Education and debate

Simple intervention to improve detection of child abuse in emergency departments

Jonathan R Benger, specialist registrar in emergency medicine, ^a Alison V Pearce, specialist registrar in paediatrics. ^b

^a Emergency Department, Frenchay Hospital, Bristol BS16 1LE, ^b Department of Community Child Health, Frenchay Hospital, Frenchay, Bristol BS16 1LE

Correspondence to: J Benger, Emergency Department, Bristol Royal Infirmary, Bristol BS2 8BW JB{at}sectae.org.uk

Problem: Child abuse is easily overlooked in a busy emergency department.
Design: Two stage audit of 1000 children before and after introduction of reminder flowchart.
Background and setting: An emergency department in a suburban teaching hospital seeing about 4000 injured preschool children a year.
Key measures for improvement: Number of records in which intentional injury was adequately documented and considered and the number of children referred for further assessment before and after introduction of reminder flowchart into emergency department notes.
Strategies for change: Nurses were asked to insert a reminder flowchart for assessing intentional injury into the notes of all children aged 0-5 years attending the department with any injury and to record the results of checking the child protection register.
Effect of change: Documentation of all eight indicators that intentional injury had been considered had increased in the second audit. Records of compatibility of history with injury and consistency of history increased from less than 2% to more than 70% (P<0.0001). More children were referred for further assessment in the second audit than the first, although the difference was not significant (6 (0.6%) v 14 (1.4%), P=0.072). The general level of awareness and vigilance increased in the second audit, even for children whose records did not contain the flowchart.
Lessons learnt: Inclusion of a simple reminder flowchart in the notes of injured preschool children attending the emergency department increases awareness, consideration, and documentation of intentional injury. Rates of referral for further assessment also increase.