Ashraf Iram J, Faivus Ackley Danielle, Razawich Kristin, Botash Ann, Schafer Melissa, Pekarsky Alicia
SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York.
Pediatr Qual Saf. 2022 Jun 14;7(3):e567. doi: 10.1097/pq9.0000000000000567. eCollection 2022 May-Jun.
The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment.
Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year.
After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months.
Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.
骨骼检查（SS）用于评估和诊断骨骼异常，包括虐待儿童所致骨折。美国儿科学会建议，对所有疑似受虐的24个月以下儿童进行初次骨骼检查，并在两周后进行随访骨骼检查（FUSS）。后者可进一步明确异常或不明确的检查结果，检测持续存在的创伤，或发现初次评估时因过于急性而无法显影的骨折。
我们医院对36个月以下儿童完成FUSS的干预前审查显示，平均每月完成率较低，为40%。我们回顾了研究期间接受骨骼检查的儿童的病历，以了解FUSS的完成情况。完成FUSS存在若干障碍，包括医护人员对FUSS重要性缺乏了解、出院前未下达FUSS检查医嘱、病历中缺乏关于FUSS决定的记录、失访以及家长拒绝。针对这些障碍的干预措施包括对医护人员进行教育、规范FUSS检查安排、使记录标准化以及与社区儿科医生进行沟通。目标是在1年内将平均每月FUSS完成率从40%提高到90%。
实施干预措施后，平均每月FUSS完成率迅速从40%提高到80%。在随后的12个月中持续改善。
干预措施是按顺序实施的，针对工作流程不同层面的障碍。医护人员教育是关键，有助于提高干预措施实施的可靠性。最有效的干预措施是改变检查流程。这种方法使FUSS完成情况得到显著改善并持续保持。
