PC2039: Development and Implementation of a Universal Non-accidental Trauma Screen at a Pediatric Emergency Department

Purpose/Objectives: Non-accidental trauma (NAT) is a significant cause of injury and death in young children. Studies have shown that a substantial portion of children with severe abusive head trauma (AHT) had a recent prior visit to a healthcare provider, which may have been a missed opportunity for early recognition and intervention. Standardized screening decreases the impact of implicit biases in the evaluation for NAT. The objective of this project was to develop and implement a standardized screening tool for NAT to improve identification of children at risk for morbidity and mortality. The SMART aim was to increase NAT screening in the pediatric ED from 0% to 90% in 12 months and sustain screening rates over 24 months.

Design/Methods: We used quality improvement methods to develop and implement our screening tool. All children from birth to 5 years-old presenting to the Children's Hospital Colorado-Colorado Springs ED were eligible for NAT screening regardless of the chief complaint or triage level. The standardized tool was modified from previously published tools (Figure 1). The screening tool incorporates historical factors that may be concerning for NAT and physical exam findings consistent with the TEN-4-FACESp bruising clinical decision rule. The primary outcome was the proportion of eligible patients screened. Secondary measures included percent of positive screens, social work consults, and referrals made to county child protection services. Nurses and providers were surveyed monthly to assess barriers and acceptability of implementation.

Results: After implementation, the mean screen rate was 60.1% over 4 months. However, over the next 6 months, the rate decreased to 37.9% when high census volumes returned due to the COVID-19 pandemic. Barriers identified included the COVID-19 pandemic, the electronic health record (EHR), and staff communication. Interventions included additional education of new nursing staff, improved reminders in the triage component of the EHR, and increased department huddles. Currently screening is 71.2% of eligible patients (Figure 2). Out of a total of 21,615 eligible patients, 10,634 (49.2%) children were screened with 2.76% (n=294) positive screens. For our secondary measures, 50.3% of positive screens had social work consults and 32.5% had child protection services referrals.

Conclusion/Discussion: Integration of NAT screening into a pediatric ED is feasible and acceptable to staff, as well as potentially sustainable. Though nursing turnover and charting may pose challenges to screening, these issues were addressed and created sustained change.