Faculty, Child Abuse Pediatrics and Pediatric Emergency Medicine Nationwide Children's Hospital Columbus, Ohio, United States
Background: Overcrowding in the Pediatric Emergency Department (ED) can overwhelm staff capabilities resulting in delays in medical treatment and impact quality care. Identifying subtle abusive injuries in young children can be challenging, and lack of time may be a barrier to recognizing non-accidental trauma (NAT). Pediatric patients with abusive injuries may be missed in an overcrowded ED. Objective: Determine if a higher modified National Emergency Department Overcrowding Score (mNEDOCS) or other overcrowding measures such as ED length of stay (ED LOS), patient volumes, and rates of patients who left without being seen (LWBS), are associated with lower child protection metrics, including physical abuse reports to Child Protective Services (CPS), skeletal surveys (SS), or hospital Child Protection Team (CPT) consults. Design/Methods: Retrospective chart review of ED encounters from January 1, 2019 to June 30, 2023. Overcrowding measures (mNEDOCS, ED LOS, patient volumes, and LWBS) and protection metrics for children < 5 years old (rates of CPS reports, SS, and CPT consults) of each 24-hour period were summarized using descriptive statistics. Associations between overcrowding measures and child protective metrics were assessed using Wilcoxon rank sum tests and Spearman’s correlation coefficients. Results: There were 2297 encounters with CPS reports, 1973 with SS, and 1646 with CPT consults. Days with a maximum mNEDOCS above the 75th percentile (N=299) had lower rates of CPS reports (0.5% vs 0.8% of ED encounters), SS (0.5 vs 0.7% of ED encounters, p=0.002), and CPT consult orders (0.5% vs 0.8% of ED encounters) than days below the 25th percentile. Increased modified NEDOCS was negatively correlated with CPS reports (rho=-0.14), CPT consults (rho=-0.16), and SS (rho=-0.1).
Patient volume was inversely correlated with CPT consults (rho=-0.21), CPS reports and SS (both rho=-0.17). ED LOS correlated negatively with CPS reports (rho=-0.1), SS (rho=-0.09), and CPT consults (rho=-0.11). LWBS rates correlated with fewer CPS reports, SS, and CPT consults (rho=-0.11, rho=-0.12, and rho=-0.13). All p-values < 0.001 unless otherwise stated.
Conclusion(s): All four metrics of ED overcrowding were correlated with all three lower child protection metrics. These findings highlight the subtle nature of NAT and increased risk of missing injuries during busy times. Future interventions could focus on evaluating clinical decision support to improve NAT recognition during peak census.
