From the Departments of Neurosciences (N.H., T.M.G.), Trauma Services (K.A.L., K.G., J.R., E.H., N.M.G.), Emergency Medicine (E.H.), and Pediatrics (G.E.), Dell Children's Medical Center of Central Texas; and Department of Surgery (K.A.L., N.M.G), University of Texas Southwestern Medical School, Austin, Texas; and Trauma Services (T.M.), Arkansas Children's Hospital, Little Rock, Arkansas.
J Trauma Acute Care Surg. 2014 Mar;76(3):871-7. doi: 10.1097/TA.0000000000000135.
Previous studies have found racial and socioeconomic status bias in the way clinicians screen for and detect child abuse in patients presenting to the emergency department. We hypothesized that implementing a guideline for screening would attenuate this bias.
An algorithm for child abuse screening in patients younger than 1 year presenting with fractures was developed for a pediatric trauma center emergency department. Data were collected 1.5 years before and after implementation of the algorithm to investigate implementation success. Data were compared before and after the implementation of the algorithm using χ and univariate logistic regression analysis.
The characteristics of patients with fractures were similar before and after the algorithm implementation. Implementation of the algorithm was related to a significant increase in algorithm required screenings: skeletal survey (p < 0.001), urinalysis (p < 0.001), and transaminase levels (p < 0.001). The racial composition of those screened did not change after the implementation of the protocol. Children with government-subsidized or no insurance were more likely to be screened for child abuse via skeletal survey before the algorithm implementation compared with those with private insurance (odds ratio, 2.7; 95% confidence interval, 1.2-6.0; p = 0.017). This relationship did not exist after the algorithm implementation (odds ratio, 1.2; 95% confidence interval, 0.56-2.46; p = 0.66). Final determination of child abuse was related to insurance status both before and after the algorithm implementation.
A child abuse screening algorithm was successfully implemented in an urban trauma center. After implementation, screening was no longer associated with socioeconomic status of the patient's family, although final determination of child abuse still was. Additional research is needed to determine utility of unbiased screening on patient outcomes.
Therapeutic study, level IV.
先前的研究发现，临床医生在急诊科对患者进行虐待儿童筛查和检测时存在种族和社会经济地位偏见。我们假设实施筛查指南可以减轻这种偏见。
为一家儿科创伤中心的急诊科开发了一种用于 1 岁以下因骨折就诊的患儿虐待筛查算法。在实施该算法前后收集了 1.5 年的数据，以调查实施的成功情况。使用 χ 和单变量逻辑回归分析比较算法实施前后的数据。
骨折患儿的特征在算法实施前后相似。算法的实施与算法要求的筛查显著增加有关：骨骼检查（p<0.001）、尿液分析（p<0.001）和转氨酶水平（p<0.001）。筛选人群的种族构成在实施协议后没有改变。与私人保险相比，在实施算法之前，政府补贴或没有保险的儿童更有可能通过骨骼检查筛查虐待儿童（优势比，2.7；95%置信区间，1.2-6.0；p=0.017）。在实施算法后，这种关系不复存在（优势比，1.2；95%置信区间，0.56-2.46；p=0.66）。虐待儿童的最终确定与算法实施前后的保险状况有关。
在城市创伤中心成功实施了儿童虐待筛查算法。实施后，筛查不再与患者家庭的社会经济地位相关，尽管最终确定虐待儿童仍然与保险状况相关。需要进一步研究无偏见筛查对患者结局的效用。
治疗性研究，四级。
