Welcome, everyone, to the Trauma Center Association of America webinar, Development of a Systematic Protocol to Identify Victims of Nonaccidental Trauma. Our webinar today will be presented by Dr. Tony Escobar. Dr. Escobar is a pediatric surgeon, medical director, and chief of staff at the Mary Bridge Children's Hospital in Tacoma, Washington. He graduated from Baylor School of Medicine in Houston, Texas. After completing his undergraduate studies at Trinity Houston University in San Antonio, Texas, he completed his surgical residency at IU and then went on to complete his pediatric surgical residency at Women's and Children's Hospital at Buffalo State University of New York. Dr. Escobar has published 27 peer-reviewed articles, seven clinical textbook chapters, and presented at multiple international and national surgical meetings. We're very happy to have Dr. Escobar with us today. Next slide. Thank you. Everyone should have received handouts prior to the webinar. If for some reason you did not receive handouts, you can look on your panel, and your panel has handouts on there, so you should be able to type them out or print them out from your panel on the side. Everyone has one free registration online as well as web access for hospital. Additional web accesses and phone lines will incur a $50 charge. As far as instructions and faculty, like I said, everyone should have received a handout. Also, all attendees are muted by default. If you have any questions, we ask you to either raise your hand in the panel. If you're able to ask a verbal or auditory question, you can do that. Only if you entered your PIN number in when you signed in through the phone system. If you didn't enter the PIN number, you will not be able to verbally ask a question. But that's okay, because we also have a question tab, so you can also enter your questions in the question tab. But we will refer or wait to answer any questions until the very end of the program. We also have, we ask you to complete evaluations, and so we'll send you an email immediately after the webinar to SurveyMonkey, and we'll send you the address for that as well. We have applied for both nursing CEs and CMEs for the webinar, so if you'd like to have those, please make sure you complete your evaluation by April 6, 2016. We're happy to say that, as far as disclosures, Dr. Escobar has no financial interest or other relationships with commercial entities. Lastly, we would also like to acknowledge that funding for the research was provided by the Heidner Charitable Trust and sponsored by MultiCare Institute for Research and Innovation. This brings us to our first polling question. Our first polling question is, how significant in the United States is non-accidental trauma of the pediatric population? Not a huge issue. Fatalities are less than 20%. A, B is not a huge issue since the majority of kids are over 10 years of age. C is a major issue since fatalities are over 40%, and D is unsure, which is the reason why I'm attending today. If everyone would go ahead and submit their responses, and we'll allow just a few seconds for this to take place. Just a few more seconds. The results are, Dr. Escobar, 88% said a major issue since fatalities are over 40%, with 12% saying they are unsure, which is why I'm attending today. With that, I will turn it over to you. Well, thank you. Thanks for having me. I'm really honored to be able to present this today. For the listeners, I have to apologize. I'm getting over a massive cold, which is what happens when you work with pediatrics. Thank you guys for your patience. The results of the poll show me that I don't have to say very much, so thank you. Let's see. The objectives of today's talk are to recognize that 48% of child fatalities each year are a result of physical abuse, and that the majority of these happen in children less than 4 years of age. We are going to discuss the fact that only 56% of cases are evaluated by a pediatric surgeon. It's not to say that every case of NAT needs to be evaluated by a pediatric surgeon, but we're going to talk about why that is an important statistic. Identify the risk factors and systematic screening programs that may help avoid escalation injuries, which contribute to worse outcomes. As a background, we just discussed that 48% of child fatalities each year are a result of physical abuse, and the majority are less than 4 years of age. Why would it be important that only 56% of cases are evaluated by a pediatric surgeon? Last study came out of Baylor, and the point was that non-accidental trauma is trauma in children, and there was a lack of a systematic approach to the evaluation of the traumatized patient, and there is the risk of having missed injuries. It's really important because the identification of what we call a sentinel injury will help hopefully identify the patient with non-accidental trauma and avoid escalation injuries. Why would that be important? Escalation injuries are injuries that happen after a subsequent and multiple episodes of abuse. Approximately 30% of children with abusive head trauma, this is a landmark study by Jenny, were evaluated by a physician, and NAT was not recognized. One of my colleagues, Kate Deans in Ohio, published a study in which recurrent NAT in children resulted in significantly higher mortality than an initial episode of NAT. Therefore, if a patient presented with NAT was not recognized as noted in the above study and then went home, there's a higher chance that that patient is going to come back with a significantly higher ISS or a significantly higher injury with the repeat visit, and I'm sure that most of the audience has had that unfortunate experience where they've had the patient present initially with a much smaller injury and then present an extremis subsequent to that. Interestingly, approximately 50% of abuse patients had previous concern in documented abdominal injury. So abdominal injury, although it's not as prevalent with NAT when it does exist, it is a much higher associated mortality. So what happened with us? Well, we had a case back in 2012 in which we experienced that significant transition from an initial presentation of injury to the representation of an escalation injuries and then subsequent mortality. That case haunted us and led an ad hoc group of physicians to examine our processes. How do we recognize NAT? How do we work up NAT? What kind of consults should we get when we have a suspected case of NAT? So one of my colleagues, Elizabeth Colson, organized us and just started having some conversations around that. Within a few months, after trying to review our data through the trauma registry, we decided to formalize an NAT subcommittee under the trauma committee to give this subcommittee some structure and also some ability to make changes within our system. From that point on, we started reviewing the literature presented to our hospital practices committees, our quality committees, etc., and we were fortunate enough to come across a screening tool from the University of Pittsburgh that we decided we wanted to adopt. But we wanted to do a few things. So first of all, as most of you know, it's really nice to come up with a brand new algorithm or pathway, but it's a big difference to actually have people adopt it. And then it's a big challenge to have them continue with it. So what we decided to do was, from the get-go, we wanted to study it. And in 2013, we were very lucky and received an intramural grant to conduct a retrospective review of where we were. So we felt like we were not going to understand what happened when we adopted the tool unless we understood where we were before we adopted the tool. And so we were very, very lucky, had this funded, and we actually had the honor to present this as a poster at the TCAA a couple of years ago, and I believe, Jennifer, correct me if I'm wrong, we won best practice for that. And so we went live with our brand new tool in January of 2014. And the data that I'm going to be presenting today is looking at our retrospective work and what I hope we'll be able to present in person at this year's TCAA, some of the stuff, some of the, what we've learned since this tool went live in January of 2014. So the University of Pittsburgh's or Children's Hospital of Pittsburgh's screening was based on three different buckets, medical history, social history, physical exam findings, and radiographic findings. I'm going to go through each of these in detail. So the red flags. The red flags that we have used were no history of the injury or an inconsistent history, a changing history, an unwitnessed injury. I don't know how many of you have had this present to you, but the four-month-old was able to toddle over to the top of the stairs and fell down. Probably unlikely that that was really what happened. Delay in seeking care. History of prior ED visits. Now this is very striking, because as you can imagine, if you have a six-month-old and they've had three visits to the ED prior, even if those are not related to an injury, you can imagine the level of stress that is occurring in the home for when the patients finally do arrive with an injury. The history of domestic violence in the home. And then a few comorbidities. History of prematurity, low birth weight or IUGR, and chronic medical conditions. Red flag physical exam findings included a torn frenulum, which I'll go a little bit deeper into in just a moment. Failure to thrive. That included weight, length, and head circumference. Of note, probably one of the most difficult things to implement once we actually started using this tool was the measurement of a head circumference in the ER. This was not a routine part of the nursing staff's vital signs, and it took quite a bit of work to get them to do this. However, we have gotten past that hump, and it is more often than not that we have head circumference, and if I ask for it, I don't get the dirty look, and it's done right away. So that's actually been really very successful. Changing culture. Any bruise in a non-ambulatory child. We have a saying that Dr. Polson loves, which is, if you don't cruise, you don't bruise. And any bruise in a non-exploratory location, which we call the 10-4, the torso, ears, and neck, and I'll go over that in a little bit more in a moment. And bruises, marks, or scars in patterns that suggest hitting with an object or could be pathognomonic for non-accidental trauma. So sentinel injuries in children. In a study by Lynn Sheets, of the 200 definitely abused infants, 27% had had a previous sentinel injury, compared to 8% of 100 infants with intermediate concern for abuse. So what does that mean? That means that in over a quarter of patients that present to us, they've had a prior injury, possibly one of the ones that I just pointed out, that would raise the awareness, or should raise a red flag, to have an evaluation at the prior visit, rather than when they finally present with an escalation injury. So some of the sentinel injuries that we're going to discuss. The oral injuries are extremely suggestive of non-accidental trauma, and typically we look at these for a year of age or less. As you can see there, the 66% of patients that present with a frenulum tear or a philtrum tear, or something along those lines, have a significantly high association with non-accidental trauma. Up until last year, I felt that this was probably related more to a physical type of abuse. Unfortunately, I had two cases that were really disturbing. One in which a family member had dipped a washcloth in Clorox to try to get the child to stop crying, to suck on it, and the patient ended up with multiple burns, intraoral burns. And another case, a very unfortunate case, in which a parent or whoever the imposter was, put the child's face against a hot grill on a car that also resulted in burns. So it doesn't have to be a tear of the philtrum or a tear of the frenulum to be associated with non-accidental trauma. So polling question number two, and Jennifer, I'm happy to read this. Kids get hurt while being kids, in sports or playing in general, all the time. Because bruising is not a red flag for NAD. So we went ahead and launched the question. If everyone would go ahead and submit their answers. We'll wait just a few seconds for everyone to put that in. And the results are 88% said false and 13% said unsure. That's wonderful. So we're going to get into bruising next. And so that phrase that I mentioned, if you don't cruise, you don't bruise. So you can see here from this study the relative incidence of bruising distributed by age. Now, I don't know how many of you out there have toddlers. But my son, he's five now, and I have two older girls as well. He has bruises that I swear I blink, and that bruise wasn't there two seconds ago on his arm. But he's a little acrobat. So bruising can be associated with pure play. But the important thing is the distribution by age. So we talked about the 10-4. And that's torso, ears, and neck at or under the age of four years of age or any bruising in a child four months of age or under. This has a high sensitivity and a moderately high specificity in trying to determine whether a bruising pattern is associated with non-accidental trauma. So here's an example of the low suspicion areas and the high suspicion areas. And again, it goes by that age distribution. So bruises are the most common indication of physical abuse. However, abnormally active children are likely to have bruises over bony prominences such as knees, shins, elbows, chin, and forehead. However, it is much less likely to have an abdominal bruising that is accidental and the appearance of the bruising pattern can be suggestive of non-accidental trauma. And of note, this type of bruising pattern can be highly associated with hollow viscous injuries, duodenal rupture, pancreatic injury. So it is important to work these patients up for possible intraabdominal injuries. Unfortunately, I don't think you can see. Perhaps you can tell that this is some bruising patterns of fingers. You get the sense there. Also grabbing of the ear, boxing, twisting of the ears. Now, I'm not a pediatrician, but somebody did remind me that you can also have fifth disease that gives you that slapped cheek appearance, and that's the virus, viral illness. So not all bruises or the appearance of bruises is necessarily non-accidental trauma, and that is what leads to some of the difficulty in trying to identify these cases. However, bruising patterns like this, which is clearly a thumb that has been grabbed around the chin, are never normal. And I have to admit, I actually got these off the Internet, and I thought this was a thing of the past until about eight months ago I actually had a patient in the emergency department that had whip marks, and that was probably one of the most disturbing things I've ever seen in my life. Cigarette burns. So this is pathopneumonic for non-accidental trauma. Again, this was something that I had pulled off from one of our old files or something like that. And until I had a case about two, two-and-a-half years ago, I'm used to seeing non-accidental trauma through the emergency department, through the trauma bay, in the hospital setting. So I had an interesting experience in which I had a patient that was presenting for a post-op routine hernia repair, and I had a five-minute post-operative appointment with them, and when I took down the pants just to look at the incision and make sure that it was healed well, sure enough I saw a cigarette burn on the thigh. And it gave me an incredible pause because it struck me. I wasn't sure what to do with that exact moment in time when I'm in the clinic in a setting that I didn't have the usual support structure that I have in the hospital. So it gave me a lot of respect for the family practice physicians and for the pediatricians and nurse practitioners that are out there that have to deal with this in a setting where they feel they don't have any resources to be able to pursue this. So luckily I got my head on straight, grabbed my algorithm, and started making all the calls, got social work, spoke to the patient's pediatrician, let them know my findings, and went from there. But, boy, it's interesting to not be in the right setting, and then that can throw you totally off your game. Burns, unfortunately, these can be horrible, can be pathognomonic for immersion injuries. Retinal hemorrhages and pathology, these are the kind of exams that we do in a setting of what used to be known as shaken baby syndrome, but I'm not sure if there's a newer term for this, but in which you have intracerebral hemorrhage without any skull fractures. And bilateral retinal hemorrhages can be associated with that pathology. So moving on to X-ray findings. There are certain radiographic findings that are red flags. These include metaphyseal fractures, which I'll show you examples of in a moment, rib fractures, especially posterior infant. Now, for those of you who take care of traumas on a daily basis, you know how hard it is for a child to get a rib fracture, and so the amount of force that has to be applied to a patient, to a baby, to be able to break the ribs is substantial. Any fracture in a nonambulatory infant should raise concerns. An undiagnosed healing fracture and subdural hematomas and or subarachnoid hematomas on imaging in young children, particularly in the absence of a skull fracture at less than 1 year of age. So what is a metaphyseal fracture? So that is a bucket-handle fracture which results from avulsion from a sudden twisting motion in the extremity. So for those of you who can see me, it's this. And unfortunately, we do see it often in the emergency department. And I'm not sure if this is going well here, but you can kind of get that sense of the crack here, the avulsion on these X-rays. Rib fractures, again, extremely uncommon in infants, and the force that has to be applied to break those ribs is substantial. And you can see here multiple rib fractures. So as I mentioned before, we had adopted this incredible NAT screening tool, but then the question was, were we using it? And we decided that one way we could potentially study this and standardize this was to build our tool into our non-accidental trauma screening note. So for those of you who have the joy of being able to work with Epic, we essentially created an Epic Smart Brace that had heart stops that made us fill out each element of the H&P that had the elements of the screening tool embedded within it. Additionally, it led to a standardized series of recommendations, which we were able to track to make sure that we were following our own guidelines. So we built this console form so that it would be in the electronic medical record, and it prompted us to collect data on all the red flags, complete a standardized history and physical examination, order a standard set of labs and skeletal surveys, and create referrals to ophthalmology, child abuse intervention department, and pediatric surgery. And this was put into system-wide use in January of 2014. And so this is just an example of what this will look like. For those of you who recognize all those little icons, basically in Epic you would force us to be able to fill out each of these things. So we had a true negative as opposed to it was just not in the chart. And then it also helped us go down a decision pathway tree of what we were going to recommend in terms of further studies as well as referrals, admissions, et cetera. And for those of you, CAID for us is our Child Abuse Intervention Department, which we have for Pierce County in Tacoma. So discharge. So clearly many of the patients that have a suspicion for non-accidental trauma do not require admission. And so one of the concerns was if we start to standardize this process, is that going to lead to an increased admission rate, increased length of stay within the emergency department, et cetera, et cetera? Well, I'm hoping that I'll have that data to be able to present in October. But we also wanted to standardize our process in the emergency department. So as most of you know, many of these non-accidental traumas come in with injuries that are very mild and may never have been activated as a trauma, and the emergency department does the disposition. So what we all agreed to was that there would be a huddle that would involve all members of the patient's care. If the patient happened to be admitted to the hospital, then of course that included all the members that hit the team, and even a phone conversation or an epic in-basket would be sufficient to have closed the loop with all the team members. Of course, we would make sure that there is some sort of outpatient child abuse follow-up. Let me go back before we do the polling question. The emergency department, we had the discussion about, well, what if the patient is well enough to be able to be discharged, but this question of NAT arose? Well, what we all decided was that the team that consisted of the emergency department physician, the bedside nurse, and our social worker, and we're very fortunate because we have emergency social work 24-7 in the ED, all three had to agree that it was safe for the patient to be discharged home or we would follow the process of getting some sort of placement or admission to the hospital until the social situation was sorted out. So with that, we're going to go on to our final polling question. Do you or your team members find it difficult to inform the family that a CPS referral has been made? If everyone would please go ahead and launch your answers. And it looks like the results are 44% said yes, 53% said no, they do not find it difficult, and 3% haven't really thought about it. Well, that's great. It's great to see that so many people are comfortable making, are able to communicate that with family. For us, that was a huge deal. There was a lot of stigma associated with the concept that we're accusing them of child abuse. And one of the nice things that resulted from us having a standardized process was that we found that when we were able to communicate, when we see this pattern of injuries or these findings, this is our process for all children. And that helped keep the focus on the child, on the process, and then not appear judgmental, and we hoped was assuring the patients of our being thorough. And at the beginning of all of this, we also offered for the new physicians, the new nursing staff, to have a more experienced person come in and inform the family, but it's gotten to the point where we really don't need that anymore. So that was a huge, what we perceive to be a big cultural change for us and our institution. So leading into the retrospective data, we had 117 NAP patients seen from 2010 to 2013, majority of which were male. And again, the majority of which were less than a year of age, and the vast majority of which were less than 4 years old. From a medical or social history side, we found that there was an inconsistent or missing history provided by the caregivers in 89% of the cases. The injury was reported as unwitnessed in 79% of the cases, and you should know that there was some waffling back and forth, too, so that both things were documented. They're changing stories. Interestingly, 38% of the patients had a prior ED visit, and of those, 58% were less than a year of age. Now, think about that. You have a baby less than 1 year, and they're having multiple emergency department visits. That should raise some sort of red flag, even if you're not suspected for suspecting abuse, that the patient's family may not have the resources to be able to appropriately care for the patient. So there's an opportunity for intervention, even if they're not being seen for an injury at that time. Now, interestingly, 41% to 73% of patients had missing social history data, 73%. And this broke over the 2010, 11, 12, and 13, so this is the range. That was on us. You know, I will be the first to tell you that at least the surgeons that I've ever known and definitely me, we're not writing five-page history and physicals typically, but in this case, we are. And in terms of social history, basically I would ask the question, anybody smoke in the household? No? Okay, great. We're done. And that was my social history. This prompted me to start asking things like, has there been any abuse in the household, drug use, alcohol use, things that I should be doing, but I just genuinely hadn't been. And I was shocked when I started to ask the answers I was getting, because people actually were telling me the truth and admitting to being abused or having had their other children abused. And just asking the question, we actually got an answer, and that was a big thing for all my partners and I. Physical exam findings. Bruising was present in 57% of the cohort, and you can see the breakdown there by age. Bruising in a non-exploratory location, or the 10-4 that we talked about, was present in 43% of patients less than four years of age. This final statistic was actually quite shocking. You'll note that perinatal bruising or injury was present in only 9% of the cohort. However, the majority of these kids were less than four, and almost a third of these childs died from their NAT-related injuries. And it's difficult to speculate as to why this association, and we're going to look at our prospective data to see if that correlation holds. But you get the sense that there was a significant amount of trauma inflicted on the child if it got to the point where they had perinatal bruising as well. Radiographic findings. So new fractures were noted in 60% of the cohort less than one year of age, and undiagnosed healing fractures in 29% of the cohort. Of the 50 patients with a subdural or subarachnoid hemorrhage, 86% were less than a year of age. Rib fractures in patients less than a year of age. So 33% of our patients less than one year of age had rib fractures. That would be compared to probably less than 1% to 2% in our accidental trauma population. Of these patients, 88% also had undiagnosed healing fractures so if they had a rib fracture, 88% had other fractures elsewhere that were healing at the same time. 77% were male. 77% were less than six months of age. So that's an even more pliable chest wall. 54% also had an associated extremity fracture. And if they had a rib fracture, 50% of those patients had an ISS of greater than 16. So these were very injured children. Looking at our mortality, we had nine fatalities. And of those, the majority had bruising or missing or inconsistent history. One question I got at the TCAA, which was a very good question, was if we'd had this screening tool in place, would we have been able to catch these patients before they died? And of course, it's a retrospective study so I don't know the answer to that. But I decided to plot out some of the findings on each of the fatalities. And you'll note that at least six of the nine patients had had a prior ED visit. So theoretically, a chance of intervention if they had presented with a sentinel injury or some other medical concern where perhaps we could have intervened to assist this family. You'll note that five patients had a CPS history. And of those one, we didn't know if they had a CPS history or not. Three had a history of domestic violence. But you'll note that five of the nine actually had no history of domestic violence recorded one way or the other. So I have to assume the question was not asked. And so forth and so on. One interesting thing to note was that when we looked at our NAT patients and compared them to our general trauma population, there was a significantly higher preponderance of ISS is greater than 16 in our non-accidental trauma population compared to our accidental trauma population. And you'll see that that was pretty consistent throughout the four years study period. We were very, very, very fortunate. I was able to present this at the TCAA, as I mentioned. And then I was able to present this information to the first annual Pediatric Trauma Society where we were able to build a lot of bridges nationally and internationally and continue to pursue work on non-accidental trauma and screening, which I'm happy to talk about more if anybody has any interest. This retrospective study was accepted for publication, Pediatric Surgery International. And I think I got an email last week that it just finally got published in journal form, in the journal. So we identified the red flags in the following case. Oh, we're gonna discuss just a couple of cases and then leave some time for questions. And just keep in mind the red flags in the following cases to keep in mind, including the history, physical, and radiographic. So we saw a four-month-old Caucasian female who presented with a disfigurement of her left arm. She resides with her mother, her mother's boyfriend, and her mother's boyfriend's parents. This baby was the result of a twin pregnancy and delivered 35 weeks of gestation. On physical exam, it was well-developed without bruising, mouth with intact frenulum, and left upper arm tender to palpation and pain with motion. And this is the X-ray. As you guys can see here. So think about this. I guess we don't have a poll for this, but what red flags do you guys see in this particular story? And I will note that, although it's not officially part of our screen, the fact that they live with mother's boyfriend always raises a little bit of a red flag. So because of a very astute emergency department physician, the twin brother happened to be in the room. They got an X-ray of him and sure enough also had upper extremity fractures. So this was a big success in terms of being able to determine a red flag and then being able to diagnose the patient's brother at the same time. Unfortunately, we also have some not so good stories. So think about what red flags you might see in this particular case study. We have an eight-month-old former 24-week preemie who presented with lack of coordination with trunk and shoulder hypotonia on neonatal follow-up. Resides between mother with extended family and the father. There is an exposure to domestic violence in the home and the patient is initially admitted with a parietal skull fracture and hematoma. So the history changed. This is provided by the father. Flung her head back and hit the chair while feeding. And then it changed to flung her head back while on the father's knee and hit the table. This was a little bit more obvious and so the patient underwent a skeletal survey, LFTs were normal, and retinal evaluation was not requested at that time. There was a little bit of a disagreement amongst the team and the patient was discharged with the patient's family. Patients presented to Mary Bridge ER 10 days later. Initially seen earlier in that day by the patient's PCP. History being that she had been crying on and off all day, had been irritable for five days. Seen by the PCP earlier and given a laxative. Later on that afternoon, gets evaluated by the Mary Bridge Emergency Department. There's no additional signs of injury. The KUB at that time showed increased gas. So she was discharged home with the diagnosis of pussiness, constipation, and a history of skull fracture. She returned later that night in cardiac arrest with severe subarachnoid and subdural hemorrhages. And although underwent successful CPR, was essentially brain dead and declared later in the ICU. So this is the case that prompted us to look at our NAT standard. So in this particular case and the case before, prematurity, chronic medical conditions, changing history, history of domestic violence in the home, skull fracture, and return for irritability. So these were the things that, you know, were red flags in this particular case with a tragic outcome. Well, not every NAT falls in a death in the ER and the ICU. And the majority of these kids actually survive. For those of you who are aware of this, there's something called adverse childhood events that actually have long-term repercussions on the physical, mental, and emotional development of a patient. And the result of abuse can have a lifetime series of consequences for a patient, including significant increased incidence of comorbidities like diabetes, hypertension, sexual promiscuity, obesity. And this can have a heavy toll on society. And this is something of great interest to the AAP as well as my colleagues. So for future research, we do have a prospective study that has just recently been completed evaluating the use of our standardized tool. We did put into practice a system-wide evaluation of NAT, and we were actually able to get the other hospitals in our system to sign on to these evaluations. That was a feat. Evaluation of association between hospital and emergency department-length of stay and use of standardized tool. So in conclusion, the majority of patients less than one year old had prior ED visits, providing at least one earlier instance in which intervention could have changed the child's outcome. In the absence of a standardized process, we are not consistent in obtaining a thorough social history. Perineal bruising, although rare, was an ominous finding associated with high mortality. Nearly a third of patients had undiagnosed healing fractures, justifying routine use of skeletal surveys. Anecdotal evidence suggests that implementation of a standardized tool has raised system-wide awareness of NAT, and we hope to present that data in October. I really would like to acknowledge the members of the Non-Accidental Trauma Committee, including my good friend and colleague, Elizabeth Poulsen, who is the chair. And she has been fortunate enough to be chosen with our child abuse expert, Dr. Duralde, to present at the Helfer Society some of our work. And, excuse me, and all the unbelievable amount of staff and physicians who have really felt that this was an important piece of work and have supported us as we've worked through the process. Thank you. Sorry about my voice. Thank you guys for sticking through with me. I really appreciate it. If there are any questions, I'd be happy to answer. This is Jennifer. So, we do have a couple questions. And so, I'm going to unmute Mr. Paul Campbell if you want to go ahead and ask your question. What is the visual trauma on that one diagram? Let's see. The visual trauma on the one diagram. Let me see if I can find it for you. It's about three or four slides back. On types of abuse, one of the things was visual abuse. Maybe it's a typo. I don't know. I don't know what it is. Verbal? Verbal, visual, physical, sexual. Oh. Oh. That is the observation of abuse. So, the child witnesses, for instance, their father beating their mother, but they're not actually physically beat themselves. Okay. Am I on the right? Is that...? Thank you. Our next question is, in evaluating your standardized protocol, have you found any elements that we ultimately, not necessarily, and were discarded... were we ultimately, not necessarily, and were discarded or changed? Some of our labs are probably overkill, especially when blood is precious in the little guys. Oh, that is a great question. That goes towards the prospective analysis, and I have actually been... I am not supposed to give that data out yet until they've had the opportunity to make that first presentation. However, however, that being said, what we've... Right. Blood is precious on these little guys, and once we've kind of flipped the switch that we're working them up as a trauma, we have tried to err, more often than not, on the at least drawing of the initial LFTs and the CBC, and the results have actually been very surprising because, as you may be aware, there was a publication in Pediatrics, I think in 2014, correlating the high association of LFTs and the association of intraabdominal injury in NAT. So we've been paying attention, and when we do find that our LFTs are elevated, we have, in fact, found liver fractures, splenic fractures, potentially bowel injuries. So because of that high findings, we do push forward with the blood draws, and I know that at times that that's not a popular request, but as a trauma surgeon, that is the request I end up making, and oftentimes we do find something. Thank you. Our next question is from Ms. Anjanette. So, Anjanette, please go ahead and ask your question. Yes, we were wondering if asking, like, CPS, part of the screening tool, is that asked on every admission, or is that for up to a certain age? Oh, that's a great question. So we get CPS involved for every admission, and, yes, for every admission. We've had some unique situations where we've actually had CPS involved We've had some unique situations where we've actually had... So I've showed that 92% or 96% were less than 4%. However, we have had a handful of cases that have been greater than 4%. Not surprisingly, the mechanisms of those injuries occasionally are slightly different, being beat up, assaulted, those sorts of things. And so even in those situations, we even had a metaphyseal fracture in an older child. So we do get CPS involved in all of those cases. We do. And you said specifically admissions. What about coming through the ER? We do. Because we have that three-team huddle with our emergency physician, our bedside nurse, and our social worker, we discuss it with the social worker at that time, and we can make a CPS follow-up so that they don't... I mean, let's be realistic. CPS is not going to be coming every single time to the emergency department, but at least that they're in the system. Okay. Sounds good. And the second question was, we currently have EPIC, and we have a high rate of child abuse in our area, so we would be very interested to implement a tool like this. It's hard to see on the PowerPoint. Is there any way that you could share contact information for future questions? Oh, yeah. Oh, absolutely. Jennifer and Angie should have my e-mails, and I have an e-mail all ready to go to share this with anybody who would like it. Oh, okay. Perfect. Sounds good. Thank you. You're welcome. All right. And our next question is going to be... I'm going to ask this one for Michaela. What if there is no reason other than the suspected trauma? So what if there's no reason? That's a really, really good question. So what we have... That's what we were worried about, is if we suspect NAT, does that mean that we're going to have an increased number of admissions? And that's what I'm going to be presenting, hopefully, in October. I'm going to give you a brief preview and to say that we were surprised by the results. And what we do in that situation is we actually then do have our social worker talk to CPS. If CPS determines that they need to be out of the home, then we will find either another family member that that patient can go home with. And oftentimes, it doesn't even have to be maybe just one parent. Or if we have to, then we find foster. And we've had that set up in the emergency department where we get an emergency foster care set up, and within a few hours, they're there to pick up the child. So we've definitely done that as well. And then the ultimate backup is if we are... It's Saturday at 1 o'clock in the morning and we just know this isn't going to happen, we admit them. Thank you. Our next question is from Ms. Sarah. So go ahead and ask your question, Sarah. Okay, I'll ask her question on her behalf. Who is on the Child Abuse Intervention Department, and what is the role in the management of the patient? So we actually have a child abuse expert who actually trained, interestingly, through family medicine and then became a child abuse expert. So there's a physician, there's an ARNP, there are social workers, and let's see. I think there's two ARNPs, I can't remember. And then there's contacts with CPS and law enforcement through that Child Abuse Intervention Department. And in terms of the county resources, it's organized by county. So if we're in Tacoma, which is in Pierce County, Seattle, to the north of us, is in King County, but occasionally South King County can come to us just by the nature of traffic patterns or whatnot. And in those situations, then we have to coordinate with CPS and King County and through their child abuse people over there. And so those are who are the members of the Child Abuse Intervention Department. The Non-Accidental Trauma Committee is composed of the physician from the Child Abuse Intervention Department, two pediatric surgeons, a pediatric hospitalist, a pediatric intensivist, a pediatric emergency department physician. We have a social worker, as well as a member from palliative care, who not so much because we think everybody's going to die, but it's in terms of being able to coordinate complex follow-up for patients that often don't have the resources to be able to do so. And so those are who attend those NAT subcommittee meetings. In fact, we just had one yesterday that was a very robust, thought-provoking conversation. Thank you. Our next question is from Ms. Cleek. Can you explain again what the triggers are to complete the screening tool? Yes. So let me... It might be easier. So it was a pilot. So let me first say that it was a pilot. So as you know, many of these kids never even get onto the trauma service because they can go home from the ER. So there's a certain selection bias already occurring whenever I get involved. And so what we do is, if any of those triggers are... or those switches are flipped on those three... Actually, let me just do this. Let's see. So if we see any of those three things, any of the...in those three buckets, then we get involved immediately, and then we do a much more thorough assessment and evaluation. So to the question of the prior question asker, which was...or the prior question asked, which was, which one of these things, you know, fall out? What was not as important, or could we throw off? We're looking at that now because in our ideal world, what we would like to do is to have a pop-up on EPIC. Whenever a child gets checked in, when they're just in triage, these three or four important things that will automatically...an evaluation. And so, like, the triage nurse asks, and for those of you who are familiar with EPIC, you can have pop-ups for glucose monitoring or congestive heart failure or pneumonia risk or whatever, so that we create something like this for automatic screening and that this automatically generates the next steps in our algorithm, which would be, unfortunately sometimes, blood draw, X-ray, skeletal survey. If the LFTs are elevated, CT scan, the abdomen and pelvis, head CT, et cetera, so that at least triggers the evaluation. Now, the ED physician may choose not to do those things, but at the very minimum, everybody's been alerted to that possibility. And so, or even something as simple as, oh, this child has been in the emergency department three times in the last six months, so just to get people keyed in. So that's where we hope to go next. Thank you. Our next question comes from Ms. Kessner. Amy, please go ahead and ask your question. I will ask Amy's question for her as well. What was your counterargument to a pediatric trauma surgeon who feels they have nothing further to add to the management of an abused child once the abuse is suspected? So they feel like they have nothing to offer other than just suspecting the abuse. I think that's a culture issue. That is. That's a really good question. So going back towards the idea of, you know, 56% or whatever that was published a couple of years ago from Baylor, the idea is that the reason you have a child The idea is that the reason you want to get a pediatric surgeon involved or a trauma surgeon or whoever, depending on your institution, is because there's a significant risk of missing associated occult injuries. So you want that standardized trauma evaluation from head to foot of the patient. Now, that's not to say... NAT is kind of a tricky one because historically it tends to live in the pediatrics admission, at least in the big children's hospitals. Even when I was doing my fellowship or my residency, some of those kids would clearly end up on the pediatrics ward or the pediatric service. And then if there was a real injury, then we would get consulted. So I actually don't propose that that patient has to live on the trauma service the entire time. I think that, as in anything, for instance, in geriatric trauma, as we start to learn more and more about the comorbidities and how they can impact long-term morbidity and mortality, there is a role for collaboration between the surgeon and the geriatrician or the surgeon and the pediatrician. And that doesn't necessarily mean that they have to stay on the trauma service once they've been stabilized and there's no other injuries. But it probably does behoove the child and the organization. If you're going to try to treat a non-accidental trauma like you would treat any other trauma, then there should be some elements of involvement from your surgical service. And however that looks like in your institution, I will say that we are actively working on, through the Pediatric Trauma Society, we're trying to get together some sort of review article on non-accidental trauma for the general traumatologist. And so that's a work in progress, trying to raise awareness, because the majority of kids, as most of you know, don't get seen at a specialized pediatric hospital. They're going to be seen in the general emergency department or general trauma center. And so trying to raise that awareness and perhaps help change, do some paradigm shifts and change cultures to understand why this is so important for a traumatologist to take care of. So we're going to limit it to two more questions. So the first question, and this might have already been answered, Dr. Escobar, but how is it decided which kids get an NAT consult? Because they understand that templates help standardize the workup for suspected NAT patients, but how do you make sure that they aren't missed referrals? Well, for us, that's a great point. So what we try to do is, well, we were following it quarterly, and we were reviewing our data on a real-time basis and then making our suggestions back to different departments if we were finding a trend. The second thing is, if you really want to try to be able to use EPIC to its full ability or wherever, CERN or whatever you're on, is we try to create order sets so that you could then mine back and double-check to make sure the referral for ophthalmology was done, the referral for the child abuse intervention department was done, surgery, whatever, and so that we could have some sort of objective way to look things up. So that's how we did it. And luckily, this was such a, I guess, multidisciplinary grassroots effort that if there was any spike in missed consults, we were able to collegially go back to that particular department and voice why is it so important and work on that, and so we had buy-in from each of our representatives that's made the discussions really collegial. Okay, and our last question, Deb, on the twin case you presented, how do you do an X-ray on a nonpatient that you suspected the twin brother might also have fractures? Oh, that's a very good question. So that actually led to... The ED physician actually examined the twin brother and we registered the patient. We did get permission from the, I think, the mother, if I remember correctly. And so then we had a registered patient. We then had a physical exam that had a concerning finding, which we were then able to X-ray. So it didn't just, like, go straight to X-ray. The finding from the sister led to us looking the kid over, registering the kid, actually documenting, you know, doing the history and physical that led to the X-ray. Well, thank you, Dr. Escobar. I think you've answered all of our questions. So I would like to thank everyone for joining us today and especially thank Dr. Escobar for a great presentation and the wealth of information provided. As you digest the information, if you have any additional questions, please feel free to e-mail them to myself or to Deb, and we, again, will send out the follow-up evaluation e-mail. And Dr. Escobar mentioned follow-up information that he would provide to us and potential contact information, and we will make sure everyone gets that as well. So we want to wish everyone a great day, and we love the purple shirt because that's our favorite color. Thank you. Thank you, guys. Have a great day, everyone. Bye-bye. Bye.

webinar

nonaccidental trauma

systematic protocol

Dr. Tony Escobar

pediatric surgeon

standardized approach

retrospective study

red flags

sentinel injuries

multidisciplinary team