Developing and Testing the Usability of a Novel Child Abuse Clinical Decision Support System: Mixed Methods Study.

BACKGROUND: Despite the impact of physical abuse on children, it is often underdiagnosed, especially among children evaluated in emergency departments (EDs). Electronic clinical decision support (CDS) can improve the recognition of child physical abuse. OBJECTIVE: We aimed to develop and test the usability of a natural language processing-based child abuse CDS system, known as the Child Abuse Clinical Decision Support (CA-CDS), to alert ED clinicians about high-risk injuries suggestive of abuse in infants' charts. METHODS: Informed by available evidence, a multidisciplinary team, including an expert in user design, developed the CA-CDS prototype that provided evidence-based recommendations for the evaluation and management of suspected child abuse when triggered by documentation of a high-risk injury. Content was customized for medical versus nursing providers and initial versus subsequent exposure to the alert. To assess the usability of and refine the CA-CDS, we interviewed 24 clinicians from 4 EDs about their interactions with the prototype. Interview transcripts were coded and analyzed using conventional content analysis. RESULTS: Overall, 5 main categories of themes emerged from the study. CA-CDS benefits included providing an extra layer of protection, providing evidence-based recommendations, and alerting the entire clinical ED team. The user-centered, workflow-compatible design included soft-stop alert configuration, editable and automatic documentation, and attention-grabbing formatting. Recommendations for improvement included consolidating content, clearer design elements, and adding a hyperlink with additional resources. Barriers to future implementation included alert fatigue, hesitancy to change, and concerns regarding documentation. Facilitators of future implementation included stakeholder buy-in, provider education, and sharing the test characteristics. On the basis of user feedback, iterative modifications were made to the prototype. CONCLUSIONS: With its user-centered design and evidence-based content, the CA-CDS can aid providers in the real-time recognition and evaluation of infant physical abuse and has the potential to reduce the number of missed cases.

Correction: Developing and Testing the Usability of a Novel Child Abuse Clinical Decision Support System: Mixed Methods Study.

[This corrects the article DOI: 10.2196/51058.].

Development and Evaluation of a Community Advisory Board for Family Violence.

Although intimate partner violence (IPV) is an important risk factor for child physical abuse, most IPV-exposed children are not evaluated for abusive injuries. A Community Advisory Board (CAB) was formed to (a) optimize a program to evaluate IPV-exposed children for abusive injuries and (b) inform research methods to engage IPV victims and their children. The objectives of this study were to implement and to evaluate the family violence CAB. Following best practices on CAB formation, we recruited local stakeholders with key roles as service providers, community leaders, and knowledge experts in IPV, child abuse, and emergency care. Fourteen members met bimonthly to develop a family-centered intervention and to inform research and advocacy activities. A shared memorandum of understanding outlined goals and objectives. One year after the CAB's implementation, a research assistant interviewed CAB members to understand their experiences, perceived benefits of participation, and desired improvements. Eleven CAB members, including an IPV survivor, participated. Emerging categories included (a) motivations to join the CAB (victim advocacy), (b) benefits of participation (development of relationships among members and increased acceptability of research methods), (c) facilitators of sustainability (program adaptability and development of trust), and (d) desired improvements (case-based follow-up). The CAB was successfully implemented and facilitated the development of collaborative relationships among stakeholders with key roles in IPV and child abuse. The CAB led to community member-proposed changes in research activities and clinical care for victims of IPV.

Evaluation of Children after Caregiver Intimate Partner Violence: A Qualitative Study of Barriers, Facilitators, and Trauma- and Violence-Informed Care.

OBJECTIVE: To identify barriers and facilitators of evaluating children exposed to caregiver intimate partner violence (IPV) and develop a strategy to optimize the evaluation. STUDY DESIGN: Using the EPIS (Exploration, Preparation, Implementation, and Sustainment) framework, we conducted qualitative interviews of 49 stakeholders, including emergency department clinicians (n = 18), child abuse pediatricians (n = 15), child protective services staff (n = 12), and caregivers who experienced IPV (n = 4), and reviewed meeting minutes of a family violence community advisory board (CAB). Researchers coded and analyzed interviews and CAB minutes using the constant comparative method of grounded theory. Codes were expanded and revised until a final structure emerged. RESULTS: Four themes emerged: (1) benefits of evaluation, including the opportunity to assess children for physical abuse and to engage caregivers; (2) barriers, including limited evidence about the risk of abuse in these children, burdening a resource-limited system, and the complexity of IPV; (3) facilitators, including collaboration between medical and IPV providers; and (4) recommendations for trauma- and violence-informed care (TVIC) in which a child's evaluation is leveraged to link caregivers with an IPV advocate to address the caregiver's needs. CONCLUSIONS: Routine evaluation of IPV-exposed children may lead to the detection of physical abuse and linkage to services for the child and the caregiver. Collaboration, improved data on the risk of child physical abuse in the context of IPV and implementation of TVIC may improve outcomes for families experiencing IPV.

Bruising in Infants: An Approach to the Recognition of Child Physical Abuse.

Infants (children <12 months of age) are maltreated at more than twice the rate of any other child age group, and infants die because of maltreatment at 3 times the rate of any other age group in childhood. The incidence of hospitalization for serious physical abuse in children also is highest for infants. Successful recognition of medically mild signs of physical abuse in infants, such as certain bruising patterns, can, therefore, lead to lifesaving interventions. The importance of the recognition of medically mild injuries due to physical abuse is underscored by the finding that a high percentage of infants (27.5%) hospitalized with serious physical abuse were found to have previously sustained milder injuries, such as bruising. Clinicians must be aware of patterns of bruising suggestive of abuse to distinguish between infants who have been abused and those who have been accidentally injured. To maximize the likelihood that abused infants will be identified and protected, as well to minimize the likelihood that an accidentally injured infant will be mischaracterized as abused, the application of an evidence-based approach to the evaluation of bruised infants should be applied. A consistent, evidence-based practice in this setting also may reduce the influence of racial and socioeconomic bias and decrease disparities in care.

Early Involvement of the Child Protection Team in the Care of Injured Infants in a Pediatric Emergency Department.

BACKGROUND: Physical abuse is a significant cause of infant morbidity and mortality. Early detection in the emergency department (ED) is crucial. OBJECTIVE: We describe the impact of a clinical pathway focused on early involvement of the child protection team (CPT) and social work (SW) team for infants presenting to a pediatric emergency department with an injury concerning for abuse. METHODS: The pathway lists 10 injuries associated with abuse in infants and directs consultation of the CPT and SW. It was implemented at a single site on April 1, 2014. Seasonally matched data were collected 12 months before and after implementation on all children < 12 months of age with a qualifying injury. Demographics, CPT and SW consults, referral to Child Protective Services, diagnostic studies, and ultimate determination of abuse by the CPT were collected. RESULTS: Implementation of the pathway was associated with an increase in consultation of the CPT from 17% to 47% (p < 0.001) and SW from 33% to 52% (p < 0.001). CPT and SW consultations were obtained more frequently for those on public compared to private insurance prior to implementation but not after (CPT: odds ratio [OR] 4.32; p = 0.046; 95% confidence interval [CI] 1.03-18.15; SW: OR 3.23, p = 0.034; 95% CI 1.09-9.74). Diagnostic testing increased in the post-pathway period. There was no difference in the detection of abusive injury or number of missed cases. CONCLUSIONS: These findings suggest that this clinical pathway was successful in increasing involvement of the CPT and SW teams and reducing socioeconomic disparity in the evaluation of infants with injuries concerning for abuse.

What Do Pediatricians Tell Parents About Bed-Sharing?

Background and objectives Despite the risks of bed-sharing, little is known about what pediatricians tell parents about bed-sharing with infants and whether pediatricians provide specific recommendations outlined by the American Academy of Pediatrics (AAP). This study aimed to understand pediatricians' opinions about bed-sharing and the advice pediatricians provide to parents about bed sharing. Methods The study employed a qualitative study design and the conceptual framework of the Theory of Planned Behavior. 24 primary care pediatricians from a variety of practice settings were interviewed about the anticipatory guidance they provide to families whose infants are in the at-risk age group for SIDS. Results Pediatricians' opinions about bed-sharing differed widely both with respect to identifying bed-sharing as a topic they routinely address in anticipatory guidance as well as in what they tell parents about bed sharing. Some strongly and routinely advise against bed-sharing and identify bed-sharing as a clear risk to infants. Others believe bed-sharing to be both safe and useful. A third group allow the content of anticipatory guidance to be driven by parental concerns. Most pediatricians are clearer in their recommendation to place infants supine to sleep than in their recommendation to avoid bed-sharing. Conclusions Overall, there is considerable variation among pediatricians in the advice they provide about bed-sharing, and most advice is not congruent with the AAP recommendations. Additional efforts to educate pediatricians may be necessary to change attitudes and behaviors with respect to anticipatory guidance about safe sleep.

Barriers and Facilitators to Detecting Child Abuse and Neglect in General Emergency Departments.

STUDY OBJECTIVE: Child abuse and neglect is common in the United States, and victims often present to emergency departments (EDs) for care. Most US children who seek care in EDs are treated in general EDs without specialized pediatric services. We aim to explore general ED providers' experiences with screening and reporting of child abuse and neglect to identify barriers and facilitators to detection of child abuse and neglect in the ED setting. METHODS: We conducted 29 semistructured interviews with medical providers at 3 general EDs, exploring experiences with child abuse and neglect. Consistent with grounded theory, researchers coded transcripts and then collectively refined codes and identified themes. Data collection and analysis continued until theoretical saturation was achieved. RESULTS: Barriers to recognizing child abuse and neglect included providers' desire to believe the caregiver, failure to recognize that a child's presentation could be due to child abuse and neglect, challenges innate to working in an ED such as lack of ongoing contact with a family and provider biases. Barriers to reporting child abuse and neglect included factors associated with the reporting process, lack of follow-up of reported cases, and negative consequences of reporting such as testifying in court. Reported facilitators included real-time case discussion with peers or supervisors and the belief that it was better for the patient to report in the setting of suspicion. Finally, providers requested case-based education and child abuse and neglect consultation for unclear cases. CONCLUSION: Our interviews identified several approaches to improving detection of child abuse and neglect by general ED providers. These included providing education through case review, improving follow-up by Child Protective Services agencies, and increasing real-time assistance with patient care decisions.

Diagnosing abusive head trauma: the challenges faced by clinicians.

This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.

Natural Language Processing - A Surveillance Stepping Stone to Identify Child Abuse.

OBJECTIVE: We aimed to refine a natural language processing (NLP) algorithm that identified injuries associated with child abuse and identify areas in which integration into a real-time clinical decision support (CDS) tool may improve clinical care. METHODS: We applied an NLP algorithm in "silent mode" to all emergency department (ED) provider notes between July 2021 and December 2022 (n = 353) at 1 pediatric and 8 general EDs. We refined triggers for the NLP, assessed adherence to clinical guidelines, and evaluated disparities in degree of evaluation by examining associations between demographic variables and abuse evaluation or reporting to child protective services. RESULTS: Seventy-three cases falsely triggered the NLP, often due to errors in interpreting linguistic context. We identified common false-positive scenarios and refined the algorithm to improve NLP specificity. Adherence to recommended evaluation standards for injuries defined by nationally accepted clinical guidelines was 63%. There were significant demographic differences in evaluation and reporting based on presenting ED type, insurance status, and race and ethnicity. CONCLUSIONS: Analysis of an NLP algorithm in "silent mode" allowed for refinement of the algorithm and highlighted areas in which real-time CDS may help ED providers identify and pursue appropriate evaluation of injuries associated with child physical abuse.

Resilience Curriculum Improves Skills of Pediatric Fellows in Delivery of Difficult News.

BACKGROUND: Delivering difficult news to families is an essential but challenging skill. Pediatric trainees report limited confidence in this skill and perform poorly in simulation. We implemented the American Academy of Pediatrics (AAP) Resilience Curriculum and evaluated performance and self-efficacy in delivering difficult news. METHODS: The AAP Resilience Curriculum, using the SPIKES (Set-up, Perception, Invitation, Knowledge, Empathy, and Summary) framework, was taught to pediatric fellows. Fellows' performance during simulations with standardized patients before and after curriculum implementation was scored with a SPIKES checklist. Pre- and post-test surveys assessed self-efficacy in delivering difficult news. RESULTS: Fellows (n=19) significantly improved their performance in delivering difficult news, increasing the median SPIKES checklist scores from 78% to 90% completion (P<0.001). Pediatric fellows (n=35) reported improved confidence from 3.4/5 to 3.9 (P=0.01). CONCLUSIONS: Pediatric fellows demonstrated significant improvement in their ability to deliver difficult news during a simulated patient encounter and reported increased self-efficacy in delivering difficult news.

Identification of physical abuse cases in hospitalized children: accuracy of International Classification of Diseases codes.

OBJECTIVE: Hospital discharge databases are being increasingly used to track the incidence of child physical abuse in the United States. These databases use International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to categorize illnesses and injuries in hospitalized patients. We assessed the accuracy of the assignment of these codes for cases of child physical abuse. STUDY DESIGN: Participants were all children (N = 133) evaluated by a child abuse pediatrician (CAP) for suspicion of abuse at Yale-New Haven Children's Hospital from January 1, 2007-December 31, 2010. These children included both those judged to have injuries from abuse and those judged to have injuries accidental/medical in nature. We compared the ICD-9-CM codes entered in the hospital discharge database for each child with the decisions made by the CAPs, as documented in their child abuse registry. The CAPs' decisions were considered to be the gold standard. Sensitivity and specificity were calculated. Medical records were reviewed for cases in which the ICD-9-CM codes disagreed with the CAP's decision. RESULTS: In 133 cases of suspected child physical abuse, the sensitivity and specificity of ICD-9-CM codes for abuse were 76.7 % (CI 61.4%, 88.2%) and 100% (CI 96.0%, 100%), respectively. Analysis of the 10 cases of abuse not receiving ICD-9-CM codes for abuse revealed that errors in physician documentation (n = 5) and in coding (n = 5) contributed to the reduction in sensitivity. CONCLUSIONS: Despite high specificity in identifying child physical abuse, the sensitivity of ICD-9-CM codes is 77%, indicating that these codes underestimate the occurrence of abuse.

Frequency of injuries in a voluntary program evaluating young children exposed to intimate partner violence.

OBJECTIVE: Intimate partner violence (IPV) affects 1 in 4 American women, and physical child abuse is reported to occur in 10-67 % of homes with IPV. Routine evaluation of physical abuse in IPV-exposed children is neither widespread nor informed by clinical guidelines. Thus, the true frequency of detectable injuries in IPV-exposed children remains unknown. The purpose of this study was to examine the frequency of injuries in children <3-years-old reported for IPV to a regional child protective services (CPS) office. METHODS: In this prospective observational study, we reviewed encounters of children whose caregivers agreed to an evaluation for injuries (physical exam and imaging, if indicated) from July 2019-June 2022. Children were included if: 1) a CPS investigator referred a child for evaluation for injuries ("non-acute" evaluation) or 2) a child presented immediately after an IPV incident ("acute" evaluation). RESULTS: Of 326 children <3-years-old reported to the CPS office after IPV exposure, 90 (27.6 %) were evaluated: 81(90 %) presented for a non-acute evaluation, and 21(23 %) were reported to have sustained trauma during the IPV event. Of the 90 children evaluated, 3 (3.3 %, 95 % CI 0.7-9.4) were found to have cutaneous injuries, fractures, and/or intracranial findings. Each was <6-months old and had an "acute" evaluation. CONCLUSION: In this study of children reported to CPS for IPV exposure, a small percentage was found to have injuries. A multi-center study that examines the frequency of and factors that increase the risk of abusive injuries in IPV-exposed children may ensure that testing targets children at highest risk.

Hospital Admissions for Abusive Head Trauma Before and During the COVID-19 Pandemic.

Importance: Several studies have demonstrated a decrease in the occurrence of child abuse in the US since the start of the COVID-19 pandemic. This finding has generated concern for missed cases due to the initial lockdowns and lack of childcare resources. Determining the association of the pandemic on hospitalizations for severe forms of abuse is essential to focus preventive efforts. Objective: To examine trends in abusive head trauma (AHT) before and during the COVID-19 pandemic. Design, Setting, and Participants: Retrospective, multicenter, repeated cross-sectional study, conducted January 1, 2016, through April 30, 2022, with data from tertiary care children's hospitals and contributors to the Pediatric Health Information System. Data were obtained for 2380 hospitalizations of children younger than 5 years with International Classification of Diseases, Tenth Revision, Clinical Modification codes for both abuse and head trauma. Main Outcomes and Measures: Monthly hospitalizations were analyzed using interrupted time-series analysis. Hospitalization severity (eg, intensive care unit stay) and clinical characteristics (subdural hemorrhages and retinal hemorrhages) were compared before and after the start of the pandemic. Results: We identified 2380 hospitalizations due to AHT (median age, 140 [IQR, 75.0-325.5] days) from 45 hospitals. The mean (SD) monthly incidence of AHT was 34.3 (5.8) before the COVID-19 pandemic compared with 25.6 (4.2) during COVID-19 (a 25.4% decrease). When the pre-COVID-19 and during COVID-19 periods were compared, there were no significant differences in severity or clinical characteristics. On interrupted time-series analysis, there was a significant decrease in the number of monthly hospitalizations (-8.1; 95% CI, -12.41 to -3.72; P < .001) in the first month of the pandemic. In the subgroup of children younger than 1 year, there was a significant decrease in monthly hospitalizations at the onset of the pandemic (-8.2; 95% CI, -12.02 to -4.43; P < .001) followed by a significant temporal increase across the COVID-19 period (P = .01). Conclusions and Relevance: The findings of this cross-sectional study suggest there was a significant decrease in monthly hospitalizations for AHT following the start of the pandemic in March 2020. Although there was no corresponding increase in hospitalization severity, the decrease during the pandemic may have been transient, as monthly hospitalizations for children younger than 1 year increased significantly over time during COVID-19, after the initial decrease.

Child safety assessments during a caregiver's evaluation in emergency departments after intimate partner violence.

BACKGROUND: Physical abuse of children is reported to occur in 30%-60% of homes with intimate partner violence (IPV). IPV in adult victims presenting to emergency departments (EDs) represents a critical opportunity to evaluate for child safety. OBJECTIVES: The primary objective was to determine the frequency of child safety assessments (CSAs), defined as any documented inquiry about the presence of children in the household, when adults presented to EDs for IPV. The secondary aims were to assess (1) the impact of demographic factors, ED type, and social work (SW) involvement on the likelihood of CSAs; (2) the nature of children's exposure; and (3) the frequency of child protective services (CPS) reports. METHODS: We performed a chart review of encounters with ICD-10-CM codes for patients aged 18-60 with IPV presenting to three EDs in Connecticut from 2017 through 2019. RESULTS: CSAs were completed in 179/277 encounters (78.9%) and were more likely to be completed in encounters with SW involvement than without (162/171 [94.7%] vs. 17/56 [30.3%], p < 0.001). A total of 143 children lived in the home at the time of the incident; of the 107 children for whom the nature of exposure was known, 10 (9.3%) were physically involved and 26 (24.2%) were direct witnesses to the violence. CPS reports were made in 52.4% of the encounters in which children lived in the home. CONCLUSIONS: CSAs were omitted in one-fifth of encounters for IPV. Given the high prevalence of children involved in IPV episodes, ED encounters for IPV represent an opportunity to improve the safety of children.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice.

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors' actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a qualitative study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors' behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner's autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

Proxy Detection of Resident Burnout by Program Directors and Domestic Partners.

BACKGROUND: Resident burnout is associated with increased incidence of depression, suicide, and poor patient outcomes, yet identification of it is difficult. This study was designed to compare how well program directors (directors) and a resident's spouse or domestic partner (partner) can serve as a proxy to identify burnout in the resident. STUDY DESIGN: An electronic survey, including the Maslach Burnout Inventory, was distributed to residents, their partners, and directors of all ACGME-accredited residencies at a single university-affiliated hospital. Burnout rates were compared with McNemar's test. Emotional exhaustion and depersonalization rates were compared with Spearman's correlation. RESULTS: The response rate by respondent type was 33% (292 of 876) for residents, 48% (55 of 114) for partners, and 57% (13 of 23) for directors. Residents' self-reported burnout rate was 51% (148 of 292), while partners' proxy predicted burnout rate was 25% (14 of 55), and directors' was 5% (9 of 174). There was moderate correlation of partners' prediction of resident emotional exhaustion (ρ = 0.537, p < 0.01), depersonalization (ρ = 0.501, p < 0.01), and personal accomplishment (ρ = 0.416, p < 0.01). There was poor correlation of directors' prediction of residents' emotional exhaustion (ρ = 0.361, p < 0.01) and depersonalization (ρ = 0.223, p < 0.01). Partners had a 50% sensitivity, 94% specificity, 86% positive predictive value, and 71% negative predictive value in predicting resident burnout. Directors had a 6% sensitivity, 96% specificity, 56% positive predictive value, and 54% negative predictive value in predicting resident burnout. CONCLUSIONS: Directors are not skilled in detecting burnout in their trainees. Partners are an underused group for detecting burnout and may represent an important target audience for awareness of available resources to benefit residents.