An evaluation of the efficacy and impact of a clinical prediction tool to identify maltreatment associated with children’s burns

Background An estimated 10%–24% of children attending emergency departments with a burn are maltreated. Objective To test whether a clinical prediction tool (Burns Risk assessment for Neglect or abuse Tool; BuRN-Tool) improved the recognition of maltreatment and increased the referral of high-risk children to safeguarding services for assessment. Methods A prospective study of children presenting with burns to four UK hospitals (2015–2018), each centre providing a minimum of 200 cases before and after the introduction of the BuRN-Tool. The proportions of children referred to safeguarding services were compared preintervention and postintervention, and the relationship between referral and the recommended cut-off for concern (BuRN-Tool score (BT-score) ≥3) was explored. Results The sample was 2443 children (median age 2 years). Nurses and junior doctors mainly completed the BuRN-Tool, and a BT-score was available for 90.8% of cases. After intervention, 28.4% (334/1174) had a BT-score ≥3 and were nearly five times more likely to be discussed with a senior clinician than those with a BT-score <3 (65.3% vs 13.4%, p<0.001). There was no overall difference in the proportion of safeguarding referrals preintervention and postintervention. After intervention, the proportion of referrals for safeguarding concerns was greater when the BT-score was ≥3 (p=0.05) but not for scores <3 (p=0.60). A BT-score of 3 as a cut-off for referral had a sensitivity of 72.1, a specificity of 82.7 and a positive likelihood ratio of 4.2. Conclusions A BT-score ≥3 encouraged discussion of cases of concern with senior colleagues and increased the referral of <5 year-olds with safeguarding concerns to children’s social care

Potential impact of the validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A clinical vignette study

Background The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) in children <3 years old with intracranial injury. Objective To explore the impact of PredAHT on clinicians’ AHT probability estimates and child protection (CP) actions, and assess inter-rater agreement between their estimates and between their CP actions, before and after PredAHT. Participants and Setting Twenty-nine clinicians from different specialties, at teaching and community hospitals. Methods Clinicians estimated the probability of AHT and indicated their CP actions in six clinical vignettes. One vignette described a child with AHT, another described a child with non-AHT, and four represented “gray” cases, where the diagnosis was uncertain. Clinicians calculated the PredAHT score, and reported whether this altered their estimate/actions. The ‘think-aloud’ method was used to capture the reasoning behind their responses. Analysis included linear modelling, linear mixed-effects modelling, chi-square tests, Fisher’s exact tests, intraclass correlation, Gwet’s AC1 coefficient and thematic analysis. Results Overall, PredAHT significantly influenced clinicians’ probability estimates in all vignettes (p < 0.001), although the impact on individual clinicians varied. However, the influence of PredAHT on clinicians’ CP actions was limited; after using PredAHT, 9/29 clinicians changed their CP actions in only 11/174 instances. Clinicians’ AHT probability estimates and CP actions varied somewhat both before and after PredAHT. Qualitative data suggested that PredAHT may increase clinicians’ confidence in their decisions when considered alongside other associated clinical, historical and social factors. Conclusions PredAHT significantly influenced clinicians’ AHT probability estimates, but had minimal impact on their CP actions

To what extent are GCS and AVPU equivalent to each other when assessing the level of consciousness of children with head injury? A cross-sectional study of UK hospital admissions.

Objective To evaluate utility and equivalence of Glasgow Coma Scale (GCS) and the Alert, Voice, Pain, Unresponsive (AVPU) scale in children with head injury. Design Cross sectional study. Setting UK hospital admissions: September 2009–February 2010. Patients 1 year significantly more had a CT scan when GCS<14 was recorded than ‘V/P/U only’ and the diagnostic yield was greater. Prehospital GCS and GCS in the ED were the same for 77.4% (705/911). Conclusion There was a clear correlation between Alert and GCS=15 and between Unresponsive and GCS=3 but a wider range of GCS scores for responsive to Pain or Voice that varied with age. AVPU was valuable at initial assessment of infants and did not adversely affect the proportion of infants who had head CT or the diagnostic yield

Factors influencing child protection professionals' decision-making and multidisciplinary collaboration in suspected abusive head trauma cases: a qualitative study

Clinicians face unique challenges when assessing suspected child abuse cases. The majority of the literature exploring diagnostic decision-making in this field is anecdotal or survey-based and there is a lack of studies exploring decision-making around suspected abusive head trauma (AHT). We aimed to determine factors influencing decision-making and multidisciplinary collaboration in suspected AHT cases, amongst 56 child protection professionals. Semi-structured interviews were conducted with clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We identified six themes influencing decision-making: ‘professional’, ‘medical’, ‘circumstantial’, ‘family’, ‘psychological’ and ‘legal’ factors. Participants diagnose AHT based on clinical features, the history, and the social history, after excluding potential differential diagnoses. Participants find these cases emotionally challenging but are aware of potential biases in their evaluations and strive to overcome these. Barriers to decision-making include lack of experience, uncertainty, the impact on the family, the pressure of making the correct diagnosis, and disagreements between professionals. Legal barriers include alternative theories of causation proposed in court. Facilitators include support from colleagues and knowledge of the evidence-base. Participants’ experiences with multidisciplinary collaboration are generally positive, however child protection social workers and police officers are heavily reliant on clinicians to guide their decision-making, suggesting the need for training on the medical aspects of physical abuse for these professionals and multidisciplinary training that provides knowledge about the roles of each agency

Acceptability of the Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A qualitative study with child protection professionals

The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) based on combinations of six clinical features: head/neck bruising; apnea; seizures; rib/long-bone fractures; retinal hemorrhages. We aimed to determine the acceptability of PredAHT to child protection professionals. We conducted qualitative semi-structured interviews with 56 participants: clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We explored participants’ evaluations of PredAHT, their opinions about the optimal way to present the calculated probabilities, and their interpretation of probabilities in the context of suspected AHT. Clinicians, child protection social workers and police thought PredAHT would be beneficial as an objective adjunct to their professional judgment, to give them greater confidence in their decisions. Lawyers and pathologists appreciated its value for prompting multidisciplinary investigations, but were uncertain of its usefulness in court. Perceived disadvantages included: possible over-reliance and false reassurance from a low score. Interpretations regarding which percentages equate to ‘low’, ‘medium’ or ‘high’ likelihood of AHT varied; participants preferred a precise % probability over these general terms. Participants would use PredAHT with provisos: if they received multi-agency training to define accepted risk thresholds for consistent interpretation; with knowledge of its development; if it was accepted by colleagues. PredAHT may therefore increase professionals’ confidence in their decision-making when investigating suspected AHT, but may be of less value in court

Incidence of medically attended paediatric burns across the UK

Objective: Childhood burns represent a burden on health services, yet the full extent of the problem is difficult to quantify. We estimated the annual UK incidence from primary care (PC), emergency attendances (EA), hospital admissions (HA) and deaths.Methods: The population was children (0-15 years), across England, Wales, Scotland and Northern Ireland (NI), with medically attended burns 2013-2015. Routinely collected data sources included PC attendances from Clinical Practice Research Datalink 2013-2015), EAs from Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI, 2014) and National Health Services Wales Informatics Services, HAs from Hospital Episode Statistics, National Services Scotland and Social Services and Public Safety (2014), and mortality from the Office for National Statistics, National Records of Scotland and NI Statistics and Research Agency 2013-2015. The population denominators were based on Office for National Statistics mid-year population estimates.Results: The annual PC burns attendance was 16.1/10 000 persons at risk (95% CI 15.6 to 16.6); EAs were 35.1/10 000 persons at risk (95% CI 34.7 to 35.5) in England and 28.9 (95% CI 27.5 to 30.3) in Wales. HAs ranged from 6.0/10 000 person at risk (95% CI 5.9 to 6.2) in England to 3.1 in Wales and Scotland (95% CI 2.7 to 3.8 and 2.7 to 3.5, respectively) and 2.8 (95% CI 2.4 to 3.4) in NI. In England, Wales and Scotland, 75% of HAs were aged < 5 years. Mortality was low with 0.1/1 000 000 persons at risk (95% CI 0.06 to 0.2).Conclusions: With an estimated 19 574 PC attendances, 37 703 EAs (England and Wales only), 6639 HAs and 1–6 childhood deaths annually, there is an urgent need to improve UK childhood burns prevention

P-31 magnetization transfer measurements of P-i -> ATP flux in exercising human muscle

Fundamental criticisms have been made over the use of (31)P magnetic resonance spectroscopy (MRS) magnetization transfer estimates of inorganic phosphate (P(i))→ATP flux (V(Pi-ATP)) in human resting skeletal muscle for assessing mitochondrial function. Although the discrepancy in the magnitude of V(Pi-ATP) is now acknowledged, little is known about its metabolic determinants. Here we use a novel protocol to measure V(Pi-ATP) in human exercising muscle for the first time. Steady-state V(Pi-ATP) was measured at rest and over a range of exercise intensities and compared with suprabasal oxidative ATP synthesis rates estimated from the initial rates of postexercise phosphocreatine resynthesis (V(ATP)). We define a surplus P(i)→ATP flux as the difference between V(Pi-ATP) and V(ATP). The coupled reactions catalyzed by the glycolytic enzymes GAPDH and phosphoglycerate kinase (PGK) have been shown to catalyze measurable exchange between ATP and P(i) in some systems and have been suggested to be responsible for this surplus flux. Surplus V(Pi-ATP) did not change between rest and exercise, even though the concentrations of P(i) and ADP, which are substrates for GAPDH and PGK, respectively, increased as expected. However, involvement of these enzymes is suggested by correlations between absolute and surplus P(i)→ATP flux, both at rest and during exercise, and the intensity of the phosphomonoester peak in the (31)P NMR spectrum. This peak includes contributions from sugar phosphates in the glycolytic pathway, and changes in its intensity may indicate changes in downstream glycolytic intermediates, including 3-phosphoglycerate, which has been shown to influence the exchange between ATP and P(i) catalyzed by GAPDH and PGK

Qualitative analysis of clinician experience in utilising the BuRN Tool (Burns Risk assessment for Neglect or abuse Tool) in clinical practice

Introduction The BuRN-Tool (Burns Risk assessment for Neglect or abuse Tool) is a clinical prediction tool (CPT) aiding the identification of child maltreatment in children with burn injuries. The tool has been derived from systematic reviews and epidemiological studies, validated and is under-going an implementation evaluation. Clinician opinion on the use of this CPT is a key part of its evaluation. Objectives To explore the experience of emergency clinicians use of the BuRN-Tool in an emergency department (ED). Methods Three focus groups were conducted over a six-week period by the research team in the ED in the University Hospital of Wales; 25 emergency clinicians attended. A semi-structured approach was taken with pre-determined open-ended questions asked followed by a series of case vignettes to which the CPT was applied. The focus groups were recorded and transcribed verbatim. Thematic analysis was conducted for identification of pre-set and emergent themes. All data were double-coded. Results All participants said that it was acceptable to use the BuRN-Tool to aid in the decision-making process surrounding child maltreatment. All participants said that the BuRN-Tool was helpful and straight forward to use. All participants said that the tool was clinically beneficial, particularly for junior staff and those who do not always work in a paediatric environment. The clinical vignettes identified subjectivity in interpretation questions around adequate supervision, previous social care involvement and full thickness burns. This resulted in some variation in scoring. Conclusions This study confirms that the BuRN-Tool is acceptable in an ED setting. The focus groups demonstrated a homogenous and positive attitude regarding the layout, benefits and use of the BuRN-Tool. The subjective interpretation of some variables accounts for the non-uniformity in the scores generated. Clarification of questions will be made

Patterns of bruising in preschool children - a longitudinal study

ntroduction This study aims to identify the prevalence and pattern of bruises in preschool children over time, and explore influential variables Methods Prospective longitudinal study of children (<6 years) where bruises were recorded on a body chart, weekly for up to 12 weeks. The number and location of bruises were analysed according to development. Longitudinal analysis was performed using multilevel modelling. Results 3523 bruises recorded from 2570 data collections from 328 children (mean age 19 months); 6.7% of 1010 collections from premobile children had at least one bruise (2.2% of babies who could not roll over and 9.8% in those who could), compared with 45.6% of 478 early mobile and 78.8% of 1082 walking child collections. The most common site affected in all groups was below the knees, followed by ‘facial T’ and head in premobile and early mobile. The ears, neck, buttocks, genitalia and hands were rarely bruised (<1% of all collections). None of gender, season or the level of social deprivation significantly influenced bruising patterns, although having a sibling increased the mean number of bruises. There was considerable variation in the number of bruises recorded between different children which increased with developmental stage and was greater than the variation between numbers of bruises in collections from the same child over time. Conclusions These data should help clinicians understand the patterns of ‘everyday bruising’ and recognise children who have an unusual numbers or distribution of bruises who may need assessment for physical abuse or bleeding disorders