Integration of physical abuse clinical decision support into the electronic health record at a Tertiary Care Children's Hospital

Abstract

Objective: To evaluate the effect of a previously validated electronic health record-based child abuse trigger system on physician compliance with clinical guidelines for evaluation of physical abuse.

Methods: A randomized controlled trial (RCT) with comparison to a preintervention group was performed. RCT-experimental subjects' providers received alerts with a direct link to a physical abuse-specific order set. RCT-control subjects' providers had no alerts, but could manually search for the order set. Preintervention subjects' providers had neither alerts nor access to the order set. Compliance with clinical guidelines was calculated.

Results: Ninety-nine preintervention subjects and 130 RCT subjects (73 RCT-experimental and 57 RCT-control) met criteria to undergo a physical abuse evaluation. Full compliance with clinical guidelines was 84% pre-intervention, 86% in RCT-control group, and 89% in RCT-experimental group. The physical abuse order set was used 43 times during the 7-month RCT. When the abuse order set was used, full compliance was 100%. The proportion of cases in which there was partial compliance decreased from 10% to 3% once the order set became available (P = .04). Male gender, having >10 years of experience and completion of a pediatric emergency medicine fellowship were associated with increased compliance.

Discussion/conclusion: A child abuse clinical decision support system comprised of a trigger system, alerts and a physical abuse order set was quickly accepted into clinical practice. Use of the physical abuse order set always resulted in full compliance with clinical guidelines. Given the high baseline compliance at our site, evaluation of this alert system in hospitals with lower baseline compliance rates will be more valuable in assessing the efficacy in adherence to clinical guidelines for the evaluation of suspected child abuse.

Figure 1.

(A) The orders which are added to Cerner when a patient triggers the CA-CDSS. These orders are for the nurse to complete. (B) The pop-up alert received by the physician/APP when a child triggers the CA-CDSS. (C) The main ED Physical Abuse Order Set/Power Plan screen that a provider sees when they select “yes” from the pop-up alert or when searching for the order set in the order catalog. Providers need to check the relevant box next to the subphase in order to get the complete order set for that injury. The darker highlighting reflects 3 sections of the order set—single injuries concerning for abuse, injuries which are concerning for abuse, but not included in the list above and multiple injury types. (D) The “Bruise/petechiae in a child who is not yet cruising” subphase of the order set. Some of the orders are prechecked and some orders have instructional notes. (E) The “Fracture in a child who is not yet cruising” subphase of the order set.

Figure 2.

Flowchart of all subjects in the RCT.