title: Improving child protection in the emergency department: a systematic review of professional interventions for health care providers.
abstract: OBJECTIVE
  This systematic review evaluated the effectiveness of professional and organizational interventions aimed at improving medical processes, such as documentation or clinical assessments by health care providers, in the care of pediatric emergency department (ED) patients where abuse was suspected.
  
  
  METHODS
  A search of electronic databases, references, key journals, and conference proceedings was conducted and primary authors were contacted. Studies whose purpose was to evaluate a strategy aimed at improving ED clinical care of suspected abuse were included. Study methodologic quality was assessed by two independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy.
  
  
  RESULTS
  Six studies met the inclusion criteria: one randomized controlled trial (RCT), one quasi-RCT, and four observational studies. Study quality ranged from modest (observational studies) to good (trials). Variation in study interventions and outcomes limited between-study comparisons. The quasi-RCT supported self-instructional education kits as a means to improve physician knowledge for both physical abuse (mean +/- standard deviation [SD] pretest score = 13.12 +/- 2.36; mean +/- SD posttest score = 18.16 +/- 1.64) and sexual abuse (mean +/- SD pretest score = 10.81 +/- 3.20; mean +/- SD posttest score = 18.45 +/- 1.79). Modest-quality observational studies evaluated reminder systems for physician documentation with similar results across studies. Compared to standard practice, chart checklists paired with an educational program increased physician consideration of nonaccidental burns in burn cases (59% increase), documentation of time of injury (36% increase), and documentation of consistency (53% increase) and compatibility (55% increase) of reported histories. Decisional flow charts for suspected physical abuse also increased documentation of nonaccidental physical injury (69.5% increase; p < 0.0001) and had a similar significant effect as checklists on increasing documentation of history consistency and compatibility (69.5 and 70.0% increases, respectively; p < 0.0001) when compared to standard practice. No improvements were noted in these studies for documentation of consultations or current status with child protective services. The introduction of a specialized team and crisis center to standardize practice had little effect on physician documentation, but did increase documentation of child protective services involvement (22.7% increase; p < 0.005) and discharge status (23.7% increase; p < 0.02). Referral to social services increased in one study following the introduction of a chart checklist (8.6% increase; p = 0.018). A recently conducted multisite RCT did not support observational findings, reporting no significant effect of educational sessions and/or a chart checklist on ED practices.
  
  
  CONCLUSIONS
  The small number of studies identified in this review highlights the need for future quality studies that address care of a vulnerable clinical population. While moderate-quality observational studies suggest that education and reminder systems increase clinical knowledge and documentation, these findings are not supported by a multisite randomized trial. The limited theoretical base for conceptualizing change in health care providers and the influence of the ED environment on clinical practice are limitations to this current evidence base.
authors.affiliation: Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. mandi.newton@ualberta.ca
authors.forename: Amanda S
authors.initials: AS
authors.lastname: Newton
authors.forename: Belle
authors.initials: B
authors.lastname: Zou
authors.forename: Michele P
authors.initials: MP
authors.lastname: Hamm
authors.forename: Janet
authors.initials: J
authors.lastname: Curran
authors.forename: Sahil
authors.initials: S
authors.lastname: Gupta
authors.forename: Celeste
authors.initials: C
authors.lastname: Dumonceaux
authors.forename: Melanie
authors.initials: M
authors.lastname: Lewis
mesh_terms: D057189:Checklist; D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D004282:Documentation / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D017010:Reminder Systems