The factors contributing to delayed discharge of patients with suspected non-accidental injury in a quaternary paediatric orthopaedic ward

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Introduction Child abuse is a critically important discussion within any society and poses challenges in the social, legal and medical systems. The international literature is rich with descriptions of patient and family based risk factors and suspicious injuries. Based on these descriptions, we have created a protocol for the identification and investigation of children with suspected non-accidental injuries. The paediatric orthopaedic ward is faced with many children being delayed in the ward once fit for discharge due to delays in investigations or regulatory body assessments of these cases. This study aimed to quantify those delayed discharges and describe the demographics and risk factors for abuse we see within the local population. Methodology After obtaining ethics clearance and hospital approval, the study was conducted as a retrospective review of records from the Teddy Bear Clinic, as well as admission records of the children. The study examined the demographic characteristics of the children, their family background, injury characteristics and referral to Child Welfare. The delay of discharge from hospital was quantified for each child in days and was then compared to the initial characteristics of each child. Results Records were collected from 1 January 2015 to 31 December 2020. Seventy-nine complete records were included in the review. There were 40 male and 39 female patients with an average age of 20 months. Sixty children (75.9%) were under the age of 36 months. Of the 35 (44.3%) foreign nationals, 31 were undocumented. Seventy-three (94.1%) of the cases sustained lower limb fractures of which 51 were femur fractures. Fifty-two of the cases showed a delayed discharge of the child. The delay ranged from 1 to 233 days. Examining patient characteristics showed an association between an age less than 36 months and delayed discharge. There were no significant correlations between caregiver characteristics and delayed discharge. The admission progress revealed that the later the day of completion of investigations, the more likely there was to be a discharge delay. There was also a statistically significant correlation between referral to Child Welfare and delayed discharge. Discussion The majority of the patients referred for investigation were below the age of 36 months which agrees with the literature that this is the highest risk group. We could not identify any specific caregiver characteristics which were risk factors for suspicion. Delayed discharge of patients was associated with age less than 36 months, upper limb fractures and referral to Child Welfare. Despite the delayed discharge, most children were returned to the same home environments and in two described cases they were placed back into a high risk situation. Conclusion This review investigated the demographics of the children in the paediatric orthopaedic ward with a suspected non-accidental injury. The study also highlighted the challenges of inadequate support from regulatory social services when trying to assist these children.
A research report submitted in partial fulfilment of the requirement for the degree of Master of Science in Medicine to the Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, 2023
Child abuse, Paediatric, Orthopaedic ward