RESUMO
OBJECTIVES: To evaluate the impact of layering routine child abuse screening on top of a preexisting electronic health record-embedded Child Abuse Clinical Decision Support System (CA-CDSS) in a pediatric emergency department. STUDY DESIGN: The Pittsburgh Child Abuse Screening Tool (P-CAST) was performed in all children aged <13 years and in nonverbal children aged ≥13 years who presented to a pediatric tertiary care center over a 6-month period. The P-CAST was layered on top of a preexisting CA-CDSS that included passive triggers, alerts, and abuse-specific order sets. RESULTS: Of the 28 797 screens performed, 1.8% were positive in children aged <13 years and 1.6% were positive in nonverbal children aged ≥13 years. One-half of the children with a positive P-CAST also triggered the CA-CDSS; the other one-half triggered only because of the P-CAST. Nineteen percent of the patients with a positive P-CAST were reported to Child Protective Services (CPS). There was no relationship between race and the odds of a positive P-CAST or between race and the likelihood of a report being made to CPS. CONCLUSIONS: Active routine child abuse screening improves identification of suspected child maltreatment in a children's hospital above and beyond what is identified with a CA-CDSS, which depends on passive triggers. The lack of a relationship between race and a positive P-CAST or a report to CPS suggest that systematic child abuse screening may mitigate well-recognized racial disparities in identifying and reporting suspected child maltreatment.
Assuntos
Maus-Tratos Infantis , Hospitais Pediátricos , Criança , Maus-Tratos Infantis/diagnóstico , Maus-Tratos Infantis/prevenção & controle , Serviços de Proteção Infantil , Humanos , Notificação de Abuso , Atenção Terciária à SaúdeRESUMO
OBJECTIVE: s: Few feasibility, safety, and efficacy data exist regarding ICU-based rehabilitative services for children. We hypothesized that early protocolized assessment and therapy would be feasible and safe versus usual care in pediatric neurocritical care patients. DESIGN: Randomized controlled trial. SETTING: Three tertiary care PICUs in the United States. PATIENTS: Fifty-eight children between the ages of 3-17 years with new traumatic or nontraumatic brain insult and expected ICU admission greater than 48 hours. INTERVENTIONS: Early protocolized (consultation of physical therapy, occupational therapy, and speech and language therapy within 72 hr ICU admission, n = 26) or usual care (consultation per treating team, n = 32). MEASUREMENTS AND MAIN RESULTS: Primary outcomes were consultation timing, treatment type, and frequency of deferrals and safety events. Secondary outcomes included patient and family functional and quality of life outcomes at 6 months. Comparing early protocolized (n = 26) and usual care groups (n = 32), physical therapy was consulted during the hospital admission in 26 of 26 versus 28 of 32 subjects (p = 0.062) on day 2.4 ± 0.8 versus 7.7 ± 4.8 (p = 0.001); occupational therapy in 26 of 26 versus 23 of 32 (p = 0.003), on day 2.3 ± 0.6 versus 6.9 ± 4.8 (p = 0.001); and speech and language therapy in 26 of 26 versus 17 of 32 (p = 0.011) on day 2.3 ± 0.7 versus 13.0 ± 10.8 (p = 0.026). More children in the early protocolized group had consults and treatments occur in the ICU versus ward for all three services (all p < 0.001). Eleven sessions were discontinued early: nine during physical therapy and two during occupational therapy, none impacting patient outcome. There were no group differences in functional or quality of life outcomes. CONCLUSIONS: A protocol for early personalized rehabilitation by physical therapy, occupational therapy, and speech and language therapy in pediatric neurocritical care patients could be safely implemented and led to more ICU-based treatment sessions, accelerating the temporal profile and changing composition of interventions versus usual care, but not altering the total dose of rehabilitation.
Assuntos
Lesões Encefálicas/reabilitação , Estado Terminal/reabilitação , Unidades de Terapia Intensiva Pediátrica/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Adolescente , Criança , Pré-Escolar , Protocolos Clínicos , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica/normas , Terapia da Linguagem/organização & administração , Masculino , Terapia Ocupacional/organização & administração , Especialidade de Fisioterapia/organização & administração , Encaminhamento e Consulta , Centros de Atenção Terciária , Fatores de Tempo , Tempo para o Tratamento , Estados UnidosRESUMO
OBJECTIVE: To determine whether D-dimer would be increased in children with traumatic brain injury (TBI), specifically mild abusive head trauma. STUDY DESIGN: D-dimer was measured using multiplex bead technology in 195 children <4 years old (n = 93 controls without TBI, n = 102 cases with TBI) using previously collected serum. D-dimer was then measured prospectively in a clinical setting in 44 children (n = 24 controls, n = 20 cases). Receiver operator curves were generated for prospective data. RESULTS: In both the retrospective and prospective cohorts, median (25th-75th percentile) D-dimer was significantly higher in cases vs controls. A receiver operator curve demonstrated an area under the curve of 0.91 (95% CI 0.83-0.99) in the prospective cohort. At a cut-off of 0.59 µg/L, the sensitivity and specificity for identification of a case was 90% and 75%, respectively. CONCLUSIONS: Our data suggest that serum D-dimer may be able to be used to identify which young children at risk for abusive head trauma might benefit from a head computed tomography or other additional evaluation. Additional data are needed to better identify the clinical scenarios that may result in false positive or false negative D-dimer concentrations.