Summer 2022

Document Type

Scholarly Project


College of Nursing

First Advisor

Kate Chappell


Problem Statement: Nationally, infants and young children who present to emergency departments with fractures are not being screened adequately for possible physical abuse with a skeletal survey (Paine & Wood, 2018; Shelmerdine et al., 2014; Wood et al., 2019). Without universal screenings, implicit bias along racial and socioeconomic lines becomes a factor in deciding which children with fractures get screened, resulting in either under-or over-utilization of skeletal survey screenings (Kim et al., 2017; Paine & Wood, 2018). When child abuse is not diagnosed correctly, further abusive injuries or death can occur (Ravischandiran et al., 2010). Purpose: This evidence-based practice project aimed to determine if an electronic clinical pathway increased skeletal survey screenings, improved adherence to American Academy of Pediatrics guidelines, and decreased implicit bias in screening young children with skeletal fractures for physical abuse. Methods: A diagnostic screening tool was developed that incorporated a child abuse clinical pathway for patients 24 months or less presenting with fractures in a pediatric trauma center emergency department. Data was collected from March 2021 to implementation and three months after implementing the clinical pathway to evaluate implementation success. Analysis: Skeletal Survey performance was compared before and after implementation using chi-square analysis with univariate regression to evaluate the odds of having a skeletal survey ordered. Results: Skeletal survey performance did not improve post-pathway (p = 0.36) but adherence to AAP guidelines improved in children 0-12 months from 86% to 90% (p = .076). The average number of occult fractures detected also increased post-pathway from 7 to 14%. Race and insurance type did not significantly influence SS performance pre or post-pathway. Implications For Practice: Implementing a child abuse clinical pathway can increase adherence to national screening guidelines in young children.


© 2022, Stephanie Li Schaller

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