Standardization of the child physical abuse evaluation in a pediatric emergency department

BACKGROUND: Child abuse is the third leading cause of death in children aged 4 years and younger. In children aged 24 months or younger with suspected nonaccidental trauma (NAT), a skeletal survey (SS) to evaluate for occult fracture is recommended. Laboratory testing and cranial imaging are recommended in specific ages and scenarios. Before this initiative, there was no standardized guideline for NAT evaluation in our pediatric emergency department (ED). 

METHODS: A team of ED nurses and physicians and child abuse pediatricians reviewed data and identified barriers to obtaining laboratory testing, SS, and head computed tomography in cases of suspected NAT. Interventions included education on implicit bias and abuse recognition, creation of an age-based NAT guideline, the launch of an electronic health record order-set, and physician specific feedback. Primary aims were to increase the proportion of patients aged 24 months or younger with suspected NAT with (1) a SS ordered or planned in the ED from 74% to greater than 95% and (2) required laboratory testing completed from 13% to greater than 60% in 7 months. Results were stratified by race/ethnicity. We used statistical process control charts to examine changes in measures over time. 

RESULTS: From October 2020 to September 2021, the proportion of patients aged 24 months or younger in the ED with SS ordered/planned increased from 74% to 91%, and those with required laboratory testing increased from 13% to 71%. There were no differences in testing stratified by race/ethnicity. 

CONCLUSION: We improved adherence to the recommended medical work-up for suspected NAT in patients aged 24 months or younger across racial and ethnic groups by implementation of an ED guideline with accompanying order-set, education, and individualized physician feedback.