Development of a Child Abuse Checklist to Evaluate Prehospital Provider Performance

Figures & data

Table 1. Participant demographics by level of training

Characteristics	All participants N (%)	EMT-B N (%)	EMT-P N (%)	p-value^*
Median number of years of experience (IQR)	7.0 (1–21)	2.5 (0–6.5)	21.0 (9–24)	<0.001
Gender				0.560
Male	25 (89.3)	15 (93.8)	10 (83.3)
Female	3 (10.7)	1 (6.2)	2 (16.7)
Race/ethnicity				0.999
White	25 (89.3)	14 (87.5)	11 (92)
Black/African American	1 (3.5)	1 (6.2)	0 (0)
Hispanic/Latino	1 (3.5)	1 (6.2)	0 (0)
Other	1 (3.5)	0 (0)	1 (8)
Confidence in detecting abuse (Mean ± SD)	64.5 ± 24.6	59.7 ± 27.0	71.0 ± 27.1	0.283
Reported child abuse to DCF in past 6 months				<0.001
0 times	13 (46.4)	12 (75.0)	1 (8.3)
≥1 times	8 (28.6)	1 (6.3)	7 (58.3)
Not specified	7 (35.7)	3 (18.7)	4 (33.3)

^*P-values were calculated using Fisher's exact test for ratios, Mann-Whitney U test for continuous nonparametric variables, and two-sided, independent T-test for normal continuous variables; EMT-B = Emergency Medical Technician-Basic; EMT-P = Emergency Medical Technician-Paramedic; IQR = interquartile range; DCF = Department of Children and Families.

Table 2. Delphi results for final checklist items

			Score (Likert Scale 1–5; 1 = strong disagreement, 5 = strong agreement)
Task Group	Task No.	Task	Median	Interquartile Range
Airway/Breathing	1-1	Assesses airway	4.5	4.0–5.0
	1-2	Assesses breathing	4.5	4.0–5.0
Circulation	2-1	Assess heart rate/pulse	4.5	4.0–5.0
	2-2	Assesses blood pressure	4.5	3.3–5.0
	2-3	Assesses distal perfusion	4.5	4.0–5.0
	2-4	Assesses temperature	5.0	4.0–5.0
Neurologic Assessment	3-1	Assesses level of consciousness	5.0	5.0–5.0
	3-2	Assesses pupil size and reaction	5.0	5.0–5.0
Exposure	4-1	Exposes anterior torso	5.0	5.0–5.0
	4-2	Exposes posterior torso	5.0	5.0–5.0
	4-3	Exposes entire head and face	5.0	5.0–5.0
	4-4	Inspects exposed areas for signs of abuse	5.0	5.0–5.0
	4-5	Palpates entire skeleton for tenderness	4.0	4.0–4.0
Scene Evaluation and Safety	5-1	Evaluates the condition of the home	4.0	4.0–4.8
	5-2	Identifies caregiver relationship to infant	5.0	4.3–5.0
	5-3	Identifies other adults at scene	4.5	4.0–5.0
	5-4	Identifies other children at scene	4.5	4.0–5.0
Basic History	6-1	Solicits reason for call	5.0	5.0–5.0
	6-2	Solicits pertinent past medical history	5.0	4.3–5.0
	6-3	Solicits information about history of present illness/injury	5.0	5.0–5.0
	6-4	Solicits details about actions of caregiver prior to EMS arrival	5.0	4.3–5.0
Identification of Risk Factors	7-1	Identifies inconsistency of history of injury with physical findings	5.0	4.3–5.0
	7-2	Identifies changes in stated history	4.5	4.0–5.0
	7-3	Assesses behavior of caregiver	4.0	4.0–4.8

Table 3. Inter-rater reliability and Light's Kappa

Checklist item	Light's Kappa
Airway/Breathing	0.77
Assesses airway	0.54
Assesses breathing	1.00
Circulation	0.74
Assesses heart rate/pulse	1.00
Assesses blood pressure	0.67
Assesses distal perfusion	0.61
Assesses temperature	0.68
Neurologic Assessment	0.83
Assesses level of consciousness	0.83
Assesses pupil size and reaction	0.82
Exposure	0.83
Exposes anterior torso	0.59
Exposes posterior torso	1.00
Exposes entire head and face	1.00
Inspects exposed area for signs of abuse	0.95
Palpates entire skeleton for tenderness	0.60
Scene Evaluation and Safety	0.74
Evaluates the condition of the home	0.57
Identifies caregiver relationship to infant	1.00
Identifies other adults at scene	0.64
Identifies other children at scene	0.75
Basic History	0.31
Solicits reason for call	1.00
Solicits pertinent past medical history	0.23
Solicits information about history of present illness/injury	0.12
Solicits details about actions of caregiver prior to EMS arrival	−0.09
Overall	0.70

EMS = Emergency Medical Services; κ < 0 for Light's kappa indicates no agreement; κ = 0–0.20, slight; κ = 0.21–0.40, fair; κ = 0.41–0.60, moderate; κ = 0.61–0.80 substantial; and κ = 0.81–1 almost perfect agreement.

Table 4. Associations between participant characteristics and screening for abuse

	Did not screen for abuse, N (%)	Screened for abuse, N (%)	p-value^*
Training			1.000
EMT-B	8/16 (50)	8/16 (50)
EMT-P	6/12 (50)	6/12 (50)
Race/ethnicity			0.385
White	13/25 (52)	12/25 (48)
Black/African American	0/1 (50)	1/1 (100)
Hispanic/Latino	1/1 (100)	0/1 (0)
Other	0/1 (0)	1/1 (100)
Gender			0.539
Male	12/13 (92)	11/13 (84)
Female	1/3 (33)	2/3 (77)
Reported child abuse to DCF in past 6 months			0.360
0 times	6/13 (55)	5/13 (45)
≥1 time	3/8 (50)	5/8 (50)
Confidence in abuse
(mean ± SD)	63.5 ± 23.8	65.6 ± 30.9	0.844

^* P-values for calculated using Pearson's chi square test for ratios, Mann-Whitney U test for continuous nonparametric variables, and Student's independent T-test for normal continuous variables; EMT-B = Emergency Medical Technician-Basic; EMT-P = Emergency Medical Technician-Paramedic; DCF = Department of Children and Families.

Table 5. Associations between checklist items and successful screening for abuse

Checklist item	Overall, N (%)^*	Did not screen for abuse, N (%)^*	Screened for abuse, N (%)^*	p- value^†
Airway/Breathing
Assesses airway	27/27 (100)	13/13 (100)	14/14 (100)	–
Assesses breathing	27/28 (96)	13/14 (93)	14/14 (100)	0.309
Circulation
Assesses heart rate/pulse	28/28 (100)	14/14 (100)	14/14 (100)	–
Assesses blood pressure	9/27 (33)	5/17 (29)	4/13 (31)	0.785
Assesses distal perfusion	21/27 (78)	11/14 (79)	10/14 (71)	0.918
Assesses temperature	28/28 (100)	14/14 (100)	14/14 (100)	–
Neurologic Assessment
Assesses level of consciousness	18/27 (67)	7/14 (50)	11/13 (85)	0.057
Assesses pupil size and reaction	16/27 (59)	8/14 (57)	8/13 (62)	0.816
Exposure
Exposes anterior torso	21/25 (84)	8/12 (67)	13/13 (100)	0.023
Exposes posterior torso	11/28 (39)	1/14 (7)	10/14 (71)	<0.001
Exposes entire head and face	15/28 (54)	4/14 (29)	11/14 (79)	0.008
Inspects exposed area for signs of abuse	14/28 (50)	0/14 (0)	14/14 (100)	<0.001
Palpates entire skeleton for tenderness	4/26 (15)	0/13 (0)	4/13 (31)	0.030
Scene Evaluation and Safety
Evaluates the condition of the home	16/20 (80)	7/10 (70)	9/10 (90)	0.264
Identifies caregiver relationship to infant	27/28 (96)	13/14 (93)	14/14 (100)	0.309
Identifies other adults at scene	1/26 (4)	1/13 (8)	0/13 (0)	0.308
Identifies other children at scene	4/27 (15)	1/13 (8)	3/14 (21)	0.315
Basic History
Solicits reason for call	27/28 (96)	13/14 (93)	14/14 (100)	0.309
Solicits pertinent past medical history	25/27 (93)	13/14 (93)	12/13 (92)	0.957
Solicits information about history of present illness/injury	26/27 (96)	13/14 (93)	13/13 (100)	0.326
Solicits details about actions of caregiver prior to EMS arrival	5/22 (23)	4/11 (36)	1/11 (9)	0.127

^*Sums between checklist items are not equal due to missing data.

^†P-values calculated using Pearson chi square test.

Table

Task Group	Task No.	Task	Description	Done	Not Done	Not Required
Airway/Breathing	1-1	Assesses airway	Checks patency: looks, listens; or provides supplemental oxygen	□	□	N/A
	1-2	Assesses breathing	Auscultates, looks for chest rise and work of breathing	□	□	N/A
Circulation	2-1	Assess heart rate/pulse	Either (1) Auscultates HR or notes HR on monitor, or (2) Feels central or peripheral pulse(s)	□	□	N/A
	2-2	Assesses blood pressure	Notes BP on monitor or asks moderator for BP	□	□	N/A
	2-3	Assesses distal perfusion	Checks distal capillary refill and/or asks the moderator about skin color and condition	□	□	N/A
	2-4	Assesses temperature	Asks moderator about temperature (e.g., fever or hypothermia)	□	□	N/A
Neurologic Assessment	3-1	Assesses level of consciousness	Asks moderator about mental status (e.g., AVPU)	□	□	N/A
	3-2	Assesses pupil size and reaction	Asks moderator about pupil size and reaction	□	□	N/A
Exposure	4-1	Exposes anterior torso	Looks under front of shirt or unzips onesie	□	□	N/A
	4-2	Exposes posterior torso	Looks under or removes back of shirt or onesie	□	□	N/A
	4-3	Exposes entire head and face	Removes all headwear so that ears, fontanelles, and neck can be examined	□	□	N/A
	4-4	Inspects exposed areas for signs of abuse	Visually detects any bruises, lacerations, burns, and/or fractures present	□	□	N/A
	4-5	Palpates entire skeleton for tenderness	Manually palpates for crepitus or signs of tenderness	□	□	N/A
Scene Evaluation and Safety	5-1	Evaluates the condition of the home	Considers general cleanliness: notes presence or absence of drug paraphernalia, alcohol, harmful chemicals, or cigarette smoke	□	□	N/A
	5-2	Identifies caregiver relationship to infant	Verbally confirms relationship	□	□	N/A
	5-3	Identifies other adults at scene	Asks moderator about presence of other adults at scene, including witnesses, paramours, boyfriend, girlfriend	□	□	N/A
	5-4	Identifies other children at scene	Asks moderator about children/sibling(s) at scene	□	□	N/A
Basic History	6-1	Solicits reason for call	Asks about chief complaint, signs and symptoms	□	□	N/A
	6-2	Solicits pertinent past medical history	Asks about previous injury or illnesses, basic birth history	□	□	N/A
	6-3	Solicits information about history of present illness/injury	Asks about events preceding injury or illness and/or events of the injury/illness itself (e.g., mechanism of injury)	□	□	N/A
	6-4	Solicits details about actions of caregiver prior to EMS arrival	Asks caregiver what he/she did to help the child after discovery of illness/injury but before EMS arrived; includes information about delay in seeking care	□	□	N/A
Identification of Risk Factors	7-1	Identifies inconsistency of history of injury with physical findings	Notes lack of agreement of history given by caregiver with physical signs and symptoms; includes history that is inconsistent with age or developmental abilities of child	□	□	N/A
	7-2	Identifies changes in stated history	Notes multiple histories or changes in history provided	□	□	N/A
	7-3	Assesses behavior of caregiver	Notes caregiver anxiety/stress or lack of concern for child	□	□	N/A

Table

Checklist item	Cronbach's α if item deleted
Airway/Breathing
Assesses airway	0.585
Assesses breathing	0.585
Circulation
Assesses heart rate/pulse	0.601
Assesses blood pressure	0.648
Assesses distal perfusion	0.619
Assesses temperature	0.617
Neurologic Assessment
Assesses level of consciousness	0.556
Assesses pupil size and reaction	0.606
Exposure
Exposes anterior torso	0.549
Exposes posterior torso	0.607
Exposes entire head and face	0.531
Inspects exposed area for signs of abuse	0.539
Palpates entire skeleton for tenderness	0.573
Scene Evaluation and Safety
Evaluates the condition of the home	0.574
Identifies caregiver relationship to infant	0.601
Identifies other adults at scene	0.597
Identifies other children at scene	0.589
Basic History
Solicits reason for call	0.601
Solicits pertinent past medical history	0.585
Solicits information about history of present illness/injury	0.585
Solicits details about actions of caregiver prior to EMS arrival	0.591
Overall	0.601