Physical Abuse Clinical Pathway — Outpatient Specialty and Primary Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Related Pathways

Scheduled Primary/Subspecialty Care Visit

No Findings Suggestive of Abuse

No injuries or risk factors indicating abuse present
No historical indicators of abuse
Physical exam findings explained by plausible developmentally appropriate mechanism or medical etiology
No safety concerns

Findings Suggestive of Abuse

Witnessed or disclosed abuse
Injury pathognomonic for abuse
Injuries Suggestive of Abuse not explained by plausible mechanism
Multiple injuries
Suspicious occult injuries identified by patient workup
Infant’s head circumference > 85% or increased at least 2SD from prior measurement
Irritability in infants without identifiable cause
Social history of substance use, IPV or violent criminal history of adult in home

Note:
Age < 6 months with any injury warrants consideration of suspected abuse
Household contacts or siblings of children with abusive injuries are at high risk
Consider ED referral, as clinically indicated

Recommendations

No further work up for abuse
No CPS report indicated
Routine follow-up
Discharge home

Concern for Abuse

ED Referral
Age < 2 years with any concern for possible abuse
Findings suggestive of abuse requiring further evaluation
Historical or social concerns that require social work consultation
Injury that requires further evaluation, treatment
Child accompanied by social services for abuse evaluation

CPS Referral for the following:
- Immediate safety concerns for discharge
- Concern for other children at risk in the home
Communication
- PCP contacts referral line 215-590-2160
- Speaks with MCP as indicated, leaves cell number
- Assures patient arrives ED
- CPS referral as indicated

Posted: September 2018
Revised: June 2021
Authors: P. Scribano, MD; J. Wood, MD; K. Henry, MD; V. Scheid, MD; L. Palacio, LSW; C. Jacobstein, MD; J. Lavelle, MD

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Outpatient Specialty Care and Primary Care Pathway for Evaluation/Treatment of Children with Physical Abuse Concerns

Evidence