceived vulnerability to disease, and smartphone use during the COVID-19 pandemic.Methods: A sample of 194 volunteer college students (i.e., 86 males and 108 females) aged between 18 and 30 years (M = 21.74; SD = 2.39) were recruited to participate in this study. Participants were recruited through an online questionnaire sent to students of the University of Catania, Italy, and distributed from September 2020 to January 2021. The volunteer participants were given an online protocol that included the Fear of COVID-19 Scale (FCV-19S) for the evaluation of fear, the Perceived Vulnerability to Disease (PVD) for the evaluation of perceived vulnerability to disease, the State-Trait Anxiety Inventory (STAI) for the evaluation of trait and state anxiety, and the Smartphone Addiction Scale Short Version for Adolescents and Young Adults (SAS-SV) for the evaluation of use, abuse, or addiction of smartphone use.Results: The fear of COVID-19 did not reach an intensity such as to be defined as serious (i.e., fear score: 15.53) in the whole sample. Both men and women showed a high risk of smartphone addiction (i.e., score of males: 28.33 and score of females: 26.88) in SAS-SV. University students showed moderate trait and state anxiety [i.e., a score of 51.60 in Trait Anxiety Inventory (TAI) and a score of 47.21 in State Anxiety Inventory (SAI)] in STAI. In addition, students showed moderate perceived vulnerability to disease (i.e., a score of 51.51) in PVD. The results showed that fear of COVID-19 and trait anxiety appear to be the predictors of SAI and PVD but not the predictors of risk of smartphone addiction (SAS-SV).Conclusions: The data highlighted the presence of a perception of vulnerability to infections in subjects in which there was also a moderate anxiety, both state and trait, associated with the fear of the COVID-19 pandemic. It is hoped that a large part of the population will soon be vaccinated, including University students, and therefore, it would be desirable to carry out further assessments in the post-vaccine phase to highlight any differences in the state of anxiety and the perception of vulnerability to infections. The possible positive role of the use of smartphones in maintaining social contacts should also be emphasized.

Abusive supervision: A systematic review and fundamental rethink

We report a systematic and critical review of abusive supervision research to provide a comprehensive catalogue of the correlates of abusive supervision (i.e., antecedents, outcomes, mediators, and moderators) and identify four major challenges facing the field. First, abusive supervision is conceptualized in a confused manner that conflates followers’ subjective evaluations of abuse with leaders’ behaviors. Second, we consider how conceptual confusion is reflected in and undermines dominant measurement tools. Third, we identify and critique overreliance on cross-sectional survey-based studies and vignette experiments, which vary considerably in the extent to which they can evidence causal effects. Fourth, we consider the fact that abusive supervision is a low base rate phenomenon (i.e., is rarely reported). Using novel and simulated data we demonstrate that most past research is ill-equipped to make claims about the effects of intermediate or high levels of abusive supervision. Throughout, we explain how each challenge limits past research and offer achievable recommendations for a fundamental rethink of abusive supervision. In the discussion, we synthesize the recommendations for rethinking the conceptualization, measurement, and empirical study of abusive supervision. Only by overcoming these challenges will future research be robust enough to provide meaningful theoretical advances and useful policy implications.

Cluster Randomized Trials in Pediatric Research

In an article published in this volume of The Journal, Hymel et al described the findings of the effectiveness of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR), aimed at improving abuse evaluations and reducing rates of missed abusive head trauma in pediatric intensive care settings.1 The CDR was assessed via a randomized trial, but a specific type of trial, referred to as a cluster randomized trial (CRT). Also known as group randomized trials, there is no shortage of articles that explain CRTs.

Youth suicide risk screening in an outpatient child abuse clinic.

Child abuse is an important independent risk factor for suicide. The purpose of the project was to evaluate the implementation of a universal suicide risk screening and assessment tool in an outpatient child abuse evaluation clinic. Participants consisted of all patients between the ages of 10 and 18 years who received services at the study site within a 3-month period (n = 162). The study site implemented a tool created for the sole purpose of detecting suicide risk, the Ask Suicide-Screening Questions (ASQ) tool. Data was retrospectively collected using electronic health records; rates of compliance with screening and screen positive rates were calculated. Suicide risk screening with the ASQ was conducted on 90.7% (147) of the patients. Forty-three (29.2%) patients screened positive for suicide risk. This is a significant increase in detection rates compared to baseline preimplementation data. Of the 67 preteens, 10-12 years of age, that were screened, 14.9% (10/67) screened positive for suicide risk, making up 23% of the positive screens. Implementing a universal suicide risk screening tool was a successful strategy for detecting suicide risk. A quarter of the youth who screened positive on the ASQ were preteens, highlighting the importance of screening the 10- to 12-year olds for suicide risk.

A National Cost Analysis of Community Interventions to Prevent Underage Drinking and Prescription Drug Misuse

This prospective cost analysis addresses a gap in the prevention literature by providing estimates of the typical real-world costs to implement community interventions focused on preventing underage drinking and prescription drug misuse. The study uses cost data reported by more than 400 community subrecipients participating in a national cross-site evaluation of the Substance Abuse and Mental Health Services Administration's Strategic Prevention Framework Partnerships for Success grant program during 2013-2017. Community subrecipient organizations completed an annual Web-based survey to report their intervention costs. The analysis compares the relative startup and annual ongoing implementation costs of different prevention strategies and services. Partnerships for Success communities implemented a wide variety of interventions. Annual ongoing implementation was typically more costly than intervention startup. Costs were generally similar for population-level interventions, such as information dissemination and environmental strategies, and individual-level interventions, such as prevention education and positive alternative activities. However, population-level interventions reached considerably more people and consequently had much lower costs per person. Personnel contributed the most to intervention costs, followed by intervention supplies and overhead. Startup costs for initial training and costs for incentives, ongoing training, and in-kind contributions (nonlabor) during ongoing implementation were not typically reported. This study informs prevention planning by providing detailed information about the costs of classes of interventions used in communities, outside of research settings.

Siblings Are Also at Risk for Abuse.

Approximately 9 of every 1000 children in the United States are identified as victims of maltreatment, including neglect, physical abuse, emotional abuse, or sexual abuse.1 However, many cases of maltreatment are not identified,2 which has severe consequences for affected children.3 Although it is important to evaluate any child at risk for abuse, identifying risk can be challenging. In this issue of Pediatrics, Kisely et al4 evaluated whether siblings of children with suspected abuse are themselves at increased risk. These researchers followed a large cohort of sibling pairs in Australia. They found a 60-fold increase in abuse reports for siblings of children who had themselves been reported as abused previously. The risk was even greater when the mother was <20 years of age. The type of abuse (eg, physical, sexual, neglect) was often concordant between sibling pairs.Sibling risk has previously been studied but not on the scale of this new publication. Lindberg et al5 collected data from almost 3000 children who were evaluated for physical abuse. Contacts, including siblings or others in the same environment (including day care) of physically abused children were at significantly increased risk for injury.5 This risk was even higher among twins.Armed with the knowledge of the increased risk to siblings, medical providers and child welfare professionals should advocate for evaluations of these children at high risk. In cases of physical abuse, the evaluation by Lindberg et al5 included head imaging for contacts aged <6 months or those with mental status changes, skeletal surveys for contacts aged <2 years, and physical examinations for all contacts aged <5 years. This evaluation by Lindberg’s team parallels the recommended evaluation for any child when there is concern for physical abuse, although it may be reasonable to perform head imaging on any infant at high risk for abuse, such as siblings.6,7 To conduct a thorough examination, providers should familiarize themselves with injuries that are most specific for abuse, such as facial bruises and frenular injuries.8Siblings of sexual abuse victims should also be evaluated. Although the American Academy of Pediatrics policy statement on sexual abuse does not mention siblings or contacts, the National Children’s Alliance (the accrediting body for children’s advocacy centers) recognizes that siblings and other household contacts of abuse victims are themselves at risk.9,10 Evaluations for possible sexual abuse typically involve a forensic interview (if a child is developmentally capable) and a sexual abuse evaluation performed by a provider with training in pediatric sexual abuse examinations.9,10 Children’s advocacy centers are present throughout the country to assist in these evaluations of both suspected sexual abuse victims and their siblings.10The finding that children are at increased risk for maltreatment if they live with a young mother can help inform prevention efforts. For example, some home visitation programs, such as Nurse-Family Partnership, which works with first-time mothers in poverty, can help target the risks seen with young mothers, including lack of support and lack of education, and may have some benefit to prevent physical abuse.11As pediatricians, we are advocates for children, so our evaluation for suspected child abuse or neglect should include asking about the presence of siblings or other children in that environment. Subsequently, we should follow-up to ensure that any siblings are appropriately evaluated for abuse themselves.

Clinical evaluation and management of children with suspected physical abuse.

Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.

Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages.

The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist. This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls. Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises. These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.

Evaluation of Drug Abuse by Hair Analysis and Self-Reported Use Among MSM Under PrEP: Results From a French Substudy of the ANRS-IPERGAY Trial.

We used the Agence nationale de Recherches sur le sida et les hépatites virales (ANRS)-IPERGAY trial to qualitatively and quantitatively measure drug use among men who have sex with men under preexposure prophylaxis using 2 different methods, to better understand and collectively respond to risky practices. We included 69 volunteers of the ANRS-IPERGAY trial. We measured drug use by 2 methods: (1) drug detection by hair analysis and (2) reported drug use by self-reported drug consumption. New psychoactive substances (NPS) and conventional drugs were detected in 53 of the 69 (77%) volunteers by hair analysis and in 39 of the 69 (57%) volunteers by questionnaires. On the 219 hair segments analyzed, the most commonly used drugs were cocaine in 47 of the 69 (68%), 3,4-methylenedioxymethamphetamine/ecstasy in 31 of the 69 (45%), and NPS in 27 of the 69 (39%). On the 1061 collected questionnaires, the most commonly used drugs were cocaine in 31 of the 69 (45%), 3,4-methylenedioxymethamphetamine/ecstasy in 29 of the 69 (42%), and NPS in 16 of the 69 (23%). Hair analysis detects more conventional drugs and/or NPS use (P < 0.05). Drug use identified by hair was significantly associated with a higher number of sexual partners in the past 2 months (P ≤ 0.001), more often casual partners (P ≤ 0.001), condomless anal sex (P ≤ 0.005), hardcore sexual practices (P ≤ 0.001), a higher number of sexually transmitted infections, and chemsex (P ≤ 0.05). Self-report drug use by questionnaires remains the reference tool for harm reduction at the individual level because of its feasibility and low cost. However, hair analysis is more sensitive, objectively assessing consumption, and interesting to understand uses and to be able to collectively respond to risky practices with adapted messages.

The Likelihood of an Occult Fracture in Skeletal Surveys Obtained in Children More Than 2 Years Old With Concerns of Physical Abuse.

Skeletal surveys are necessary in the evaluation for physical abuse in children less than 2 years old, but when to obtain a skeletal survey in older children is less clear. A retrospective study of patients older than 2 years who underwent skeletal survey over a 3-year period after implementation of an electronic health record physical abuse order set was conducted. Data were analyzed using descriptive statistics and compared with data from a cohort before order set implementation. The radiation dose of a skeletal survey in a 5-year old was calculated using a previously published technique. There were 325 skeletal surveys, a marked increase in the rate of skeletal surveys compared with before order set implementation. Less than 2% (6/325) of skeletal surveys demonstrated an occult fracture. Of the 6 patients with occult fractures, 4 were physically abused; in each case, the diagnosis of abuse was evident before the skeletal survey. The other 2 patients fell from windows. The radiation exposure was 0.34 mSv. The rate of occult fractures on skeletal survey is significantly lower than previously reported. This is likely because our population included all children who underwent skeletal survey and not the subset referred to a child abuse pediatrician. In addition, our data demonstrate that in children older than 2 years, skeletal surveys are unlikely to assist in making a diagnosis of physical abuse. The radiation exposure in a 5-year-old is 70% greater than in an infant, but still a dose, which represents a negligible health risk.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System

BackgroundWe sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. Materials and methodsThe Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. ResultsA total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. ConclusionsPOT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.Level of Evidence: Epidemiologic study, level III.

A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings

To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3years (n=183 and n=237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P=.11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P=.05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P=.22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P=.01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P=.003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P=.22). PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. ClinicalTrials.gov: NCT03162354.