title: Utility of a child abuse screening guideline in an urban pediatric emergency department.
abstract: BACKGROUND
  Previous studies have found racial and socioeconomic status bias in the way clinicians screen for and detect child abuse in patients presenting to the emergency department. We hypothesized that implementing a guideline for screening would attenuate this bias.
  
  
  METHODS
  An algorithm for child abuse screening in patients younger than 1 year presenting with fractures was developed for a pediatric trauma center emergency department. Data were collected 1.5 years before and after implementation of the algorithm to investigate implementation success. Data were compared before and after the implementation of the algorithm using χ and univariate logistic regression analysis.
  
  
  RESULTS
  The characteristics of patients with fractures were similar before and after the algorithm implementation. Implementation of the algorithm was related to a significant increase in algorithm required screenings: skeletal survey (p < 0.001), urinalysis (p < 0.001), and transaminase levels (p < 0.001). The racial composition of those screened did not change after the implementation of the protocol. Children with government-subsidized or no insurance were more likely to be screened for child abuse via skeletal survey before the algorithm implementation compared with those with private insurance (odds ratio, 2.7; 95% confidence interval, 1.2-6.0; p = 0.017). This relationship did not exist after the algorithm implementation (odds ratio, 1.2; 95% confidence interval, 0.56-2.46; p = 0.66). Final determination of child abuse was related to insurance status both before and after the algorithm implementation.
  
  
  CONCLUSIONS
  A child abuse screening algorithm was successfully implemented in an urban trauma center. After implementation, screening was no longer associated with socioeconomic status of the patient's family, although final determination of child abuse still was. Additional research is needed to determine utility of unbiased screening on patient outcomes.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: From the Departments of Neurosciences (N.H., T.M.G.), Trauma Services (K.A.L., K.G., J.R., E.H., N.M.G.), Emergency Medicine (E.H.), and Pediatrics (G.E.), Dell Children's Medical Center of Central Texas; and Department of Surgery (K.A.L., N.M.G), University of Texas Southwestern Medical School, Austin, Texas; and Trauma Services (T.M.), Arkansas Children's Hospital, Little Rock, Arkansas.
authors.forename: Nicole
authors.initials: N
authors.lastname: Higginbotham
authors.forename: Karla A
authors.initials: KA
authors.lastname: Lawson
authors.forename: Kelly
authors.initials: K
authors.lastname: Gettig
authors.forename: Jodie
authors.initials: J
authors.lastname: Roth
authors.forename: Emily
authors.initials: E
authors.lastname: Hopper
authors.forename: Eric
authors.initials: E
authors.lastname: Higginbotham
authors.forename: Timothy M
authors.initials: TM
authors.lastname: George
authors.forename: Todd
authors.initials: T
authors.lastname: Maxson
authors.forename: George
authors.initials: G
authors.lastname: Edwards
authors.forename: Nilda M
authors.initials: NM
authors.lastname: Garcia
mesh_terms: D000367:Age Factors; D000465:Algorithms; D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000592:standards; D005260:Female; D050723:Fractures, Bone / Q000209:etiology; D019983:Guideline Adherence; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000592:standards; D006801:Humans; D007223:Infant; D008297:Male; D017410:Practice Guidelines as Topic; D016730:Program Development; D044469:Racial Groups / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D012959:Socioeconomic Factors; D014947:Wounds and Injuries / Q000209:etiology