P0970 - Improving Compliance in Completion of Secondary Skeletal Surveys for suspected Physical Child Abuse: A Quality Improvement Project

Background:
The secondary skeletal survey is an important component in the screening of suspected physical child abuse (PCA, formerly nonaccidental trauma) because certain fractures are difficult to detect in the acute setting. However, compliance remains a challenge due to issues with patient tracking and care coordination. The purpose of this quality improvement project was to implement a standardized protocol to improve compliance in obtaining secondary skeletal surveys in the appropriate timeframe for children who underwent initial skeletal survey for possible PCA.

Methods:
A quality improvement project was initiated to institute a standardized process to improve rates of completing secondary skeletal surveys within 14 days from the initial screening consult for CPA. Beginning in July 2019, a dedicated case coordinator was assigned to engage both the patient’s caregivers and the state Child Protective Services to ensure completion of indicated secondary skeletal surveys. Weekly compliance reports were compiled and reviewed by a physician in the Child Abuse Intervention Department. A prospective review of compliance was then conducted through December 2019 and compared to pre-implementation data from 2018 via standard frequentist and Bayesian statistical analyses.

Results:
204 patients included in this study, 127 patients (62.5%) in the pre-implementation group and 77 patients (37.7%) in the post-implementation group. Appropriate PCA screening completion rates were significantly higher following the implementation of the protocol (94.8% vs. 74.0%; p<0.001). Bayesian analysis confirmed a 20% higher probability of receiving the appropriate screening following programmatic implementation (Fig. 1). There was a trend towards decreased time to completion of the secondary survey in the post-implementation group though this difference did not achieve statistical significance (14.3 v. 17.0 days, p=0.058).

Conclusion:
The implementation of a standardized protocol can significantly improve the compliance rate for secondary skeletal surveys and should be included in a systematic approach to screening for PCA.