Letters
Emergency medicine Child health
Volume 200 - Issue 1

Fortnightly emergency department case-file audit for timely detection of missed cases of suspicious injury

Authors:  Amanda Gwee, Benjamin Coghlan, Cate Rayner, Anne Smith and David Krieser

Med J Aust 2014; 200 (1): 23. || doi: 10.5694/mja13.10303
Published online: 20 January 2014
Finding missed cases of possible child abuse is a positive outcome from fortnightly review of ED case files for children
Download PDF (170 KB)
Share: Share on Blue Sky Share on Facebook Share on LinkedIn Share by email

To the Editor: A key role of emergency department (ED) doctors who assess injured children is to determine if abuse or neglect could have caused or exacerbated an injury. Physically abused children have a median of one to two ED presentations before non-accidental injury is diagnosed.1 Better identification may be life-saving, as repeat injury occurs in up to 70% of cases.2 We assessed the impact of a fortnightly review of the case files of young children who presented to the ED with injury on the detection of cases of possible non-accidental injury.

Every fortnight over 12 weeks (31 August to 22 November 2011), we retrospectively identified all children aged 0–3 years who attended our hospital ED with an injury. Case files were reviewed in two stages: (1) a paediatric registrar and paediatric emergency physician reviewed each case file and classified the child’s injury as “suspicious” or “not suspicious” for non-accidental injury based on predefined criteria developed from the literature; and (2) a paediatric forensic expert reviewed the files of cases suspicious for non-accidental injury that had not already been identified and appropriately managed by ED staff, and advised on follow-up for the child. This included evaluation by the Victorian Forensic Paediatric Medical Service (VFPMS), referral to the statutory child protection service (CPS), or voluntary referral to social support (Child FIRST). Ethics approval was obtained from the Melbourne Health and Western Health Human Research Ethics Committees (HREC 2011.135).

Our findings are summarised in the Box. During the study period, 176 children aged 0–3 years presented with a physical injury; 23 cases (13%) were classified as highly suspicious for non-accidental injury after Stage 1; and in Stage 2, seven of 15 highly suspicious cases not initially referred to forensic services were followed up with evaluation by VFPMS (four children), referral to ChildFIRST (one) or referral to the CPS (two).

Our case-file review identified missed cases of non-accidental injury, allowing protective intervention to be initiated. Checklists and flow charts have been shown to improve detection of suspected cases of non-accidental injury,3 but these tools require staff compliance and training.4 While our process avoids these requirements, it is still dependent on the quality of injury documentation. Also, confidentiality issues meant that we do not know if suspicious cases were confirmed.

Our study was designed to ensure universal case-file review of every injured child aged less than 3 years to allow prompt referral to the CPS. Ideally, this review process should be carried out more frequently, but intervention delayed by a maximum of 2 weeks is preferable to no intervention. This approach does not replace the need to improve education and training of clinicians, but could be a useful adjunct to improve the detection of non-accidental injury in EDs.

Summary of a fortnightly ED case-file audit from 31 August to 22 November 2011 to identify cases suspicious for non-accidental injury in children aged 0–3 years

Child FIRST = Child and Family Information, Referral and Support Teams. ED = emergency department. VFPMS = Victorian Forensic Paediatric Medical Service.

Authors

  • Amanda Gwee1
  • Benjamin Coghlan2
  • Cate Rayner1
  • Anne Smith3
  • David Krieser1
  • 1. Department of Emergency Medicine, Sunshine Hospital, Melbourne, VIC.
  • 2. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC.
  • 3. Victorian Forensic Paediatric Medical Service, Melbourne, VIC.

Correspondence: amanda.gwee@rch.org.au

Competing interests

No relevant disclosures.

Acknowledgements

We thank the Windermere foundation for providing the funding for this study.

References

View this article on Wiley Online Library

More like this

View more