Suspected Child Abuse Revealed During ED Screenings

Diedtra Henderson

August 27, 2012

August 27, 2012 — Systematically screening for child abuse in emergency departments increases the detection of suspected child abuse 5-fold, and detection rates can be further increased by properly training staff and making such screening mandatory, according to a prospective intervention cohort study.

Findings from the study, conducted by Eveline C.F.M. Louwers, MD, from the Department of Public Health, Erasmus MC, at the University Medical Centre and the Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, both in Rotterdam, the Netherlands, and colleagues were published online August 27 in Pediatrics.

Although the literature concludes that screening tests for child abuse in emergency departments improves detection, studies supporting this contention are scarce. In addition, in many countries, it is not common to screen for child abuse in emergency departments.

The authors sought to determine whether training nurses how to conduct interviews and introducing child abuse screening to fast-paced emergency departments increases the detection rate.

The Netherlands provides medical care for its 3.5 million residents through 22 hospitals. The researchers focused on 7 of these hospitals, which tally about 200,000 emergency department visits each year. The researchers included data from all children aged 18 years or younger who visited the emergency department from February 2008 to December 2009.

The study authors developed a new checklist for screening potential child abuse in which the nurse must answer 6 questions such as, "Was there unnecessary delay in seeking medical help?" A positive answer to any of the questions would trigger the nurse to inform the emergency department physician, who then evaluated the increased risk for child abuse and, if necessary, took action. To increase nurses' competence, the researchers held a workshop on interview techniques at 4 of the hospitals that emergency department nurses could attend during regular working hours. The remaining 3 hospitals served as the controls.

ED Abuse Checklist

1. Is the history consistent?
2. Was there unnecessary delay in seeking medical help?
3. Does the onset of the injury fit with the developmental level of the child?
4. Is the behavior of the child/the carers and the interaction appropriate?
5. Are the findings of the top-to-toe examination in accordance with the history?
6. Are there any other signals that make you doubt the safety of the child or other family members? If ‘Yes’ describe the signals in the box 'Other comments' below.

Source: Pediatrics. Published online August 27, 2012.

During the 23-month study period, the research team included 104,028 emergency department visits by children younger than 18 years, 56% of whom were boys. Some 243 cases (0.2%) were considered suspected child abuse. The detection rate of suspected child abuse was significantly higher in children who were screened than in children who were not screened (0.5% vs 0.1%; P < .001). The pooled odds ratios for detection of suspected abuse in the children who were screened was 4.88 (95% confidence interval, 3.58 - 6.68).

These patients were younger than the overall pediatric emergency department population (age, 4.7 vs 7.2 years; P < .001) and were hospitalized more often. The most frequent injuries included fractures (19%), burns (8%), and minor head injury (8%).

ln the midst of the study, the Dutch Health Care Inspectorate began legally requiring screening for child abuse in all emergency departments. The national policy change sharply increased the screening rate, a trend that has persisted.

"Screening for child abuse in Dutch emergency departments proved to be effective in detecting suspected child abuse," the authors write. "Training of emergency department nurses and making screening a legal requirement were appropriate interventions for optimizing the screening rate for child abuse in emergency departments."

Study limitations include the fact that the hospitals were not randomized, but the authors argue that randomization was impossible for logistical and ethical reasons. In addition, because emergency departments are busy, it was difficult to achieve a 100% screening rate. The study may overestimate actual cases of child abuse by presenting suspected cases. Screening tools also may have been applied inconsistently by nurses, yet the 243 cases of suspected abuse among 37,404 completed screening instruments argues against this concern.

"Screening for child abuse in the emergency department should be embedded in the routine structure of all hospitals and (on a practical level) supported by electronic systems and (on a rational level) supported by policymakers and emergency department managers," the authors conclude. "For optimal effect, the screening instrument could be made a required part of the electronic patient file, thereby obliging emergency department staff to complete the form before they can close the patient's chart," they add.

This study was financially supported by the Netherlands Institute for Health Research and Development and Foundation Physico Therapeutic Institute. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online August 27, 2012.

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