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Abstract
Background Appropriate medical care of sexual abuse victims who present to the paediatric emergency department (PED) is vital to facilitate forensic evidence collection and prevent pregnancy and sexually transmitted infections. Despite recommendations from the American Academy of Paediatrics and Centres for Disease Control, adherence to guidelines remains low.
Objectives We aimed to increase the proportion of patient encounters at a PED for reported sexual abuse that receive guideline-adherent care from 57% to 90% within 12 months.
Methods Our team of PED and child abuse paediatricians constructed a key driver diagram to outline our theory for improvement (Figure 1). Multiple plan-do-study-act cycles were conducted to test interventions aimed at key drivers, including construction of a best practice algorithm, targeted clinician education, and integration of an electronic order set. Our primary outcome was the proportion of patient encounters in which care adhered to guideline recommendations. Data were abstracted from the records of all patient encounters evaluated in the PED for reported sexual abuse.
Results We analysed 567 patient encounters for reported sexual abuse over 24 months. A statistical process control chart depicting the proportion of encounters with guideline-adherent care (Figure 2) illustrates special cause variation and a shift in the centerline from 57% to 87% which has been sustained for 7 months. We categorised reasons for non-adherence on a Pareto chart (Figure 3).
Conclusions Using improvement methodology, we successfully increased guideline-adherent evaluation and management of patients presenting for sexual abuse. Targeted education and an electronic order set were associated with improved adherence to a novel care guideline.
Evaluation of sexual abuse key driver diagram (KDD)
Proportion of encounters for alleged sexual abuse with guideline-adherent care July 2015 – July 2017
Causes of non-adherence to guidline for evaluation and management of alleged sexual abuse by category Jan 2017 – June 2017, n=23