<p><strong>OBJECTIVES: </strong>The aim of this study was to evaluate the effectiveness of clinical pathway implementation and quality improvement (QI) interventions to increase the percentage of infants with extremity fractures undergoing evaluation for suspected physical abuse, including skeletal survey (SS), and consultation with social work, and/or Child Protection Team.</p>

<p><strong>METHODS: </strong>Charts were retrospectively reviewed to establish percentage of infants less than 12 months old with extremity fractures undergoing an SS and consultation during the prepathway (January 1, 2012 to December 31, 2013) and postpathway (January 1, 2014 to June 30, 2015) periods. Using an Ishikawa framework, key process drivers were identified and additional QI interventions (clinical decision support and provider education) were developed and implemented. Impact of QI interventions on study metrics during active QI (July 1, 2015 to June 30, 2016) and post-QI periods (July 1, 2016 to December 31, 2016) was monitored using statistical process control charts. Logistic regression assessed predictors of obtaining an SS, consultation use, and occult fracture detection.</p>

<p><strong>RESULTS: </strong>Skeletal survey use pre- and postpathway averaged 40%, surpassing 60% on average during active QI and post-QI periods. Consultation performance averaged 46% pre- and postpathway, increasing to nearly 67% during active QI; consultation performance decreased during post-QI to 60%. A lack of trauma history and presence of femur or humerus fracture were associated with increased SS use and consultation (both P &lt; 0.001). Overall 20% of SS revealed occult fractures.</p>

<p><strong>OBJECTIVES: </strong>The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI).</p>

<p><strong>METHODS: </strong>We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.</p>

<p><strong>RESULTS: </strong>Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.</p>

<p><strong>CONCLUSIONS: </strong>Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.</p>

<p><strong>OBJECTIVES: </strong>Cervical imaging practices are poorly understood in young children with Traumatic Brain Injury (TBI). We therefore sought to: identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT); and describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children.</p>

<p><strong>METHODS: </strong>We performed a retrospective study of children younger than 2 years of age with TBI from 2009-2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls.</p>

<p><strong>RESULTS: </strong>Of 2,347 children with TBI, 18.7% were from abuse, and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (OR 7.10; 95% CI 2.75, 18.35) and falls (OR 2.25; 95% CI 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3 to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P &lt; 0.001).</p>

<p><strong>CONCLUSIONS: </strong>These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly twenty-fold) and TBI from falls (over ten-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.</p>