PC1235: Improving Detection of Non-accidental Trauma in the Pediatric Emergency Department - A Quality Initiative

Purpose/Objectives: In 2020, >674,000 children were victims of maltreatment, and 1750 children died of child abuse. 25% of children diagnosed with non-accidental trauma (NAT) have a prior sentinel injury that was unnoticed. There is limited data on rates of NAT seen in Emergency Department (ED); however there is increasing evidence on effective screening tools such as the TENS-4-FACESp. NYCH+H/Jacobi is the only pediatric trauma center in the Bronx. It serves underserved communities, with >60% self-identifying as African-American/Latino and >30% immigrants. Our triage NAT screen in electronic medical records (EMR) historically was a subjective, binary “yes/no abuse suspected”, fraught with potential bias and nursing hesitancy towards implementation. Our objective was to have a 20% increase in detection of possible NAT in children ages 0-4 years by implementing a standardized, objective tool and a closed-loop process within 6 months.

Design/Methods: A multidisciplinary team of ED nurses, social workers, pediatric residents and attending physicians developed and added a comprehensive NAT triage paper screen for all ED patients 0-4 years old. This screen was based on the objective TEN-4-FACESp, with decision support and implemented in Nov 2021. The team reviewed charts for every 10th patient who presented to ED from Nov 1, 2021 to Feb 28, 2022 (study period) and compared to patients from Nov 1, 2020 to Feb 28, 2021 (baseline) who received only the binary screen. Tests of change included monthly meetings with staff, nurse and physician education, monthly huddle/workshop, revising the screen to remove stigma, and the hand off from triage to provider for positive screens.

Results: 1684/1896 (89%) vs. 3147/3858 (81%) patients were screened using binary check in baseline vs. study period. 65% of the patients were screened via TEN-4-FACESp during the study period.(Fig 2) 36/3147 patients were positive via binary check vs. 50/2507 were positive via TEN-4-FACESp during study period, a 39% increase in detection. Of the positive screens, 48/50 (96%) had appropriate physician documentation and disposition.

Conclusion/Discussion: TEN-4-FACESp is an objective and easy to implement screening tool for NAT that was effective in detecting a significantly higher number of at-risk patients in ED triage despite a surge in number of patients. The detection of possible NAT increased positive screening by 39% within 4 months, hence meeting our objective. Our process of closed-loop acknowledgement facilitated physician assessment and documentation in almost all patients.