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Acad Emerg Med. Author manuscript; available in PMC 2015 June 09.
Published in final edited form as:
Acad Emerg Med. 2009 March ; 16(3): 249257. doi:10.1111/j.1553-2712.2008.00346.x.

Randomized Prospective Study to Evaluate Child Abuse


Documentation in the Emergency Department

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Elisabeth Guenther, MD, MPH, Cody Olsen, MS, Heather Keenan, MD, PhD, Cynthia
Newberry, BS, J. Michael Dean, MD, MBA, and Lenora M. Olson, PhD
Division of Pediatric Emergency Medicine (EG), Division of Pediatric Critical Care (CO, HK, JMD,
LMO), Intermountain Injury Control Research Center (EG, CO, HK, JMD, LMO), Department of
Pediatrics, University of Utah, Salt Lake City, UT; University of Utah School of Medicine (CN),
Salt Lake City, UT

Abstract
ObjectivesTo determine whether an educational intervention for health care providers would
result in improved documentation of cases of possible physical child abuse in children < 36
months old treated in the emergency department (ED) setting.

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MethodsThis study had a statewide group-randomized prospective trial design. Participating


EDs were randomized to one of three intervention groups: no intervention, partial intervention,
full intervention. Medical records for children < 36 months of age were abstracted before, during,
and after the intervention periods for specific documentation elements. The main outcome
measure was the change in documentation from baseline. Generalized estimating equations
(GEEs) were used to test for intervention effect.
ResultsOne thousand five hundred and seventy-five charts from 14 hospitals EDs were
abstracted. Hospital and demographic characteristics were similar across intervention groups.
There were 922 (59%) injury visits and 653 (41%) non-injury visits. For each specific
documentation element, a GEE model gave p values of > 0.2 in independent tests, indicating no
evidence of significant change in documentation after the intervention. Even among the 26 charts
in which the possibility of physical abuse was noted, documentation remained variable.

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ConclusionsThe educational interventions studied did not improve ED documentation of


cases of possible physical child abuse. The need for improved health care provider education in
child abuse identification and documentation remains. Future innovative educational studies to
improve recognition of abuse are warranted.
Keywords
child abuse; emergency department; intervention

Corresponding Author: Elisabeth Guenther, MD, MPH, Division of Pediatric Emergency Medicine, University of Utah School of
Medicine, PO Box 581289, Salt Lake City, Utah 84158 Phone: (801)587-7450 Fax: (801)587-7455 elisabeth.guenther@hsc.utah.edu.
Presentations: Pediatric Academic Societies/American Academy of Pediatrics meeting in Washington DC, May 2005

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INTRODUCTION
Child abuse and neglect is a serious public health problem in the United States. The U.S.
Department of Health and Human Services reported that an estimated 905,000 children
experienced child abuse or neglect in the United States in 2006.1 The consequences of child
abuse and neglect for children and their families include increased risk for suicide,
depression, substance abuse, and chronic health problems.27 As a result, primary and
secondary prevention of child abuse are important to the long term health of children.

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Several studies have shown that children who have experienced abuse are often seen in an
emergency department (ED) before the diagnosis of the abuse is made.812 Chang and
colleagues estimate that in the United States, 10% of all children presenting to an ED have
experienced abuse.8 A recent study found that children with substantiated child abuse have
higher ED use prior to a diagnosis of abuse, when compared with the general pediatric
population.13 These statistics suggest that the ED is one of the health care settings in which
the diagnosis of child abuse should be considered.
Appropriate documentation in the medical record is important to show that child abuse was
considered in the differential diagnosis of an injury. In addition, adequate documentation
helps differentiate abusive from non-abusive injury in the legal realm. Unfortunately, a
study by Ziegler and colleagues found that the staff in a general hospital often did not
document consideration of child abuse in pertinent cases, nor did the staff routinely
document or assess all of the indicators of child abuse in children at risk for abuse.9
Similarly, several studies conducted in the ED setting showed that documentation in the
medical chart is inadequate to differentiate unintentional from inflicted injury.1417

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Child abuse or neglect may not be consistently diagnosed and/or reported in the medical
record in the outpatient health care setting for multiple reasons, including misleading
histories by the caretaker, differences in health care training of practitioners,18,19
practitioner bias,2022 concerns for the legal implications of this diagnosis,23 and physician
error in recognition and/or interpretation of presenting signs and symptoms.16,24,25 As a
result, documentation of the diagnosis of child abuse in the outpatient medical record
remains suboptimal. In order to overcome these barriers, knowledge, skills, and attitudes of
physicians need to be changed.25 One way to change knowledge, skills, and attitudes is
through targeted education.18,26,27 We conducted a randomized prospective study to
evaluate two educational interventions designed for ED health care providers (i.e.,
physicians, nurses, and technicians), compared to no intervention. The two interventions
were designed to increase general knowledge and understanding of physical child abuse, to
improve recognition and detection of physical child abuse, and to meet current management
and documentation recommendations when physical child abuse is considered in children
younger than 36 months.16 The two interventions contained similar material; however, one
intervention was a one time only intervention, while the other intervention was more
comprehensive, required more time of the participants, and included additional information.
The goal of the educational program was to educate health care providers regarding signs
and symptoms suggestive of physical child abuse in children under 36 months, provide
information regarding referrals to the Division of Child and Family Services (DCFS) if child

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abuse is considered, and review the requirements of documentation for suspected physical
child abuse in the ED chart. We hypothesized that an ED-based educational intervention for
health care providers would result in improved documentation in institutions receiving
education of the consideration of the diagnosis of physical child abuse in injured children
presenting in the ED setting. Furthermore, we hypothesized that an ongoing intervention
would create a greater change than a single intervention.

METHODS
Study Design

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A group randomized prospective trial design was used to evaluate the effectiveness of two
different structured educational programs designed for health care providers in the ED
setting. This study was considered exempt by our University Institutional Review Board.
Separate Institutional Review Board approval was obtained from each of the hospitals
involved in this study.
Study Setting and Population
The sampling frame was each of the 39 hospitals in Utah with an ED that evaluates children.
We excluded the only pediatric trauma center and childrens hospital due to a lack of
comparable institutions in the state. Fourteen hospitals agreed to participate in this study.
None of the participating hospitals had a hospital-based specialized team to evaluate
possible child abuse and neglect; however, all 14 hospitals had access to the child abuse
specialist at the tertiary pediatric hospital in the state.
Study Protocol

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Hospitals were divided into five groups, dependent on the number of annual pre-adolescent
visits to the ED and blocked by stratum. Blocking was used to ensure equal numbers of
small to large hospitals in the sample so that results could generalize to state hospitals of any
size; the experimental design was not developed to statistically evaluate the effect of blocks
itself. Of these five initial groups, three were randomly assigned to one of the three
intervention groups. Initially, fifteen hospitals were randomly selected from the sampling
frame to participate in the study, with the goal of five hospitals in each of three intervention
groups described below. If the representatives of a hospital chose not to participate in the
study, the next hospital in the equivalent stratum was approached for participation. We were
limited to 15 institutions by the available resources to conduct this study.

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The educational program was designed for general practitioners, emergency physicians
(EPs), family practice physicians, pediatricians, nurse practitioners, physician assistants,
registered and licensed nurses, and technicians employed to work in the ED setting. To
minimize intrinsic selection bias and assure that the attendees were not more likely to be
those already interested in improving the recognition of child abuse, the educational
interventions were most often presented as part of an ED staff meeting or an ED physicians
meeting. In addition, we felt that this would maximize ED health care provider attendance.
Health care providers at each of the participating hospitals were not aware of the educational
arms of the study or the chart abstraction for specific documentation elements.

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The three intervention groups were as follows. Intervention Group 1: no intervention (five
hospitals). Participants did not receive an intervention. Intervention Group 2: single-contact
intervention (five hospitals). During the intervention period, the primary investigator (PI) or
a trained health care educator presented a standardized educational program to the
emergency health care providers. The educational program was a one hour didactic session
consisting of a 45 minute PowerPoint presentation on the recognition of physical child abuse
in the ED and appropriate documentation, and 15 minutes for case-centered discussion.
There were no additional site visits. Intervention Group 3: On-going education and chart
reminder intervention (four hospitals). An extended educational program consisting of three
one-hour didactic sessions held over a six month period was presented to this group by the
PI or the trained health care educator during the intervention period. The one hour didactic
sessions were: 1) Session 1: the 45 minute PowerPoint presentation used for Intervention
Group 2 was presented. 2) Session 2: two journal articles, one on child abuse recognition,22
and the second on appropriate documentation of child physical abuse,16 were presented and
discussed approximately 1 to 3 months after session 1. Case-centered discussions were also
held at the second educational session. In addition, a screening instrument, designed to
remind the health care provider to consider the diagnosis of physical child abuse, was
presented and discussed (see online Data Supplement 1 for instrument). Following this
presentation, the checklist was then inserted by the ED triage nurse into the chart of every
patient less than 36 months of age seen in that ED with a chief complaint of injury, from the
time session 2 was conducted until the end of the intervention period. 3) Session 3: in
addition to all of the interventions from Session 2, a child abuse specialist was available to
answer questions posed by the group on documentation elements, child abuse recognition,
and the most appropriate disposition of patients in which there is a concern for child abuse.
The total intervention time was 3 to 4 months.

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InstrumentsTwo focus groups were used to develop, test, and modify the one-hour
didactic training session used for intervention groups 2 and 3, and the checklist used in
intervention group 3. The educational interventions and guidelines for the evaluation tool
used in the chart abstraction were constructed a priori from elements of published child
abuse evaluations.16

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Data CollectionA review of randomly chosen medical records before, during, and after
the intervention period was conducted at each participating hospital to assess the effect of
the standardized educational program on the medical chart documentation of the
consideration and diagnosis of physical child abuse. Time 1 chart abstraction was conducted
to measure baseline documentation for each institution. Time 2 chart abstraction (midintervention) was performed to ascertain the immediate effect of education on
documentation. In those programs in which no intervention occurred, charts were abstracted
from dates that coincided with the time of the educational presentations at the intervention
sites. Time 3 chart abstraction (post-intervention) was conducted on charts from all groups
to discern presence of long-term effects of the education intervention on documentation.
Baseline documentation (time 1): For intervention groups 1, 2 and 3, all medical charts of
children less than 36 months of age evaluated in the ED setting from November 1, 2004 to

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February 28, 2005, were obtained. From these medical charts, those with discharge
diagnoses described in the medical literature as most often associated with the presentation
of possible physical child abuse were obtained for data abstraction (see online Data
Supplement 2 for a description of the clinical indicators). Due to the high volume of
pediatric charts from this time period, a subset of charts from 30 randomly generated dates
was then obtained for data abstraction.

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Mid-intervention documentation (time 2): We abstracted this from medical charts as


follows. Intervention group 1: Medical charts for children < 36 months of age from the
Group 1 hospitals were derived from 30 random dates generated from October 18, 2005 to
February 2, 2006. Intervention group 2: All medical charts of ED visits for children < 36
months of age were abstracted from visits on day 1 through day 30 following the first
didactic session. Intervention group 3: All medical charts of ED visits for children < 36
months of age were abstracted from visit days 1 through 30 following the second didactic
session (presentation and discussion of the journal articles).
Post-intervention chart abstraction (time 3): Data were abstracted from all medical charts
of visits for children less than 36 months of age evaluated in the ED 30 days through 60
days for all three groups after the date of the final intervention for intervention group 3.

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Two of the study authors abstracted the following data elements from each medical chart:
child age, sex, ethnicity and race, date and time of arrival to the ED, chief complaint, date
and time of presenting injury, type of presenting injury, history of past injuries, description
of presenting injuries (including location, size and color), genital exam results (if
performed), radiograph results (if obtained), lab test results (if obtained), involvement of
child protective services, disposition of the patient, and International Classification of
Diseases, Ninth Revision (ICD-9) codes for discharge diagnosis. If the patient presented
with a chief complaint or evidence of injury, the following specific items, noted in the
literature to be vital to appropriate documentation for possible child abuse,16 were abstracted
or marked as present or absent in the medical chart. 1) Documentation of delay between
injury and seeking medical advice of greater than 24 hours without plausible explanation. 2)
Documentation of consistency of history with the injury (any notation of historys
consistency with the presenting injury was recorded as present). 3) A complete description
of the injury. 4) Documentation of an anterior fontanelle exam in patients less than 12
months of age. 5) Adequate skin exam documentation. 6) Documentation of a skeletal
survey for possible abuse. 7) Documentation of a computed tomography (CT) of the head. 8)
Documentation of either a referral to Division of Child and Family Services (DCFS) or
pediatric sub-specialist to investigate the possibility of abuse.

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For analysis of documentation patterns, only questions 15 were considered and were used
as five separate outcome variables. Questions 68 were included for data abstraction to help
determine the scope of the diagnostic work-up. In addition, any chart that included
documentation of possible physical child abuse was extracted for further analysis to
determine the documentation patterns of the ED health care provider once the diagnosis of
child abuse was considered.

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Data Analysis

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Our goal was to determine if ED practice changed, not to find out whether individual
physicians behavior changed. As a result, the unit of analysis for this group-randomized
trial was the institution, not the individual; therefore, we did not measure change by
practitioner. Descriptive analysis included describing the number of visits and the
demographic composition (age, sex, race, and ethnicity) by intervention group.
Management, consultations, and disposition were described by intervention group, as were
hospital characteristics, including the mean number of beds and the number of charts
abstracted. Descriptive analyses were repeated for the subset of patients documented as
possible child abuse in the differential diagnosis.

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Emergency department visits were categorized as injury or non-injury according to ICD-9


codes and chief complaint. The top chief complaints and diagnoses, as well as the
disposition and the number of head CT scans were described for each of the injury and noninjury groups.

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A statistical model was used to test for a change in documentation due to the intervention.
The outcome of interest was a change in documentation from baseline for injury visits.
Generalized estimating equations (GEE) were used to test for an intervention effect while
accounting for the clustering of patients in a hospital.28 An exchangeable working
correlation structure was used. Individual GEE models were fit to each of the five responses
relating to the documentation of child abuse. Adequate documentation (Yes or No) for each
outcome was used as the dichotomous response in the GEE models. Independent variables
included time (pre, mid, and post-intervention), intervention group (nonegroup 1, mid
group 2, highgroup 3), and a time-intervention interaction. A significant interaction term
would suggest an effect of the intervention compared to baseline.
Frequency of documentation for each intervention group and time period was described for
each of the five questions used in GEE models. Exact 95% confidence intervals (CI) for the
percent of documentation were also calculated for each intervention group separately for the
five questions. No a priori power analysis was performed as we were limited to 15
institutions by the available resources to conduct this study.

RESULTS
Study Population

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Data were abstracted from 1,575 charts for visits of children less than 36 months of age
evaluated in one of the 14 hospital EDs participating in this study. Table 1 shows that total
visit numbers were similar across intervention groups. Of the 1,575 charts, 34.5% (n = 544)
were pre-intervention visits (time 1), 31% (n = 488) were mid-intervention visits (time 2),
and 34.5% (n = 543) were post-intervention visits (time 3). The median patient age was 18
months (IQR: 11, 26) and the majority (78.4%) were white, reflecting the general population
of this state (89.2% white).29

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Type of ED visits, by visit type

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When grouped by visit category, there were 922 (58.5%) visits for injury-related complaints,
and 653 (41.4%) for non-injury complaints among abstracted charts. The three primary chief
complaints for injury-related visits were laceration, facial injury, and extremity fracture. The
top three non-injury chief complaints were vomiting, fever, and diarrhea. The leading three
discharge diagnostic codes for injury-related visits were ICD-9 codes 920 (contusion of face,
scalp and neck), 959.01 (injury, other and unspecified: head and neck), and 873.42 (other
open wound of head). The three discharge diagnoses coded most often for non-injury related
visits were ICD-9 codes 787.03 (symptoms involving digestive system: nausea and
vomiting), 382.9 (suppurative and unspecified otitis media), and 780.31(general symptoms:
convulsion, febrile convulsions).
Results of GEE models

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For each of the five documentation questions, a GEE model was performed based on the
presence of predetermined outcome documentation measures. Data were too sparse for a
GEE model to converge using the first outcome; explanation of the delay between injury and
seeking medical advice. Delays were documented in only 55 visits, and explanations were
documented in 22 of these visits. All of the remaining four questions had p values of > 0.2 in
independent tests, indicating no evidence of significance or trend.
Simple proportions

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Table 2 shows the frequency of documentation for each intervention group and time period.
The number of visits with a delay between injury and seeking medical advice was small
overall (n = 55), and documentation of an explanation for this delay was present in only 22
charts. Documentation of a history consistent with the injury and description of the injury,
questions 2 (documentation of consistency of history with the injury) and 3 (a complete
description of the injury) respectively, were prevalent across all intervention groups and
time points. In contrast, documentation of the anterior fontanelle and skin exams, questions
4 (documentation of an anterior fontanelle exam in patients less than 12 months of age) and
5 (adequate skin exam documentation) respectively, were much less prevalent and showed
no significant improvement over time.
Documentation and Management once Child Abuse was considered

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Documentation of the possibility of abuse was present in 26 (2%) of the medical charts
during the study period (Table 3). Of the 26 charts, 24 showed that the patient presented for
injury-related complaints. In this subset of 24 charts, we found marked variability in
documentation as well as management of the injury. No documentation of a child abuse subspecialist consultation was found in the charts we reviewed, although documentation of the
DCFS consultation occurred in 10 (37%), and the police were consulted in 4 (15%) cases.
Two (7%) injured patients were discharged to DCFS custody.

DISCUSSION
This multi-center randomized study of an educational intervention to improve
documentation of possible child abuse in the ED setting has two main findings. First, neither
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of our educational interventions appeared to significantly affect ED health care provider


documentation behavior. Second, even when consideration of possible child abuse was
documented in the chart, compliance with specific documentation recommendations
remained sporadic.

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Our first main finding is that a comprehensive educational intervention for health care
providers in the ED setting did not appear to significantly affect EP documentation behavior.
The diagnosis of child abuse is challenging for health care providers. Children less than 36
months of age present to the ED with a wide range of signs and symptoms for conditions, a
variety of which are ultimately thought to be due to child abuse and neglect.30 Many health
care providers in the outpatient setting, however, lack comfort in the diagnosis and
management of possible child abuse.20,3133 One consequence of this lack of comfort in the
diagnosis and management of possible child abuse has been variable related documentation
and reporting patterns.1517,34 We specifically designed our intervention to address these
concerns, and concentrated our efforts on the diagnosis and documentation of possible child
abuse. Similar efforts at physician education have been successful in areas of outpatient care
including asthma treatment,35 and management of non-ST-segment elevation myocardial
infarction.36 In contrast to our study, however, the asthma education program curriculum is
delivered in two 2 hour interactive sessions with mandatory physician attendance,35 while
the study on non-ST-segment elevation myocardial infarction management was performed
as a quality improvement initiative.36 Our study did not allow for mandatory physician
attendance, which may have diluted the efforts we were trying to achieve. In addition, the
recognition of child abuse remains a more challenging area for the success of educational
interventions.27,37 It is possible that mandated physician compliance with an educational
program in conjunction with procedural changes and quality assurance review of pediatric
trauma charts may be more successful in addressing the problem of child abuse recognition
than relying solely on optional health care provider education.

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Our second main finding was that even when consideration of possible child abuse was
documented in the medical record, compliance with specific documentation
recommendations16,38 remained sporadic. Although our educational interventions stressed
best documentation practices, including the importance of historical factors and unique
pertinent physical findings, consistent documentation of these factors was variable. In some
areas, such as the likelihood of the childs injury resulting from the mechanism stated by the
caregiver, baseline documentation was found in the medical chart. Docmentation
Documentation of the presence or absence of bruising on a skin exam, however, remained
poor. When the diagnosis of possible child abuse is considered but not adequately
documented, crucial medical information is lost, including pertinent historical items,
physical examination findings, supplemental diagnostic procedures, specific wording of the
diagnostic impression including use of terminology such as rule out abuse, and even final
disposition the child.1517,39 This may ultimately result in increased childhood morbidity or
mortality due to child abuse.22,4043

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LIMITATIONS

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Physician attendance at the educational programs was variable between hospitals. ED health
care providers work unusual hours, including many evenings, holidays, and weekends. Thus,
one of the great challenges in providing education to health care providers in the ED setting
is the difficulty in finding a forum in which such an educational program can be presented to
a majority of the ED staff. Although we were able to present to the physicians at a
mandatory physician meeting at two hospitals participating in this study, in the other
hospitals there was a mix of health care providers, but primarily nurses and technicians. In
addition, there was no guarantee that the same individuals for Group 3 were present at each
of the sessions. This underscores the difficulty of traditional educational interventions, such
as lectures and presentations, targeting EPs who have variable work schedules and hours of
availability. Finally, there was no obligation or pressure (i.e. continuing medical education
(CME) credit or quality assurance / credentialing requirements) for the health care providers
to attend these sessions. Thus, innovative educational modalities, such as web-based
educational experiences for CME credit or credentialing, may prove to be a more effective
method to reach ED health care providers.

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Although we were able to abstract over 1,500 charts, the design of the study required the
analysis to be performed at the institution level, limiting the true sample size to the 14
institutions, and ultimately limiting the ability of GEE models to detect significant
improvements in documentation, even though GEE models have been shown to give liberal
results for small sample sizes.44 GEE models did not converge for question 1 due to sparse
data. For outcomes with very low (question 4) or very high (questions 2 and 3) rates of
documentation, a much larger sample size would be required to detect significant
improvement. The modest number of visits and small number of institutions likely limited
the power to detect improvement in documentation for question 5.
Child abuse is a relatively rare diagnosis made in the ED setting, which again may have
affected our ability to detect a small but significant difference. However, when the analysis
was additionally performed at the chart level, it still did not show an effect.
Finally, our outcome was a change in documentation. This may not be an accurate reflection
of the thought process of the health care provider involved or the health care providers
reached by this educational intervention.

CONCLUSIONS
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Our multi-faceted educational intervention did not appear to be successful in improving


documentation in the medical record regarding possible physical child abuse in the ED
setting. The need for improved and on-going health care provider education in the area of
child abuse identification and documentation remains. This study suggests that a traditional
educational model alone may not be the best mode for transmitting the pertinent
information. Future studies based in innovative educational interventions may be indicated.

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Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgements
The authors would like to thank Dr. Bruce Herman for his assistance with development of the didactic portion of
the educational intervention for this study and Drs. Lori Frasier and Bruce Herman for their expertise in child
abuse. The authors are also indebted to Kathleen Merkely, PNP, for her tireless hours of assisting with the
educational aspects of this study. Finally, the authors would like to thank Dr. Brian Johnston of the Harborview
Medical Center, for sharing with us the checklist used to help raise awareness of possible child abuse.
Funding sources: This study was supported by National Institutes of Child Health and Human Development
(NICHD) grant for Dr. Guenther (K23HD043145).

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Table 1

Author Manuscript

Hospital characteristics and demographics abstracted from the medical charts of children < 36 months
evaluated in the ED setting over the study period (N = 1,575)&
Hospital Characteristics

Author Manuscript

No
Intervention
Five sites

Single-contact
Intervention
Five sites

On-going
Intervention
Four sites

559 (35.55)

473 (30)

543(36)

Number of teaching hospitals in each group

1/5

1/5

1/4

Number of hospitals with 100% of total physician attendance at educational intervention

N/A

2/5

0/4

Mean number of total hospital beds

163

144

201

Patient Demographics

No
Intervention
n = 559

Single-contact
Intervention
n = 473

On-going
Intervention
n = 543

Mean age, months (SD)

18.8 (9.4)

18.4 (9.2)

18.2 (9.4)

Male n (%)

320 (57.2)

284 (60)

288 (53)

White

328 (79)

326 (78)

405 (78)

Other

231 (21)

91 (22)

113 (22)

Hispanic

63 (15)

77 (18)

92 (17)

Non-Hispanic

365 (85)

352 (82)

444 (83)

Trauma-related visit n (%)

324 (58)

290 (61)

308 (57)

Head CT performed

31 (6)

35 (7)

51 (9)

Skeletal survey performed

1 (<1)

1 (<1)

1 (<1)

Division of Child and Family Services

2 (<1)

4 (1)

5 (1)

Police

2 (<1)

3 (1)

1 (<1)

Social Work

1 (<1)

0 (0)

0 (0)

Pediatrics

32 (6)

21 (4)

28 (5)

Orthopedics

11 (2)

9 (2)

3 (1)

Other

0 (0)

7 (2)

4 (1)

None

492 (88)

413 (87)

478 (88)

Total number of charts abstracted during the study period, n (%)

Race n (%)

Ethnicity n (%)

Management n (%)

Author Manuscript

Subspecialty Consult n (%)

Disposition n (%)
Discharge

539 (96)

461 (98)

534 (98)

Division of Child and Family Services

1 (<1)

0 (0)

1 (<1)

Transfer to another institution

13 (2)

11 (2)

3 (1)

Author Manuscript

&

Unless specifically reported, unknown (missing) values were excluded from calculations of percentages. ED = emergency department; CT =
computed tomography

Acad Emerg Med. Author manuscript; available in PMC 2015 June 09.

Author Manuscript

Author Manuscript
4/8

Post-Intervention

2/5

Post-Intervention
36 (11, 69)

1/3

Mid-Intervention

% (95% CI)

1/3

Pre-Intervention

35 (14, 62)

0/4

Mid-Intervention

% (95% CI)

2/5

Pre-Intervention

96 (93, 98)

110 / 114

78 / 83

99 / 101

96 (93, 98)

94 / 97

74 / 78

96 / 99

96 (94, 98)

104 / 112

102 / 104

92 / 93

Question 2

96 (93, 98)

110 / 113

78 / 83

98 / 103

96 (93, 98)

97 / 99

76 / 81

96 / 100

96 (93, 98)

108 / 112

104 / 105

87 / 94

Question 3

26 (16, 39)

12 / 26

2 / 16

2 / 19

19 (10, 31)

3 / 22

4 / 15

4 / 22

10 (3, 21)

2 / 21

1 / 12

2 / 18

Question 4

26 (21, 32)

30 / 114

23 / 83

26 / 103

18 (14, 23)

20 / 99

25 / 79

6 / 99

40 (34, 45)

49 / 112

43 / 104

31 / 94

Question 5

Acad Emerg Med. Author manuscript; available in PMC 2015 June 09.

Data displayed for five questions a by intervention and time: number of eligible charts with documentation present / number of eligible charts.

CI = confidence interval

Question 5: Adequate skin exam documentation

Question 4: Documentation of an anterior fontanelle exam in patients less than 12 months of age

Question 3: A complete description of the injury

Question 2: Documentation of consistency of history with the injury

a Question1: Documentation of delay between injury and seeking medical advice of greater than 24 hours without plausible explanation

On-going:

Single-contact:

5 / 13

Post-Intervention
44 (25, 65)

6/9

Mid-Intervention

% (95% CI)

1/5

Pre-Intervention

None:

Question 1

Time

Intervention

Author Manuscript

Frequency of documentation relating to child abuse.

Author Manuscript

Table 2
Guenther et al.
Page 14

Guenther et al.

Page 15

Table 3

Author Manuscript

Demographics and Documentation in Records in Which Child Abuse was Considered and Documented
(n=26)&
Demographics

No
Intervention
n = 10

Single-contact
Intervention
n=9

On-going
Intervention
n=7

Mean age, months (SD)

16 (7)

18 (13)

14 (11)

Male n (%)

4 (40)

5 (56)

5 (71)

White

7 (78)

6 (86)

6 (86)

Other

2 (22)

1 (14)

1 (14)

Hispanic

2 (22)

1 (14)

1 (14)

Non-Hispanic

7 (78)

6 (86)

6 (86)

Trauma-related visit n (%)

9 (90)

9 (100)

6 (86)

Was there delay between injury and seeking medical advice without satisfactory
explanation?@

0 (0) n=1

0 (0) n=0

0 (0) n=2

Is there commentary on whether the history given is consistent with the injury?

9 (90)

7 (78)

6 (86)

Is there a complete description of the injury?

9 (90)

7 (78)

6 (86)

Is an anterior fontanelle exam documented if the patient is less than 12 months of age? (n
= number of children <12 months of age).

n=5
0 (0)

n=4
1 (25)

n = 12
1 (33)

Is an adequate skin exam documented?

5 (50)

5 (56)

4 (57)

Head CT performed

0 (0)

1 (11)

4 (57)

Skeletal survey performed

1 (10)

1 (11)

0 (0)

Division of Child and Family Services

2 (20)

3 (33)

5 (71)

Police

2 (20)

1 (11)

1 (14)

Social Work

1 (10)

0 (0)

0 (0)

Pediatrics

3 (30)

1 (11)

0 (0)

Orthopedics

0 (0)

1 (11)

0 (0)

Other

0 (0)

2 (22)

0 (0)

None

4 (40)

4 (44)

2 (29)

Discharge

8 (80)

7 (78)

6 (86)

Division of Child and Family Services

1 (10)

0 (0)

1 (14)

Transfer to another institution

1 (10)

2 (22)

0 (0)

Race n (%)

Ethnicity n (%)

Author Manuscript

Documentation n (%)

Management n (%)

Author Manuscript

Subspecialty Consult n (%)

Disposition n (%)

Author Manuscript

&

Unless specifically reported, unknown (missing) values were excluded from calculations of percentages.

@
Three children met criteria for a delay in presentation, each with documentation of an explanation given.
CT = computed tomography

Acad Emerg Med. Author manuscript; available in PMC 2015 June 09.