Improved Detection of Child Maltreatment with Routine Screening in the Emergency Department of a Tertiary Care Hospital

Background: Child maltreatment is a leading cause of pediatric morbidity and mortality. Detection of maltreatment particularly in its milder forms can be difficult in a busy emergency department. Numerous studies have demonstrated that a significant proportion of children who die or nearly die from maltreatment had been seen previously by a medical provider who failed to properly recognize and report the abuse. Routine child abuse screening may be able to improve detection of maltreatment.

Methods: A 5-question child abuse screen (CAS) based on the validated 'Escape’ child abuse screen was performed in all children <13 years of age and in non-verbal children ≥13 years of age who presented to the emergency department (ED) of a pediatric tertiary care center over a 6-month period. The CAS was layered on top of a pre-existing EHR-embedded child abuse clinical decision support system (CA-CDSS) which included passive triggers, alerts and abuse-specific order sets. The CAS was a hard stop; the primary assessment form couldn’t be signed unless the CAS was completed.

Results: Descriptive analyses were used to describe the sample and assess the outcomes. Logistic regression was done to assess the effect of race, age and insurance type on the likelihood of a positive CAS (as a binary variable) and a report being filed with child protective services (CPS). Of the 28,797 screens performed, 1.8% were positive in children <13 years old and 1.6% were positive in non-verbal children ≥13 years old. Distribution of positive responses is detailed in Table 1. The difference by age was significant for each CAS question except for Question #5 (the open-ended response). The comments in Question #5 varied in topic and length; nurses most frequently described injuries in more detail, indicated patient disclosures, documented family member concerns, or detailed social concerns (Table 2). Of the 512 children with a positive CAS, 58% (297/512) triggered only due to positive CAS; the remaining 42% (215/512) triggered both on the CAS and a CA-CDSS trigger. Nineteen percent of patients with a positive CAS were reported to CPS. There was no relationship between race and the odds of a positive CAS, or the likelihood of a report being made to CPS.

Conclusion: This is the first study to evaluate the use of a routine CAS in the ED of a hospital which already has an EHR-embedded CA-CDSS. Active routine child abuse screening by the ED nurse improves identification of suspected child maltreatment in a children’s hospital above and beyond what is identified with a CA-CDSS which depends on passive triggers. Our data suggest that systematic use of a CAS is a valuable approach to decreasing well-recognized racial disparities in identification and reporting of suspected maltreatment.