Evaluation of an Emergency Department High-risk Bruising Screening Protocol

Pediatrics. 2021 Apr;147(4):e2020002444. doi: 10.1542/peds.2020-002444. Epub 2021 Mar 2.


Objectives: The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED).

Methods: A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed.

Results: Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse.

Conclusions: High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Video-Audio Media

MeSH terms

  • Blood Coagulation Tests
  • Child Abuse / diagnosis*
  • Child Protective Services / statistics & numerical data
  • Child, Preschool
  • Clinical Protocols*
  • Contusions / diagnosis*
  • Critical Pathways
  • Emergency Service, Hospital*
  • Female
  • Fractures, Closed / diagnostic imaging
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Retrospective Studies
  • Washington