189 - Identifying Non-accidental Trauma: Sentinel Injuries and Subsequent Serious Injury within 1 Year in General versus Pediatric Emergency Departments

Poster Number: 189
Publication Number: 189.1107

Background: Non-accidental trauma (NAT) is a major cause of morbidity and mortality in children and delayed recognition leads to more serious injury or death. A sentinel injury is an injury suspicious for abuse including oropharyngeal injuries, bruising, extremity and rib fractures. We hypothesized that general emergency departments (EDs) may have higher rates of serious injury or death within 12 months following a sentinel visit compared to pediatric EDs.

Objective: To describe the epidemiology of sentinel injuries in general and pediatric EDs and compare the rate of serious injury associated with child abuse within 12 months in general and pediatric EDs.

Design/Methods: We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project database across 5 states from 2014-2019. We included ED patients 0-2 years old with a sentinel injury diagnostic code. We measured ED encounters in the subsequent 12 months. General EDs were defined by having a mean annual pediatric volume < 10,000. Exclusion criteria for initial encounter included motor vehicle accidents, birth injuries, and metabolic bone or bleeding disorders. Our primary outcome was any subsequent ED visit with serious injury (admission for fracture, traumatic brain injury, burn, abdominal or thoracic injury) or death with an associated diagnosis of child abuse. We compared general and pediatric EDs using multivariable logistic regression.

Results: Of 168,246 patients with at least one sentinel injury (mean age 14 months, 57% male (Table 1)), 91% were for oropharyngeal injuries, bruising and fractures (Table 2). Less than 1% (n=393) had a subsequent serious abusive injury overall with a 46% increased risk in patients seen in general EDs for a fracture on initial visit compared to pediatric EDs [OR 1.46 (CI 1.15-1.85)]. There was no difference between general and pediatric EDs for bruising [OR 0.98 (CI 0.83-1.17)] and there were insufficient cases of subsequent serious injury for oropharyngeal injuries to analyze (Table 3).

Conclusion(s): In our large database study, the epidemiology of sentinel injuries is similar in general and pediatric EDs, but we found an overall lower rate of subsequent serious abusive injury compared to prior literature. Patients seen in general EDs with an initial sentinel fracture injury have a 46% increased odds for subsequent abusive injury compared to pediatric EDs. We propose implementing strategies such as clinical pathways to improve recognition of concern for abuse in young children with fractures in general EDs.