Nurses are key players in intervention: Don’t miss child abuse in your ED

Recognize both subtle and obvious signs for physical and sexual abuse; know how to intervene when you suspect abuse

When you suspect a child is abused, it is one of the most challenging situations you’ll encounter, both medically and emotionally, says Julie Ann Cantlon, BSN, manager of the Children at Risk Evaluation Services (CARES) at St. Luke’s Regional Medical Center in Boise, ID. "It requires thinking in a crisis about a subject that is very uncomfortable for most people," she notes.

Emergency department (ED) nurses are key players in this difficult intervention, says Elizabeth Nicholson, MS, SW, LISW, director of Care House, a child advocacy center at the Children’s Medical Center in Dayton, OH. "As a social worker in the ED setting, I am a threatening person to the family, because they can’t differentiate between me and protective services who could remove their child," she explains. "But a nurse traditionally is viewed as the least threatening member of the health care team, more so than the physician."

Nurses also have the first contact with patients, says Nicholson. "Nurses are the first responders in the ED setting, so they may have the opportunity to connect with families in a way the rest of us don’t have."

It’s imperative for nurses to be proactive in detecting child abuse, Cantlon stresses. "In addition, the Joint Commission has come out with criteria that all medical facilities need to identify, assess, treat, and plan for any victim of abuse or neglect, so we can no longer be in denial," she reports. "Also, the American Nurses Association has recognized SANEs [Sexual Assult Nurse Examiners] as a subspecialty for the first time, so there is a real recognition of forensic work done by nurses."

Abuse does not discriminate, says Michael Altieri, MD, FACEP, an ED physician at Fairfax Hospital in Falls Church, VA. "Some clinicians feel that they will see a lot of abuse if they practice in an inner city, but not in the suburbs," he notes. "The truth is that nobody is immune from abuse."

Studies have estimated that as many as one out of five children [that] come to the ED are there for reasons related to abuse, notes Altieri. "That is a staggeringly high number," he says. "Abuse takes on many faces, including physical, sexual, and emotional. It can also take the form of neglect, which accounts for about 60% of abuse cases." (See chart on categories of child maltreatment.)

Use protocols for child abuse

Protocols can ensure that appropriate steps are followed when abuse is suspected, says Brenda Barton, RN, BSN, an ED nurse who developed a protocol for child abuse at St. Luke’s Regional Medical Center. (See ED’s policy in this issue.) "We view abuse as a low frequency, high risk situation. So we have a step-by-step policy so there is no need to leave the victim from the time the evaluation is started, to turning over evidence to the police,’ she explains.

The policy also streamlines charting. "We don’t have to repeat in our charting every single thing we did. Instead, we just note evidence collected as per protocol,’" says Barton.

When abuse is suspected, a confidential cursory triage is done. "We then try to get the child back to a room as quickly as possible so we can get more in-depth information," Barton explains. "A triage system breaks it down into different groupings of sexual abuse, physical abuse, abuse without a medical complaint, and abuse with a medical complaint."

Like many EDs, St. Luke’s does not have SANES to rely on. "We don’t have a very high incidence of abuse in our population, so it’s not cost effective to have specialized people at this point," says Barton. All ED nurses receive a four-hour course on preserving evidence that is updated yearly, she notes.

In addition to collecting evidence, the patient must also receive effective medical treatment, stresses Barton. "We have instituted a policy where [we] can collect evidence but also treat the patient medically," she says. "We are one of few EDs which administer Nonoxynol 9, to individuals sexually assaulted within a 24-hour period," she says. "This has been shown in the literature and the lab to be a very effective anti-HIV agent, viricide, and spermicide."

Charts are flagged into categories of physical or sexual abuse for review. "I critique all of those, to make sure procedures were appropriately followed," says Barton. "If there is any problem area, I can tailor education of nurses to address that."

A good working relationship with community resources is key, says Barton. "If the state labs have any issues at all with the kit, they call me, so I can talk to the nurse or physician about it," she explains.

Here are some ways to improve detection and management of child abuse in the ED:

Look for inconsistencies. "There are cases when a parent or guardian is going to bring in a child and say the baby-sitter hit the child, but a case that is advertised as child abuse is the exception," says Altieri. "In the majority of child abuse cases, the story you’re given doesn’t fit with what you see. That is the biggest red flag."

For instance, an infant who has limited mobility comes in with bruises, and his parents insist he fell off the changing table, says Altieri. "But you notice bruises in multiple stages of healing, and you know the developmental abilities of a kid doesn’t fit with that because he isn’t walking around," he explains. "There is a disconnect between the history and what you’re seeing."

If a child has a femor fracture, the parents may explain it a number of ways, Altieri notes. "The parent may say, we were at the playground and he was up on the slide and fell 8 feet onto ground, hitting his leg on exposed concrete. In that case, the story fits together," says Altieri. "On the other hand, they may say he fell off the couch. In that case, you can tell them that we don’t usually see broken legs with that type of injury."

In other cases, the child may be old enough to be verbal and says something different, Altieri says. "Or you may look at the child and pull the record and [see that he or she] had three other broken bones, or this kid looks not well kept—he is dirty and looks like hasn’t had a bath in a week or [has] signs of other old injuries or bruises. So even though explanation is feasible, it throws up other red flags," he explains.

Know the link between domestic violence and child abuse. "When we find one kind of abuse, there is a 50% cross incidence rate on average for the other kind of abuse," says Cantlon. "If you find one, there should be a screening tool for the other, to see if the family needs help with that."

Recognize injuries indicative of physical abuse. "Physical findings highly suggestive of abuse include adult sized bite marks, cigarette marks, burns, certain types of fractures, multiple healing fractures, and retinal hemorrhages," says Altieri.

Involve EMS. "Listening to what ancillary personnel tell you is key," says Altieri. "If EMS brings in a child who is either injured or sick, the paramedic may tell you something about the home setting, such as that the parents were hitting the kids while EMS was interacting with the family, or that the kids looked neglected."

Don’t jump to conclusions. "As health care providers, our job is to report suspicious injury, but we are not the judge and jury," says Altieri. "I have seen nurses decide that a parent is abusing their child, and treat that parent like dirt. Later, it turns out the parent did nothing wrong."

Sometimes a child may appear to be abused, but it is later explained by a medical condition, notes Altieri. "A child came in with unexplained bruising, but we then found that he was a hemophiliac," he recalls. "Likewise, coining and cupping are used to cure different illnesses in Oriental cultures, and they may leave marks, but we wouldn’t approach that like abuse."

Remain objective despite your suspicions, advises Altieri. "It is difficult to see a child who has sustained significant injury, suspect parent is cause of it, and still be nice, but you have to remain detached and go the appropriate route," he says. "If the parent is at fault, that has to be dealt with. But we in the ED are not law enforcement. It is not for doctors or nurses to make remarks to [the] parent."

Consider photographing injuries. "Bruising can heal very quickly. What you see today may be practically gone by the following day," notes Marti Monk, RN, CEN, interview specialist at the CARES program at St. Luke’s. "Some hospital policies require parents to sign a permission form to photograph. If you don’t feel comfortable photographing, you may want to suggest that police bring a forensic photographer or proper equipment."

Don’t disrupt evidence. "Do not do anything you don’t have to do to that could destroy evidence," Cantlon stresses. "The clock is ticking because forensic evidence is usually biodegradable. For example, evidence could be lost by throwing a bloody diaper away which may contain the abuser’s semen."

Rule out alternate explanations. In addition to documenting injuries, necessary follow-up tests need to be performed. "We’ve had parents say they lifted their baby out of the bed with a fractured femor and they don’t have a clue how it happened," says Nicholson. "That would only occur if the child has osteogenesis imperfecta, and then you would see multiple fractures and other problems suggesting bone diseases."

The sign of bone disorders is slcera of a bright, robin’s-egg blue. "So when a parent says we have bone disorders in my family,’ it’s important to note what the family says about that, and also note what color the sclera is," says Nicholson. "If it’s white and normal-looking, that needs to be noted."

If a child presents with multiple bruises and the parents say he falls all the time, you need to do coagulation studies that would rule out a bleeding disorder, says Nicholson. "If the child doesn’t have a clotting problem, then he shouldn’t be covered with bruises," she notes.

Know signs of shaken baby syndrome. "Often, these babies present to the ED with symptoms that mimic other pediatric conditions," Nicholson says. "Some have a history of lethargy, respiratory distress, vomiting, or poor intake." Considering shaken baby syndrome with an infant who presents with those symptoms can be a lifesaving measure on the part of the nurse, she emphasizes.

Don’t assume injuries must exhibit external trauma. "It’s a myth that a baby has to look battered from a blunt force injury," says Nicholson. "There is often a delay in medical attention in these cases, because the child often presents with no signs of external trauma. If treatment is not begun immediately, the course has already set in, so there is less chance of saving them."

One child presented with a minor bruise in the lower abdomen. "It turned out the child was kicked in the stomach by the father who was wearing a steel toe boot, and later died from the injury," says Nicholson. "There was no major external trauma at all."

Use common sense. A lot of assessment has to do with common sense as opposed to hard facts, says Nicholson. "If something is told to you that just doesn’t ring true, you should heed it," she advises. "We respond to risk indicators and concerns we have, and a lot of it is not scientifically based."

Work as a team. Intervention is most effective when done by a multidisciplinary team, stresses Nicholson. "That starts with the ED team, but also includes whoever is called in to investigate," she says. "Nobody should shoulder the burden of these cases alone. Yes, as a nurse you are responsible for your patients, but these are complicated, challenging cases that require the involvement of these other systems. Effective intervention requires a team response."

Consider the parent’s demeanor. "When a parent blows things out of proportion and the focus is not on the child but on themselves, or a parent’s anger is directed at other people, that is something to be concerned about," says Nicholson. "It’s critical that nurses make those observations, because at that point social workers or law enforcement will probably not be present to observe it."

Act as a role model for parents. A critical role for nurses with neglected and abused children is that of a role model, advises Nicholson. "These are parents without appropriate coping skills, which has caused them to put their child at risk or injure them. Nurses can role model appropriate interactions with child in a way the parent can learn from, by distracting them, or giving them some attention. It’s very important for parents to see nurses physically doing those kinds of things."

Nurses should take the opportunity to teach parents how to care for their children, Nicholson advises. "It’s ironic that when a child comes in who is filthy and hasn’t been bathed, nurses will race off to clean the child, but we leave the parent out of that whole process," she says. "Instead of going off in a corner to say how horrible the parents are, ask them if they have the resources to bathe the child."

The idea is not to punish families, says Nicholson. "Our job is to ensure families are referred to and engaged in services that make it possible for them to function in an appropriate fashion," she explains.