Early Involvement of the Child Protection Team in the Care of Injured Infants in a Pediatric Emergency Department

Powers, Emily; Tiyyagura, Gunjan; Asnes, Andrea G.; Leventhal, John M.; Moles, Rebecca L.; Christison‐Lagay, Emily R.; Groisberg, Shaina; Auerbach, Marc

doi:10.1016/j.jemermed.2019.01.030

Cited by 27 publications

(28 citation statements)

References 21 publications

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“…This holds true even for small interventions. A simple clinical pathway that automatically involved a child abuse team and social worker if a child had one of ten concerning injuries was found to remove socioeconomic bias [46]. While no authors have effectively demonstrated a reduction in the bias of referrals to CPS, a standardized protocol for imaging is likely a step in the right direction.…”

Section: Standardized Nat Screeningmentioning

confidence: 99%

Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

et al. 2022

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Purpose of Review To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT). Recent Findings Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse. Summary Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.

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Section: Standardized Nat Screeningmentioning

confidence: 99%

Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

et al. 2022

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“…The primary aim of this study was to increase CPT consultations regarding infants who presented with injuries associated with child abuse to the three CEDs. We based our approach on findings from a previous study aimed to increase CPT consultations in a PED, used a QI methodology, and aimed to increase CPT consultation from the 3% baseline to an average of 50% over 12 months 19 . The secondary aims were to assess barriers and facilitators of obtaining a CPT consult to iteratively inform plan‐do‐study‐act cycles and to examine the impact of our interventions on the evaluation of infants related to suspected abuse.…”

Section: Problem Descriptionmentioning

confidence: 99%

“…Clinical pathways for the evaluation of injuries associated with child abuse may increase recognition of physical abuse by ED providers, decrease variability in outcomes, and reduce implicit bias (e.g., the influence of race/ethnicity on clinicians' judgments about whether to consider abuse). [18][19][20][21] Existing pathways vary in both content and process and have led to increased testing for occult injuries, reporting to child protective services (CPS), and in one study, detection of suspected abuse. [18][19][20][21][22][23] To our knowledge, only one study, however, has examined the impact of a child abuse pathway in CEDs in the United States, and that study did not find improved compliance with guidelines from the American Academy of Pediatrics (AAP) about management of suspected physical abuse.…”

Section: Available Knowledgementioning

confidence: 99%

“…[18][19][20][21] Existing pathways vary in both content and process and have led to increased testing for occult injuries, reporting to child protective services (CPS), and in one study, detection of suspected abuse. [18][19][20][21][22][23] To our knowledge, only one study, however, has examined the impact of a child abuse pathway in CEDs in the United States, and that study did not find improved compliance with guidelines from the American Academy of Pediatrics (AAP) about management of suspected physical abuse. 23 Therefore, we developed a novel clinical pathway aimed at increasing the CED providers' access to child abuse experts to aid in the evaluation of injuries associated with child abuse.…”

Section: Available Knowledgementioning

confidence: 99%

“…The CPT may practice facilitation, a discrete implementation strategy of collaborative problem solving, providing support, and engaging in active rapport building that may lead to future consultation. 44,53 Secondary Outcomes Studies evaluating the effectiveness of child abuse pathways in pediatric EDs have predominantly been singlecentered [19][20][21]40 and have shown an increase in the use of SS and in reports to CPS without increased detection of abuse. Similarly, our study was not designed to detect an increase in abuse and despite an increase in the percentage of patients after initiation for whom a SS was obtained or a report was made to CPS, we showed no significant change in the percentage of patients with a positive SS.…”

Section: Primary Outcomementioning

confidence: 99%

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

Tiyyagura

Emerson

Gaither

et al. 2020

Academic Emergency Medicine

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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.

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How Should Clinicians and Health Care Organizations Promote Equity in Child Abuse and Neglect Suspicion, Evaluation, and Reporting?

Lane

Seltzer²

2023

AMA Journal of Ethics

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Victims of child abuse and neglect come from every racial, ethnic, and socioeconomic background, yet clinical evaluation, reporting to child protective services, and responses to reports inequitably harm Black children and malign families of color. Racial bias and inequity in suspicion, reporting, and substantiation of abuse and neglect and in services offered and delivered, foster care placement, and criminal prosecution are widely documented. In response, clinicians and health care organizations should promote equity by educating clinicians about racial bias, standardizing evaluation using clinical decision support tools, and working with policy makers to support prevention services. If we decide that it is ethically justifiable for clinicians to err on the side of overreporting, we must ensure fair distribution of associated benefits and harms among all children and families. VulnerabilityThe term vulnerable is often used to refer to a population at risk of being harmed and worthy of society's protection. 1 Children are inherently vulnerable due to their dependency on others to survive and flourish. 2 This dependency puts them at risk of maltreatment, which includes neglect, abuse, and exploitation. States' mandated reporter laws, which require clinicians to report suspected abuse and neglect to child protective services (CPS), were created as a way to protect children from such harm. Kim et al estimate that over one-third (37%) of all US children experience a CPS investigation by 18 years of age; the rates are higher for African American children (53%) and lower for Asians/Pacific Islanders (10%). 3 While the benefit of protecting a child from abuse and neglect is clear, the harms of over-vs underreporting must also be considered, particularly when certain harms are experienced disproportionately among children from certain racial and ethnic groups.Unwarranted reports-one consequence of overreporting-not only threaten the therapeutic relationship between the patient or family and clinician but also can result in significant emotional and financial hardships for children and families, including traumatic separation, stigmatization due to CPS involvement, missed workdays, and legal costs associated with the investigation. 4,5 Such reports also increase the workload Rebecca R. Seltzer, MD, MHS is an assistant professor of pediatrics at the Johns Hopkins School of Medicine in Baltimore. Her research involves improving care for children with medical complexity, with a particular focus on those in the child welfare system.

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Early Involvement of the Child Protection Team in the Care of Injured Infants in a Pediatric Emergency Department

Cited by 27 publications

References 21 publications

Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

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

How Should Clinicians and Health Care Organizations Promote Equity in Child Abuse and Neglect Suspicion, Evaluation, and Reporting?

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