title: Development of a systematic protocol to identify victims of non-accidental trauma.
abstract: OBJECTIVE
  Each year, nearly 1 million children in the USA are victims of non-accidental trauma (NAT). Missed diagnosis or poor case management often leads to repeat/escalation injury. Victims of recurrent NAT are at higher risk for severe morbidity and mortality resulting from abuse. The objective of this review is to describe the evolution and implementation of this tool and evaluate our institutional response to NAT prior to implementation.
  
  
  METHODS
  A systematic guideline for the evaluation of pediatric patients in which NAT is suspected or confirmed was developed and implemented at a level II pediatric trauma hospital. To understand the state of our institution prior to implementation of the guideline, a review of 117 confirmed NAT cases at our hospital over the prior 4 years was conducted.
  
  
  RESULTS
  In the absence of a systematic management guideline, important and relevant social and family history red flags were often missing in the initial evaluation. Patients with perineal bruising experienced significantly higher mortality than patients without perineal bruising (27.3 vs. 5.7%; p = 0.03) and were significantly more likely to require surgery (45.5 vs. 14.2%; p = 0.02).
  
  
  CONCLUSIONS
  Development and implementation of a standardized tool for the differentiation and diagnosis of NAT and creation of a structured electronic medical record note should improve the description and documentation of child abuse cases in a community hospital setting. A retrospective analysis demonstrated that in the absence of such a tool, management of NAT may be inconsistent or incomplete. Perineal injury is an especially ominous red flag finding.
authors.affiliation: Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA. Mauricio.Escobar@multicare.org.|University of Washington School of Medicine, Seattle, WA, USA. Mauricio.Escobar@multicare.org.|Pediatric Surgery, MS: 311-3W-SUR, 311 South "L" Street, PO Box 5299, Tacoma, WA, 98415, USA. Mauricio.Escobar@multicare.org.
authors.forename: Mauricio A
authors.initials: MA
authors.lastname: Escobar
authors.affiliation: MultiCare Institute for Research and Innovation, MS: 315-C2-RS, 314 Martin Luther King Jr. Way, #402, Tacoma, WA, 98405, USA.
authors.forename: Bethann M
authors.initials: BM
authors.lastname: Pflugeisen
authors.affiliation: Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA.|Child Abuse Intervention MBH, Safe and Sound Building - 11125-1-CA, 1112 S. 5th Street, Tacoma, WA, 98415, USA.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Duralde
authors.affiliation: Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA.|Transfer Center, Business Support Center - 1002-1-TRA, 2108 Pacific Ave, Tacoma, WA, 98402, USA.
authors.forename: Carolynn J
authors.initials: CJ
authors.lastname: Morris
authors.affiliation: Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA.|University of Washington School of Medicine, Seattle, WA, USA.|Mary Bridge Children's Hosp - 315-O6-IPS, 317 Martin Luther King Jr. Way, Tacoma, WA, 98405, USA.
authors.forename: Dustin
authors.initials: D
authors.lastname: Haferbecker
authors.affiliation: MultiCare Institute for Research and Innovation, MS: 315-C2-RS, 314 Martin Luther King Jr. Way, #402, Tacoma, WA, 98405, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Amoroso
authors.affiliation: Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA.|Trauma MBH, Mary Bridge Children's Hosp - 311-1-TRM, 311 South "L" Street, Tacoma, WA, 98415, USA.
authors.forename: Hilare
authors.initials: H
authors.lastname: Lemley
authors.affiliation: Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA.|Pediatric Surgery, MS: 311-3W-SUR, 311 South "L" Street, PO Box 5299, Tacoma, WA, 98415, USA.
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Pohlson
mesh_terms: D002648:Child; D002649:Child Abuse / Q000175:diagnosis* / Q000628:therapy; D002985:Clinical Protocols / Q000592:standards*; D003288:Contusions / Q000209:etiology; D005260:Female; D050723:Fractures, Bone / Q000209:etiology; D006305:Health Status Indicators; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008487:Medical History Taking; D010502:Perineum / Q000293:injuries; D012189:Retrospective Studies; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000175:diagnosis*
keywords: Child abuse; Emergency service; Non-accidental trauma; Process improvement; Trauma assessment
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