JOHNS HOPKINS ALL CHILDREN’S HOSPITAL Physical Child Abuse Clinical Pathway Johns Hopkins All Children’s Hospital Physical Child Abuse Clinical Pathway Table of Contents: 1. Rationale 2. Background 3. Medical Risk Assessment for Child Abuse and/or Neglect 4. Risk Assessment for Possible Child Abuse and/or Neglect 5. How to Make a Report to the Florida Department of Children and Families Child Abuse Hotline 6. Clinical Evaluation for Suspected Physical Child Abuse, By Injury Type 7. Clinical Evaluation for Suspected Physical Child Abuse, By Age 8. Clinical Evaluation Footnotes 9. Non-Accidental Trauma Information and Evaluation Process 10. Disposition 11. Inpatient Check List 12. Algorithm for Suspected Child Abuse and/or Neglect 13. Patient Status 14. Documentation/Coding 15. Outcomes 16. Order Set and PowerPlan 17. References Last updated: June 4, 2019 Owners: Charles Eldridge, MD; Danielle Mercurio, DO; Holly Wasilenko, LCSW This pathway is intended as a guide for physicians, physician assistants, nurse practitioners and other healthcare providers. It should be adapted to the care of specific patient based on the patient’s individualized circumstances and the practitioner’s professional judgment. 2 Johns Hopkins All Children’s Hospital Physical Child Abuse Clinical Pathway Rationale This clinical pathway was developed by a working group consisting of members from pediatric emergency medicine, child protection team and social work to standardize the management of children with possible physical child abuse or neglect. It addresses the following clinical ques- tions or problems: 1. Identify which injured children require a non-accidental trauma evaluation. 2. Which laboratory and imaging studies to obtain when non-accidental trauma is sus- pected. 3. Which types of subspecialty care is needed for each patient. 4. When to report and the resources available at JHACH regarding non-accidental trauma patients. 5. Understand the various roles of individuals involved in non-accidental trauma patients, including the social worker, the child protection investigator (CPI) and the child protec- tion team (CPT). 6. Provide clear and precise treatment options and follow up needs for every patient who receives a clinical evaluation for non-accidental trauma. Background Child abuse, neglect, and sexual assault can pose a risk to a child’s health, ultimately impact- ing the child’s development. Therefore a thorough history (interviews with patient and/or fam- ily, how the injury occurred, etc.) and examination of the injured children is essential. This practice guideline will outline the essential elements of the evaluation for non-accidental trauma. Once the child has been stabilized and the identification of physical abuse through di- agnostic methods has occurred then treatment, intervention, and protection should be pro- vided to the patient. 3 Medical Risk Assessment for Child Abuse and/or Neglect Higher Risk Situations for Non-Accidental Trauma “Red Flag” History of Present Injury “Red Flag” Radiographic Findings Inconsistent or changing history Metaphyseal fractures (corner) Unwitnessed injury Rib fractures (especially lateral and posterior) in infants Delay in seeking care Any fracture in a non-ambulating infant Prior ED visit An undiagnosed healing fracture Domestic Violence in home SDH and/or SAH on neuro-imaging in young children, Premature infant (<37 weeks) particularly in the absence of skull fracture <1 year Low birth weight/IUGR Complex or depressed skull fractures Chronic medical conditions Vertebral fractures Injury not consistent with reported mechanism Sternal fractures Injury not compatible with developmental age Multiple fractures Previous DCF Involvement Femur or scapula fractures in patients <15 months “Red Flag” Physical Exam Findings Torn frenulum FTT (weight, length, head circumference) Large heads in fussy infants (consider head circumference in children < 1 yr) Any bruise in any non-ambulating child- “if you don’t cruise you don’t bruise” Any bruise in a non-exploratory location. Think: TEN-FACES, especially in a <4 yo Torso (area covered by a standard girl’s bathing suit), Ears, Neck, Frenulum, Angle of jaw, Cheek, Eyelid, Subconjunctiva, Bruises, marks, or scars in patterns that suggest hitting with an object, hand or fist Multiple injuries to multiple organ systems or multiple parts of body Patterned or circumferential burns Adult bite marks (inter-canine distance >3cm, arch width >4cm) Special Considerations for Non-Accidental Trauma Patients: Do siblings require evaluation? • Discuss with Social Work and CPT • Make arrangements with Emergency Center Charge Nurse/Attending (#7-7280). If NAT is of concern for an admitted patient, consult Trauma Team as soon as possible. If NAT is of concern for a patient who presents for outpatient services not already referred to JHACH by CPT (OCC, Radiology, Phlebotomy, Audiology) call Social Work (#7-4147) & make arrangements for Emergency Center evaluation (#7-7280). If patient from EC or direct admit to PICU, must be admitted to either the Trauma or Neurosurgery Service for at least 24 hours. Prior to discharge from inpatient or EC, the care team should discuss disposition and follow up appointments with social work for patient safety. If there are special circumstances, JHACH Transfer Center is available 24/7 to connect you with an EC or child protection specialist at 727-767-7337. 4 Risk Assessment for Possible Child Abuse and/or Neglect Automatic referral to Social Work Consult Social Work Consult Social Work at the discretion of the Hotline Report To Be Made Risk assessment will be completed by physician. Social Work to determine if Hotline report should be made Skull * Complex fractures * Linear fractures in children under the age * Linear fractures over Frac- * Depressed skull fractures of 15 months the age of 15 months tures * Multiple fractures or fractures which cross * Linear fractures associated with other inju- * Fractures with a verifi- suture lines ries able mechanism * Skull fractures with intracranial hemorrhage Upper * Scapula fractures * Spiral fractures of humerus, > 15 months Other upper extremity Extremi- * Humerus fractures, child < 15 months * Humerus, radius and ulna fractures associ- fractures (e.g. older chil- ties * “Corner” or “bucket handle” fractures ated with dren) other injuries * Radius/ulna fractures < 15 months * Metacarpal/phalangeal fractures, < 15 months without external evidence of trauma Ribs * Lateral and posterior rib fractures under * Clavicle fracture in infant >1 month and < Other fractures of the and age 5 15 months trunk Spine * Sternum fractures * Clavicle fracture, medial 1/3 * Vertebral fractures * Pelvis fracture if history is uncertain * Metatarsal fractures <4 years old Lower * Femur fractures < 15 months * Femur fractures >15 months and <= 4 Other lower extremity Extrem- * “Corner” and/or “ bucket handle” fractures years, no witness other than caretaker fractures ity * Tibia/fibula fractures in non-ambulatory in- fants * Fractures associated with other injuries Bruises * All bruises with a handprint or fist pattern * Bruises in non-ambulatory infants Other bruises that raise * All bruises which suggest an object; whip, * Bruises that involve soft areas instead of concern (e.g. large, mul- belt, stick, buckle, cord, etc. the usual bony prominences tiple, etc.) * Bruises with linear and/or petechial compo- nents Burns * Pattern burns (except palm burns from * Burns which may have been caused by a Other burns that raise stove top burner) e.g. grid, flame cigarette concern (e.g. large, mul- * Pattern burns from iron or curling iron of the * Other hot liquid burns > 3 cm diameter. tiple. etc.) dorsum of hand, back, or buttocks (Accidental scald burns usually have a V * Circumferential burns of hand or feet: shape as the liquid cools and flows with stocking/glove patterns gravity.) * Burns with poor or no history * Burns involving neglect * Other, non-glancing iron or curling iron burns * Bilateral burns e.g. both hands, both feet Other * Subdural hematomas except accidents wit- * Apparent life threatening injury in which the At the discretion of the nessed by other than caretakers history is not clear or social factors seem to physician * Blunt abdominal and/or chest trauma (ex- be present cept as above) without verifiable cause * Hair loss/baldness related to trauma * Adult bite marks (inter-canine distance >3 * Fictitious illness suspected cm or arch * History changes in the course of the work- width >4 cm) up * Catastrophic injury with history of routine * Caretakers appear incompetent or under fall the influence of substances * Delay in seeking care for a serious injury * Failure to thrive (primarily non-organic) * Anything suggesting abusive head trauma * Repeat injuries or repeat ingestions (unexplained altered state of conscious- * Injury is attributed to another child, related ness, intracranial hemorrhage, retinal hem- or non-related (Other than common minor orrhage) household injuries) 5 How to Make a Report to the Florida Department of Children and Families Child Abuse Hotline Per JHACH Clinical Policy - Handling of Child and Adult Victims of Alleged or Sus- pected Abuse, Neglect, or Abandonment (Policy # CLNPOL030). 1. If patient is receiving services at Main Hospital, OCC Clinics and Tampa Clinic, and there is concern for suspected child abuse and/or neglect, JHACH Social Work should be consulted to conduct assessment and determine need to file DCF report. 2. If JHACH staff member witnesses in-person child