P2.O284: Improving the Evaluation for Bleeding Disorders in Infants with Unexplained Bruising Quality Improvement Project

Purpose/Objectives: Unexplained bruising, especially during infancy, could be the first sign of child physical abuse or the result of an undiagnosed medical condition. Distinguishing between physical abuse, unintentional injury, and a medical condition is essential as both missing and misdiagnosing physical abuse can result in harm to the child. In 2013, the American Academy of Pediatrics (AAP) published guidelines, updated in 2022, on the recommended bleeding disorder evaluation for children with unexplained and concerning bruises. This quality improvement (QI) project aims to increase the percentage of infants with unexplained bruising who receive a complete bleeding disorder workup per the published AAP guidelines to at least 75%.

Design/Methods: Baseline data was collected on all infants ( < 12 months of age) for whom the child abuse pediatrics (CAP) team was consulted between January 1, 2011 and December 31, 2020 due to bruising. Patients were identified from a hospital database and medical records were reviewed to determine if the patient met criteria for a bleeding disorder workup per AAP published guidelines. The intervention period started on January 1, 2023 and is still in progress. Multiple 6-month PDSA cycles were performed. The outcome measure is the percentage of infants who meet criteria for and receive a complete bleeding disorder evaluation.

Prior to PDSA cycle 1, CAP providers were provided with the baseline data, received education about bleeding disorder evaluations and the AAP guidelines during a group journal club, and engaged in a discussion to establish team agreement on the quality improvement initiative. A bleeding disorder evaluation reminder was also added to the hospital database. Prior to PDSA cycle 2, CAP providers reviewed the results of cycle 1, discussed barriers to completion of a full work up, and attended an educational session on bleeding disorders led by a pediatric hematologist.

Results: Baseline data showed that most CAP consults for infant bruising did not meet criteria for bleeding disorder evaluation due to clear accidental mechanisms or other findings supportive of a diagnosis of physical abuse. Of the 66 baseline patients who met criteria, only 16 (24%) received a complete bleeding disorder evaluation. During PDSA cycles 1 and 2, the number of infants meeting criteria who received a complete evaluation increased to 10/11 (91%) and 6/7 (86%) respectively.

Conclusion/Discussion: Through our QI project, we successfully increased the percentage of infants with unexplained bruising who receive a complete bleeding disorder evaluation from 24% to 89%. We found that provider education, establishing group agreement to improve practice, regular hospital database reminders, and 6-month reviews were successful in improving practice. Evaluating for bleeding disorders in infants with concerning bruising is a critical part of the medical work up, and following evidence-based guidelines may help to decrease bias in this evaluation.