Hospital-wide patient safety programs, such as an antibiotic stewardship or anticoagulant monitoring programs, are frequently used to ensure consistent and appropriate care. In these programs, there is continual review of the data to assure that, hospital-wide, patient care is appropriate.
Children’s Mercy Hospital in Kansas City initiated such a program for the identification of child maltreatment. Dr. Jennifer Hansen and her colleagues at Children’s Mercy and University of Kansas describe the program, including outcomes, in an article that Pediatrics is early releasing this week (10.1542/peds.2021-050555).
In this program, if any staff member in the emergency department, urgent care, inpatient service, or ambulatory clinic had concerns for child maltreatment, a hospital social worker completed a “Patient at Risk” (PAR) form in the electronic medical record. It is important to note that not all children with PARs were referred to CPS. However, this served to engage the child and family in the child maltreatment safety program.
Each PAR was reviewed by the hospital child abuse and protection (CAP) team within 24 hours, and it was determined if additional information or intervention (e.g., immediate callback to the family; need for consult; need for CPS referral) was needed.
Over 30 months, nearly 8,000 PARs were completed. While you will want to read the entire article to learn the other details, I want to tell you about the 46 children who received immediate callbacks and returned to CAP clinic; 39% (18/46) had their diagnosis changed – in 17/18 cases, this diagnosis changed from a non-abuse diagnosis to an abuse diagnosis!
We asked Dr. Nancy Kellogg and Dr. Natalie Kissoon from UT-Health San Antonio to provide a commentary on this article (10.1542/peds.2021-051583). They note that hospital staff may be reluctant to report cases of potential maltreatment to Child Protective Services, because of the potential implications of such a report. A hospital-wide safety program removes that emotional burden and angst from the hospital staff. They can file an internal report, knowing that the report does not necessarily mean that the child will be taken out of the home but allowing for additional information-gathering to determine if a referral is needed.
Drs. Kellogg and Kissoon also note that such a hospital-wide patient safety program is probably only possible in larger children’s hospitals that have social workers in-house 24/7. Smaller hospitals without those resources, let alone CAP specialists, will need different strategies – perhaps having a PAR system and then teaming up with CAP specialists at a larger center to review these cases.
One thing seems clear. We’re probably all missing cases of child maltreatment, and we need better systems to ensure that these children don’t fall through the cracks.
