256 - Guidelines to standardize care for facial lacerations can improve racial inequities in plastic surgery repairs in the pediatric emergency department

Poster Number: 256
Publication Number: 256.1462

Background: We previously reported significant racial and ethnic inequities in the provision of plastic surgery consultation and repair of facial lacerations in our pediatric emergency department (PED). In March 2020, a facial laceration consultation guideline was instituted that (1) eliminated family requests for plastic surgery laceration repair and (2) identified objective laceration characteristics for plastic surgery consult and repair.

Objective: To measure the change in plastic surgery repair rates of facial lacerations by patient race and ethnicity after guideline implementation.

Design/Methods: We conducted a retrospective, cross-sectional study of patients aged 0-18 years with a facial laceration repair in the PED between 1/2016 and 12/2022. We reviewed pre-arrival, PED provider, plastic surgery, and follow up notes. We used natural language processing to identify patients and extract demographics, wound characteristics, and plastic surgery repair. Our primary outcome was laceration repair by plastic surgery. Race and ethnicity were determined by parental report. We performed an interrupted time series analysis of the guideline implementation effect on repairs using multivariable logistic regression between the pre-guideline and post-guideline periods. We tested whether this effect varied by race and ethnicity, controlling for demographics, laceration size, complexity, and mechanism of injury, with robust standard errors clustered on patient.

Results: 6,938 unique laceration encounters were included. Table 1 shows the pre- and post-guideline implementation demographic and laceration characteristics. A statistically significant decrease occurred in plastic surgery repair for non-Hispanic (NH) White patients (29% pre, 11% post, p=0.001) with stable rates for Hispanic patients (9% pre, 6% post, p=0.18) and NH Black patients (7% pre, 7% post, p=0.992) (Figure 1). Adjusted for demographics and wound characteristics, the effect of the pre- and post-guideline implementation difference on plastic surgery repairs were significantly greater among NH Whites compared to both Hispanic (2.5 times greater reduction, p=0.007) and NH Black patients (3.8 times greater reduction, p=0.001).

Conclusion(s): Implementation of a clinical practice guideline demonstrated a dramatic improvement in differences in rates of plastic surgery repair for NH Black and Hispanic, compared to NH White children. While structural factors are known to play a role in racial and ethnic inequities in access to care at multiple levels, implementation of standardized guidelines may be one tool to reduce inequities at a structural intervention level.