Professional Abstract
Objective
(1) To develop and validate an electronic health record (EHR)-based system for alerting pediatric emergency department (ED) clinicians of possible physical abuse and determine whether compliance with screening guidelines for suspected physical abuse in children less than two years old improves with use of the alert system compared with usual procedures; (2) To observe whether identification and reporting of child maltreatment in children under age 13 improves with use of a child abuse screen (CAS) at a network of 13 EDs
Study Design
Design Elements |
Description |
Design |
Objective 1: randomized controlled trial
Objective 2: prospective observational study
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Population |
Objective 1: 226 children under age 2 presenting with risk factors for physical abuse in a pediatric ED in the validation group and 306 children under age 2 in the randomized controlled trial
Objective 2: 17,163 health records of children under age 13 presenting at 13 general EDs
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Interventions/
Comparators |
Objective 1: pop-up alert linked to order set in EHR system versus no pop-up alert in EHR system
Objective 2: 5-item CAS versus no CAS
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Outcomes |
Objective 1: sensitivity, specificity, negative and positive predictive values for identifying physical abuse (primary); proportion of cases in which provider was fully or partially compliant with AAP guidelines for evaluating suspected physical abuse, proportion of cases in which provider was compliant by patient race and insurance status
Objective 2: rate of reporting suspected child abuse to CPS, rates of reporting based on patient and/or hospital characteristics
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Timeframe |
Objective 1: immediate follow-up for primary outcomes
Objective 2: immediate follow-up for primary outcomes
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Clinicians, social workers, medical informatics specialists, parents, and patient advocates participated in all stages of this study.
Objective 1. Researchers developed and evaluated the Child Abuse Clinical Decision Support System (CA-CDSS), an EHR alert system that prompts pediatric ED providers to use an order set to evaluate for possible child maltreatment, including physical abuse, sexual abuse, and neglect, in children under age two who trigger the alert system. The team embedded CA-CDSS in the EHR system at the Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) ED and trained providers to use it. Providers could also access the child abuse order sets directly, independent of the alert system.
Researchers measured the system’s accuracy for seven months, during which 226 children under age two triggered an alert. Of these children, 68% were white, 61% were male, and the average age was nine months.
Next, researchers conducted a randomized controlled trial to examine the system’s effect on provider adherence to the American Academy of Pediatrics (AAP) guidelines for evaluating suspected physical abuse. During the trial, if a patient triggered the CA-CDSS, the system randomized the EHR to show or not show the pop-up alert.
The trial included 306 children under age two who presented in the ED and triggered the CA-CDSS alert. Of these, 66% were white, 56% were male, and the average age was nine months.
Objective 2. Researchers compared physicians’ rates of reporting suspected child abuse to Child Protective Services (CPS) for children under 13 years old who did and did not have a completed child abuse screen (CAS), a five-item questionnaire to identify child abuse in their EHR.
Researchers embedded the CAS into the EHR system at 13 general EDs throughout the UPMC healthcare system. The study included 17,163 children who sought care at these EDs during a six-month period. Of these, 72% were white, 21% were African American, 46% were male, and the average age was six.
A nurse trained in completing the CAS examined children presenting in the EDs. A positive answer to any CAS item triggered an alert, which made the physician aware of the concern for abuse and suggested consulting a social worker and considering using the physical abuse order set.
Results
Objective 1
CA-CDSS accuracy. Sensitivity was 96.8%, specificity was 98.5%, and positive and negative predictive values were 26.5% and 99.9%, respectively, for identifying possible, probable, or definite physical abuse.
Trial. There was no significant difference in the proportion of providers who ordered physical abuse evaluations between the pop-up alert (85%) and control (77%) groups, even though providers in the control group were not prompted to use the physical abuse order set and had to search for it.
In every case in which a provider used the physical abuse order set, the provider was fully compliant with the AAP guidelines. The proportion of cases in which providers were only partially compliant decreased during the trial (p=0.04).
Providers were more likely to order evaluations when patients had public insurance than when patients had private insurance (p=0.02). There was no difference in provider compliance by patient race.
Objective 2. Providers completed the CAS with 68% of patients, and 1.9% were positive. The rate of abuse reported to CPS was significantly higher when providers completed the CAS compared with when they did not (p<0.0001). Younger children were more likely to be screened, but there were no race or income differences in the odds of being screened. There were also no significant differences in the odds of being screened by the hospital’s teaching status, size, or urban versus rural location.
Limitations
Objective 1. The trial took place at one pediatric ED. Providers, all of whom were aware of the study, may have been more attentive to signs of child abuse compared with providers in other settings. Their awareness may also have led to more providers using the order set overall. The study may have overestimated the sensitivity of the CA-CDSS because children with difficult-to-detect signs of abuse may not have been referred to the expert team that determined whether abuse was present.
Objective 2. Researchers were unable to assess whether variables such as reason for visit, severity of condition, past medical history, and history of repeated visits might have affected the likelihood of patients being screened. Therefore, there may have been differences between children who had a completed CAS compared with those who did not, which may have affected the likelihood of providers reporting abuse to CPS.
Conclusions and Relevance
Objective 1. The newly developed EHR-based alert system accurately identified children under age two in need of evaluation for physical abuse. The CA-CDSS pop-up alert did not significantly increase compliance with AAP guidelines compared with usual procedures, nor did it reduce disparities in evaluations based on type of insurance. However, providers seeing children in the control group, as well as in the pop-up alert group, accessed the order set for child physical abuse, suggesting that they found it useful.
Objective 2. Use of the CAS significantly improved rates of reporting suspected child physical abuse to CPS across multiple ED locations.
Future Research Needs
Future research could investigate the impact of these systems and conduct similar comparison studies in non-ED settings.