G462(P) When guidelines are not enough - reasons for poor adherence to a protocol for investigation of abusive head trauma

Abstract

Aims Abusive head trauma (AHT) is one of the leading causes of death in children. In infants with serious head injury, the high prevalence of non-accidental causes mandates a systematic and thorough approach to its investigation.(1,2) We aimed to study adherence to our hospital protocol and reviewed reasons for any deviation. Methods A multi-source search strategy identified all children admitted to our tertiary paediatric intensive care unit (PICU) between 2011 and 2012 with head injury or abnormal cranial imaging. Those with identified causes were excluded. A retrospective review of the remaining eligible case notes was carried out. Interdisciplinary discussion and analysis of results was then undertaken. Results 33 case records were identified; 24 sets of paper notes and 9 with electronic records. For 15 children, all aged <12 months, the working diagnosis on admission was AHT (no history or reported assault); 9 had alternative explanations for head trauma. 32 survived to discharge. Audit standard Adherence to protocol (%) All admissions Suspected AHT at presentation Social work team informed 92.0 100 Safeguarding documentation in notes 58.3 77.8 Consultant neurologist to see child by the beginning of the next working day 54.2 100 Ophthalmologist examined by 48 h 72.0 90.0 External CT reported by neuroradiologist by next working day 66.7 58.3 MRI by end of day 4 33.3 60.0 Plan for skeletal survey documented 64.0 70.0 Haematological investigations complete 27.3 53.3 Biochemical investigations complete 24.2 40.0 Conclusions Overall adherence to the protocol was poor, and this was consistent with two previous hospital audits (in 2006 and 2009). Subsequent interdisciplinary discussion has identified disagreement about appropriateness of some parts of the protocol – these are being revised to ensure multi-speciality agreement. Other important modifiable factors identified included accessibility and knowledge of the protocol, clarity of wording and layout and practical difficulties in implementation. Technological and process-based solutions have been introduced, and a re-audit is planned. Making a hospital-wide change in practice requires more than just a new guideline – it needs widespread ongoing consultation with stakeholders and a continuous evaluation of processes to ensure achievement of the original objectives. References Jayawant S, Rawlinson A, Gibbon F, Price J, Schulte J, Sharples P, et al. Subdural haemorrhages in infants: population based study. BMJ 1998 Dec 5;317(7172):1558–61 Child Protection Companion 2nd edition. London : RCPCH; 2013