Implementation of the TRAIN Initiative and Its Effect on Sentinel Injury Evaluation

Background: Child maltreatment is associated with considerable adverse consequences for individuals and society. However, the medical community has historically struggled to recognize those at risk. In 2014 the Timely Recognition of Abusive INjuries (TRAIN) collaborative was established by the Ohio Children's Hospital Association to promote screening for NAT, to decrease missed sentinel injuries (SIs), and reduce maltreatment recurrence. Our institution implemented the TRAIN initiative in 2019 which involved didactics for nurses and physicians regarding NAT identification and bias as well as marketing materials designed to increase awareness. The objective of this study was to explore the effects of TRAIN at this institution.

Methods: In this retrospective review we examined the incidence of SIs in children presenting to the ED of an independent level 2 pediatric trauma center. SIs were identified by ICD codes for ecchymosis, fracture, intracranial hemorrhage, abdominal trauma, open wound, oropharyngeal injury, or superficial injuries such as cuts, scrapes, lacerations, bruising, genital injury, and burns, in children under 6 months of age. Patients were stratified into pre-TRAIN, 1/2017-9/2018, and post-TRAIN periods, 10/2019-6/2020. Data was cross-referenced with the child abuse eam database to determine confirmed or suspected cases of child maltreatment. Data was analyzed using univariate statistics and bivariate inferential statistics, including chi-square and Welch's 2 sample t-test.

Results: Pre-TRAIN, 12,812 ED visits were made by children less than 6 months old; SIs were involved in 2.5% of these visits. Post-TRAIN, 5,225 ED visits were made by children less than 6 months old; SIs were involved in 2.4% of these visits. Pre-TRAIN, 53.8% of patients with SIs were males compared to 64.5% post-TRAIN. Neither ethnicity nor insurance status differed significantly among patients with SIs pre-versus post-TRAIN. The mean age of patients with SIs pre-TRAIN was 4 months, the mean age post-TRAIN was 3.5 months. There was no significant difference found when examining the demographic make-up, including insurance status, race, and ethnicity, of all ED patients under 6 months of age in either the pre or post-TRAIN period as compared to patients with SIs in the pre or post-TRAIN period. The proportion of confirmed or suspected child abuse cases among patients with SIs did not significantly differ between time periods. The rate of skeletal surveys performed on patients with SIs increased from 16.8% to 26.7%.

Conclusion: TRAIN resulted in a statistically significant increase in the proportion of skeletal surveys among patients with SIs. This suggests that although there was not a significant change in the proportion of confirmed or suspected child abuse among those with SIs, TRAIN successfully resulted in increased NAT screening.