The objective of this study was to evaluate disparities in skeletal survey (SS) use for pediatric. head injury patients in the emergency department (ED). This was a multi-site retrospective. cohort study of children <24 months with concern for head injury and injury on head CT from. 7/1/12 – 1/1/22. We determined adjusted associations between SS completion and race, ethnicity, language for care, insurance type, and income, with sub-analysis of children <6 months and with complex injury. We evaluated occult fracture prevalence. Two-hundred seventy children met criteria and 88 had SS. No statistical association was found between skeletal survey completion and race or ethnicity, language for care, private insurance, median census tract income, or in sub-analyses. Two of 88 (2.3%) patients had occult fracture; both had risk factors for NAT. In conclusion, no statistical association was found between SS completion and demographics. Occult fracture was uncommon. SS use can likely be decreased in lower risk patients.
AnderstJ. D. (2008). Assessment of factors resulting in abuse evaluations in young children with minor head trauma. Child Abuse & Neglect, 32(3), 405–413. https://doi.org/10.1016/j.chiabu.2007.06.007
2.
BergerR. P.FromkinJ.HermanB.PierceM. C.SaladinoR. A.FlomL.Tyler-KabaraE. C.McGinnT.RichichiR.KochanekP. M. (2016). Validation of the Pittsburgh infant brain injury Score for abusive head trauma. Pediatrics, 138(1), Article e20153756. https://doi.org/10.1542/peds.2015-3756
3.
BurkhartZ. N.ThurberC. J.ChuangA. Z.KumarK. S.DavisG. H.KellawayJ. (2015). Risk factors associated with retinal hemorrhage in suspected abusive head trauma. Journal of American Association for Pediatric Ophthalmology and Strabismus, 19(2), 119–123. https://doi.org/10.1016/j.jaapos.2014.12.007
DeyeK. P.BergerR. P.LindbergD. M.ExSTRA Investigators. (2013). Occult abusive injuries in infants with apparently isolated skull fractures. Journal of Trauma and Acute Care Surgery, 74(6), 1553–1558. https://doi.org/10.1097/TA.0b013e31828b7fc4
6.
DominguezM. M.MooreJ. L.CookM.RogersM. L.McCartenK.SlingsbyB. (2022). Selective skeletal surveys for infants with skull fractures: Examining the rates of return to medical care for concern of physical abuse. Pediatric Emergency Care, 38(12), e1678–e1683. https://doi.org/10.1097/PEC.0000000000002877
FitzGeraldC.HurstS. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8
10.
HarrisP. A.TaylorR.MinorB. L.ElliottV.FernandezM.O’NealL.McLeodL.DelacquaG.DelacquaF.KirbyJ.DudaS (2019). The REDCap consortium: Building an international community of software platform partners. Journal of Biomedical Informations, 95, Article 103208. https://doi.org/10.1016/j.jbi.2019.103208
11.
HarrisP. A.TaylorR.ThielkeR.PayneJ.GonzalezN.CondeJ. G. (2009). Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010
12.
HeinzeG.SchemperM. (2002). A solution to the problem of separation in logistic regression. Statistics in Medicine, 21(16), 2409–2419. https://doi.org/10.1002/sim.1047
13.
HymelK. P.FingarsonA. K.PierceM. C.KaczorK.MakoroffK. L.WangM. (2022a). External validation of the PediBIRN screening tool for abusive head trauma in pediatric emergency department settings. Pediatric Emergency Care, 38(6), 269–272. https://doi.org/10.1097/PEC.0000000000002670
14.
HymelK.P.KarstW.MarinelloM.HermanB.E.FrazierT. N.CarrollC. L.,…PediatricBrain Injury Research Network (PediBIRN) Investigators. (2022b). Screening for pediatricabusive head trauma: Are three variables enough?Child Abuse and Neglect, 125, 105518.https://doi.org/10.1016/j.chiabu.2022.105518
15.
IsaacR.GreeleyC.MarinelloM.HermanB. E.FrazierT. N.CarrollC. L.Armijo-GarciaV.MusickM.WeeksK.HaneyS. B.WangM.HymelK. P. (2023). Skeletal survey yields in low vs. high risk pediatric patients with skull fractures. Pediatric Brain Injury Research Network Investigators. Child Abuse & Neglect, 139, Article 106130. https://doi.org/10.1016/j.chiabu.2023.106130
16.
JohnsonT. J.HickeyR. W.SwitzerG. E.MillerE.WingerD. G.NguyenM.SaladinoR. A.HausmannL. R. (2016). The impact of cognitive stressors in the emergency department on physician implicit racial bias. Academic Emergency Medicine, 23(3), 297–305. https://doi.org/10.1111/acem.12901
17.
JohnsonT. J.WingerD. G.HickeyR. W.SwitzerG. E.MillerE.NguyenM. B.SaladinoR. A.HausmannL. R. M. (2017). Comparison of physician implicit racial bias toward adults versus children. Academic Pediatrics, 17(2), 120–126. https://doi.org/10.1016/j.acap.2016.08.010
18.
KimP. T.McCaggJ.DundonA.ZieslerZ.MoodyS.FalconeR. A.Jr. (2017). Consistent screening of admitted infants with head injuries reveals high rate of nonaccidental trauma. Journal of Pediatric Surgery, 52(11), 1827–1830. https://doi.org/10.1016/j.jpedsurg.2017.02.014
19.
LaskeyA. L.StumpT. E.HicksR. A.SmithJ. L. (2013). Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures. The Journal of Pediatrics, 162(1), 86–89. https://doi.org/10.1016/j.jpeds.2012.06.038
20.
LeeG. S.LindbergD. M.FrasierL. D.HymelK. P. (2021). A changing history: When is it a red flag for child abuse?Child Abuse & Neglect, 117, Article 105077. https://doi.org/10.1016/j.chiabu.2021.105077
21.
MaguireS. A.KempA. M.LumbR. C.FarewellD. M. (2011). Estimating the probability of abusive head trauma: A pooled analysis. Pediatrics, 128(3), e550–e564. https://doi.org/10.1542/peds.2010-2949
PaineC. W.ScribanoP. V.LocalioR.WoodJ. N. (2016). Development of guidelines for skeletal survey in young children with intracranial hemorrhage. Pediatrics, 137(4), Article e20153024. https://doi.org/10.1542/peds.2015-3024
PfeifferH.SmithA.KempA. M.CowleyL. E.CheekJ. A.DalzielS. R.BorlandM. L.O'BrienS.BonischM.NeutzeJ.OakleyE.CroweL.HearpsS. J. C.LyttleM. D.BressanS.BablF. E.Paediatric Research in Emergency Department International Collaborative PREDICT. (2018). External validation of the PediBIRN clinical prediction rule for abusive head trauma. Pediatrics, 141(5), Article e20173674. https://doi.org/10.1542/peds.2017-3674
26.
PierceM. C.KaczorK.LorenzD. J.BertocciG.FingarsonA. K.MakoroffK.BergerR. P.BennettB.MaganaJ.StaleyS.RamaiahV.FortinK.CurrieM.HermanB. E.HerrS.HymelK. P.JennyC.SheehanK.ZuckerbraunN.LeventhalJ. M. (2021). Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Network Open, 4(4), Article e215832. https://doi.org/10.1001/jamanetworkopen.2021.5832
27.
RangelE. L.CookB. S.BennettB. L.ShebestaK.YingJ.FalconeR. A. (2009). Eliminating disparity in evaluation for abuse in infants with head injury: Use of a screening guideline. Journal of Pediatric Surgery, 44(6), 1229–1235. https://doi.org/10.1016/j.jpedsurg.2009.02.044
28.
RileyR. D.SnellK. I. E.EnsorJ.BurkeD. L.HarrellF. E.MoonsK. G. M.CollinsG. S. (2019). Minimum sample size for developing a multivariable prediction model: PART II - binary and time-to-event outcomes. Statistics in Medicine, 38(7), 1276–1296. https://doi.org/10.1002/sim.7992
WoodJ. N.ChristianC. W.AdamsC. M.RubinD. M. (2009). Skeletal surveys in infants with isolated skull fractures. Pediatrics, 123(2), e247–e252. https://doi.org/10.1542/peds.2008-2467
31.
WoodJ. N.HallM.SchillingS.KerenR.MitraN.RubinD. M. (2010). Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics, 126(3), 408–414. https://doi.org/10.1542/peds.2010-0031
32.
WoodJ. N.HenryM. K.BergerR. P.LindbergD. M.AnderstJ. D.SongL.LocalioR.FeudtnerC.FeudtnerC. (2019). Use and utility of skeletal surveys to evaluate for occult fractures in young injured children. Academic Pediatrics, 19(4), 428–437. https://doi.org/10.1016/j.acap.2018.08.007
33.
zVision [Computer Software]. (2012). Clario Medical Imaging.
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