Date of Award


Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Gunjan Tiyyagura

Second Advisor

Andrea Asnes


Background: Child abuse guidelines exist to help emergency department (ED) providers evaluate injured children for suspected child abuse. Little is known about the impact of these guidelines on provider decision-making in pediatric (PED) and community EDs (CEDs). Objective: To evaluate the impact of a child abuse guideline in pediatric and community EDs through three primary studies: 1. To examine guideline adherence and the appropriateness of decision-making by CED providers. 2. To determine the impact of the guideline on differences in evaluations of infants for abuse between a PED and three CEDs. 3. To implement and assess the use of a Child Abuse Clinical Decision Support (CA-CDS) tool based on the guideline. Methods: Study 1: Two child abuse experts conducted a blinded, retrospective review of injured infants from three community EDs (n = 175). Experts rated the likelihood of abuse and made recommendations that were compared with skeletal survey (SS) testing and child protective services (CPS) reporting by providers before and after guideline implementation. Study 2: We examined infants presenting to one PED (n = 162) and three CEDs (n = 159) with three injury categories: 1) Injuries for which the American Academy of Pediatrics recommends SS testing; 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries. We assessed differences in SS testing and CPS reporting between the PED and CEDs before and after guideline implementation. Study 3: Using the Model for Improvement framework, we formed a team of leadership, champions, frontline staff, and a parent of an abused child and identified key drivers to guide implementation of the CA-CDS in nine EDs. Results: Study 1: Post-guideline implementation, there was a significant increase in CPT consultations in cases of indeterminate likelihood of abuse (14.3% vs. 72.2%, p < .001) and in SS testing when experts recommended SS (20.6% vs. 56.8%, p = .002). In contrast, a higher percentage of cases for whom the experts did not recommend reporting were reported to CPS (1.8% vs 14.6%, p = .02). Study 2: Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01-8.10; Category 2: aOR 10.1, CI: 1.2-88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3-26.7; Category 2: aOR 12.0, CI: 1.4-103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category. Study 3: The CA-CDS has been developed and refined based on user input. We continue to collect baseline data. Plans for implementation are in progress. Conclusion: A child abuse guideline linking ED providers with a child protection team improved the care of infants presenting with injuries associated with abuse by improving provider decision-making and standardizing care between pediatric and community settings. Ongoing work to implement electronic clinical decision support may sustain and augment the positive impact of the guideline across both pediatric and community EDs.


This is an Open Access Thesis.

Open Access

This Article is Open Access