Surgical service adds value in suspected child abuse

By Anne Harding

NEW YORK (Reuters Health) - Children with suspected non-accidental trauma receive better care when they are admitted to surgical service rather than a non-surgical service such as pediatrics, new findings show.

"What we found was that children who were admitted to surgical service have fewer complications," Dr. David Notrica of Phoenix Children's Hospital in Arizona, one of the study's authors, told Reuters Health. "Trauma surgeons actually do contribute meaningfully to the care of abused children."

The findings were published online January 14 in the Journal of the American College of Surgeons.

Current guidelines from the American College of Surgeons recommend that 90% of children with non-accidental trauma (sNAT) be admitted to surgical service, Dr. Notrica said. But, he added, "There's a tendency with these kids who are victims of child abuse to admit them to the pediatricians, because in a lot of ways they are social admissions."

At Dr. Notrica's hospital, a level 1 pediatric trauma center, all sNAT patients had been admitted to surgical service, but surgeons had questioned whether they were adding value to their care. In response, the hospital began allowing non-surgical service admissions for sNAT patients, and a "big uptick" in complications followed, according to Dr. Notrica.

To investigate whether the rate of care-related indicators (CRIs) varied based on whether a patient with sNAT had been admitted to surgical service (SS) or a non-surgical service (NSS), Dr. Notrica and his colleagues performed a retrospective review of patients admitted to their hospital in 2009-2013. CRIs are indicators of suboptimal care.

During the study period, 5,340 patients were admitted, including 671 (13%) with sNAT; the latter accounted for 8% (365/4,504) of the SS trauma admits and 37% (306/836) of NSS trauma admissions.

The researchers identified 145 CRIs in 116 patients, most commonly direct admit (patient admitted within 24 hours of traumatic injury without an ER evaluation), lack of consult, missed injury, and readmission. Seventy percent of the CRIs occurred in patients admitted to a NSS.

Throughout the study period, the rate of CRIs was 33 per 100 patients for NSS, versus 12 per 100 for SS patients (p<0.001).

Dr. Notrica said his hospital has returned to requiring that all sNAT patients be admitted by surgical service.

"Like most things, if you have a concentrated expertise in a particular disease process, you're more efficient at diagnosing and treating those," he added. "While in all these cases the diagnosis was eventually made, the speed at which the diagnosis was made was quicker when done by the surgeons. They also were better at making sure the children got appropriate care and follow-up because they do it all the time."

The findings also provide an evidence base for the current recommendation that most sNAT patients be admitted by surgical service, Dr. Notrica said.

SOURCE: bit.ly/1ZSCaSM

J Am Coll Surg 2016.

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