Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments

Abstract

Objectives Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children < 12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12 months. Methods We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan‐do‐study‐act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children < 1 year old with high‐risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). Results Evidence of special cause was identified beginning in June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8‐month period, the CPT was consulted for a mean of 47.5% of children with high‐risk injuries; this was sustained for an additional 7 months. The average percentage of infants with high‐risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. Conclusion Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high‐risk injuries. Such interventions may improve recognition of physical abuse.

Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative

“…Other studies on improving NAT evaluations focused on specific elements, such as a skeletal survey [33][34][35] or child abuse specialist consultation. 27,32 Some published interventions relied on the EHR to aid in detecting abuse concerns 28,30 or patient screening tools. [19][20][21][22][23][24][25][26]29,31 One QI project improved NAT bundle adherence from 47% to 69% among 640 eligible patients <3 years old.…”

“…[19][20][21][22][23][24][25][26][27][28][29][30][31] Other studies targeted specific aspects of the NAT workup, including increased consults to a hospital child protection team. 25,[32][33][34][35][36] One hospital developed pediatric emergency department (PED) NAT evaluation guidelines for patients <3 years old and observed modest improvement in provider adherence. 37 In contrast, our project implemented a multidisciplinary, hospital-wide suspected NAT clinical guideline based on AAP recommendations.…”

Organizational factors affecting nurses’ tendency to report child abuse and neglect

“…This uncertainty might explain the low reporting rate among health professionals. Other studies have shown that the absence of clear guidelines and protocols for detecting and reporting child abuse can lead to reduced willingness to report and to a reduction in the accurate identification of child abuse cases (Ben Natan et al., 2012; Flaherty et al., 2004; Flaherty et al., 2008; Gunn et al., 2005; Piltz & Wachtel, 2009; Cleek et al., 2019; Tiyyagura et al., 2021).…”

“…The implementation of a child abuse pathway led to an increase in occult injury testing for at‐risk infants, reports to child protective services, and adherence to national child abuse evaluation guidelines. Providers who had consulted the child protection team reported that they valued confirmation from an expert even when the injury was thought to be non‐abusive, appreciated the concrete screening questions asked by the child protection team about the injury and social factors given that social work was not readily available, and appreciated the support and availability of the child protection team (Tiyyagura et al., 2021).…”

Child abuse

“…showed that when Community emergency departments, referred cases to dedicated child protection team, on identifying any of the above-mentioned TEN-FACE-sp injuries, an increased reporting of child abuse occurred (from 10.7% to 32.6%). [ 29 ]…”