Expanding the Use of a Child Abuse Alert System to Improve Detection and Reporting

This PCORI-funded implementation project expanded the use of an alert system for detecting and reporting concerns of child maltreatment to Child Protective Services in two health systems using different electronic health record, or EHR, systems.

Stakeholders Involved in This Project

• Survivors of child abuse and family members of children who were abused
• Representatives from the American Academy of Pediatrics, the Center for Children’s Justice, the Wisconsin Department of Children and Families, and the Children’s Advocacy Institute at the University of San Diego School of Law
• A pediatrician specializing in child abuse from Dayton Children’s Hospital
• Representatives from departments at each participating hospital, including social work, the ED, nursing, child advocacy, and IT (including the build team, the order set review team, the go-live announcement team, the data collection team, and the usability testing team)

Project Achievements 

• Embedded a child abuse alert system into two different EHRs in two separate hospital systems. The alert systems differ significantly from each other in terms of the type of triggers that were used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets, and the order sets themselves.
• Developed a toolkit with guidance that healthcare systems can use to implement the alert system into Allscripts or Epic EHRs.
• The project team received a PCORI-funded Engagement Award to address system-level barriers to uptake of the alert system.

Implementation Strategies

• Used a clinical decision support tool.
• Adapted the child abuse alert system to work for sites’ electronic health record, or EHR, capabilities, including use of triggers, alerts, and physical abuse order sets.
• Integrated risk prediction and clinical decision support tools into sites’ EHR systems.
• Used data warehousing techniques to develop site-specific reports for monitoring implementation and outcome measures.
• Created and supported cross-disciplinary implementation teams at sites, including social work, emergency department, nursing, child advocacy, Child Protective Services, and IT.
• Trained clinicians to use the alert system, using demonstration videos and references sheets.
• Conducted cyclical small tests of change at sites.
• Provided technical assistance to sites, including consultation.

Evaluation Outcome Measures:

To document implementation:

• Number of children screened
• Number of providers trained
• Characteristics of cases in which there was a lack of compliance
• Provider confidence in recognizing, evaluating, and reporting child physical abuse and using the EHR and alert system
• Provider perceptions of how well colleagues evaluate children for physical abuse
• How providers make decisions about when to evaluate for abuse
• Provider satisfaction with alert system and EHR

To assess healthcare and health outcomes:

• Number of reports of suspected maltreatment—abuse and neglect—to CPS
• Provider compliance with the American Academy of Pediatrics’ recommendations for evaluating suspected physical abuse in children under 2 years of age