cps and ethics final 16x9 -...

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• This presentation will take approximately one hour to complete.

VIEWING TIME

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• This presentation is designed for primary care physicians.

• Other health care professionals working with patients and their families may also find this program of interest.

TARGET AUDIENCE

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•  It is the policy of Children’s Hospitals and Clinics of Minnesota to ensure balance, independence, objectivity and scientific rigor in all its educational programs. Our faculty have been asked to disclose to our program audience any real or apparent conflicts of interest related to the content of their presentations.

•  • They have also been requested to let you know when any products

mentioned in their presentations are not labeled for the use under discussion or are still under investigation.

FACULTY DISCLOSURE

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• Nneka O. Sederstrom, PhD, MPH, MA, FCCP, FCCM and Mark Hudson, MD disclose no actual or apparent conflict of interest in relation to this educational activity.

• During this educational activity they will not be

discussing the off-label use of commercial or investigational products not approved by the FDA.

SPEAKER FACULTY DISCLOSURE

Duty to Report/Warn and CPS: Understanding Your Ethical Obligations and Implications Nneka O. Sederstrom, PhD, MPH, MA, FCCP, FCCM Director, Clinical Ethics Department And Mark Hudson, MD Medical Director Midwest Children’s Resource Center

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After completing this course, you will be able to:

• Discuss the current child abuse statistics in Minnesota and how that directly affects our hospital

• Explain the “duty to report” rules • Describe internal bias and how it affects vulnerable

populations • Develop better tools for addressing suspected abuse

Objectives

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Children’s Disclaimers •  Children's makes no representations or warranties about the accuracy, reliability, or

completeness of the content. Content is provided "as is" and is for informational use only. It is not a substitute for professional medical advice, diagnosis, or treatment. Children’s disclaims all warranties, express or implied, statutory or otherwise, including without limitation the implied warranties of merchantability, non-infringement of third parties’ rights, and fitness for a particular purpose.

•  This content was developed for use in Children’s patient care environment and may not be suitable for use in other patient care environments. Children’s does not endorse, certify, or assess third parties’ competency. You hold all responsibility for your use or nonuse of the content. Children’s shall not be liable for claims, losses, or damages arising from or related to any use or misuse of the content.

•  Please ask if you have any questions about these disclaimers.

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Children’s Confidentiality Protections •  This content and its related discussions are privileged and confidential under Minnesota’s

peer review statute (Minn. Stat. § 145.61 et. seq.). Do not disclose unless appropriately authorized. Notwithstanding the foregoing, content may be subject to copyright or trademark law; use of such information requires Children’s permission.

•  This content may include patient protected health information. You agree to comply with all applicable state and federal laws protecting patient privacy and security including the Minnesota Health Records Act and the Health Insurance Portability and Accountability Act and its implementing regulations as amended from time to time.

•  Please ask if you have any questions about these confidentiality protections.

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• Children’s Hospitals and Clinics of Minnesota is accredited by the Minnesota Medical Association to provide continuing medical education for physicians.

• Children's Hospital and Clinics of Minnesota designates this enduring activity for a maximum of 1 AMA PRA Category 1 Credit.™

• Physicians should only claim credit commensurate with the extent of their participation in the activity.

• Children’s Hospitals and Clinics of Minnesota takes responsibility for the content, quality and scientific interest of these activities.

Accreditation

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• It is the policy of Children’s Medical Education program that we cannot offer to retain CME records for physicians attending or viewing the online CME activity.

• The Minnesota Medical Association designates that physicians are responsible for maintaining their own CME records.

Retention of CME Records

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• To receive CME credit, you must view the entire program. When the program is completed, click the Post Test button on the interface to access the Post Test.

•  You must successfully pass the Post Test to receive CME credit.

Receiving CME Credit

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Duty to Report/Warn and CPS: Understanding Your Ethical Obligations and Implications Nneka O. Sederstrom, PhD, MPH, MA, FCCP, FCCM Director, Clinical Ethics Department And Mark Hudson, MD Medical Director Midwest Children’s Resource Center

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Dr. Sederstrom has nothing to disclose Dr. Hudson has nothing to disclose for CME purposes Dr Hudson unofficial disclosures: •  I claim no particular expertise on some of these topics • This will be a mix of objective data and complete anecdote/

speculation

Disclosures

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What is your profession: 1.  Physician 2.  Nurse 3.  Social Worker/Case Management 4.  Resident/Fellow 5.  Other

Demographics

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How long have you been in practice? 1.  Less than 5 years 2.  5 – 10 years 3.  11 – 25 4.  More than 25 years

Demographics

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Have you called CPS or instructed someone to contact CPS for a case?

1.  Yes 2.  No

Baseline Question

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Have you ever felt uncomfortable with the decision to engage CPS for a case?

1.  Yes 2.  No

Baseline Question

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What do you think of CPS’s engagement in cases? 1.  CPS is engaged too much 2.  CPS is engaged too little 3.  CPS is engaged at the right amount

Baseline Question

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• Autonomy • Beneficence • Nonmaleficence •  Justice When dealing with duties to report or warn we are balancing

autonomy with justice, and beneficence with nonmaleficence

Ethical Principles – Our Foundation

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“Physical abuse is any physical injury to a child that is not accidental and may involve, but is not limited to, hitting, slapping, beating, biting, burning, shaking, or strangulating. As a result of these actions, a child may have bruises, broken bones, burns, or internal injuries that document the occurrence, as well as imprints of the specific object used to inflict the injury (e.g., belt buckle, hand, and knuckles).”

American Academy of Pediatrics. Children's health topics: child abuse & neglect. 2008.

http://www.aap.org/healthtopics/childabuse.cfm. Accessed November 4, 2008.

Definition of Abuse by the AAP- Physical

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“Emotional and psychological abuse exposes a child frequently and repeatedly to behaviors that impact his or her psychological well-being, including blaming, threatening, yelling at, belittling, humiliating, name calling, pointing out faults, withholding emotional support and affection, and ignoring a child. In some cases, exposure to domestic violence is considered psychological abuse.”

American Academy of Pediatrics. Children's health topics: child abuse & neglect. 2008. http://www.aap.org/

healthtopics/childabuse.cfm. Accessed November 4, 2008.

Emotional/Psychological

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“Neglect is the chronic failure to meet a child's basic needs—clothing, nutritious food, cleanliness, educational opportunity, medical and dental care, protection, shelter, and supervision.”

American Academy of Pediatrics. Children's health topics: child abuse & neglect. 2008. http://www.aap.org/

healthtopics/childabuse.cfm. Accessed November 4, 2008.

Neglect

The Data

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Scope/Trends in MN

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MN Child Abuse Mortality/Near Mortality

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•  2008-2012: Average of 24 childhood cancer deaths per year. •  2008-2012: Average of 22.2 child abuse deaths per year. • Mortality is the tip of the iceberg related to health

consequences of abuse − Adverse Childhood Event

Child Abuse vs Childhood Cancer

http://www.health.state.mn.us/divs/healthimprovement/content/documents/CancerFandF.pdf

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• CDC Estimates $124 billion lifetime cost/1 year of victims

Child Abuse and Neglect

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• CDC Estimates $124 billion lifetime cost/1 year of victims •  $210,012/survivor

− Stroke $159,846 −  Type II Diabetes $181,000-253,000

Child Abuse and Neglect

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•  In MN 35-40% of inflicted fatality/near fatality victims previously known to CPS

Mortality/Near Mortality

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•  In MN 25-30% of inflicted fatality/near fatality perpetrators maltreated a child previously


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•  In Milwaukee 27% of AHT victims <1yo with a prior “sentinel injury” −  40% known by a physician


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•  In Milwaukee 27% of AHT victims <1yo with a prior “sentinel injury” −  40% known by a physician

• Pediatrics April 2017: Child abuse fatality in counties with highest poverty concentration 3 times the rate of counties with the lowest poverty concentration


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•  MN has incredible race/ethnic disparity in the child protection system

Disparity

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•  MN has incredible race/ethnic disparity in the child protection system •  Mixed data on the true differences in maltreatment rates across race/

ethnicity − Does not account for the disparity

Disparity

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•  MN has incredible race/ethnic disparity in the child protection system •  Mixed data on the true differences in maltreatment rates across race/

ethnicity −  Does not account for the disparity

•  There are some “risk factors” −  Males more likely to sexually abuse −  Males more likely to cause fatal/near fatal injury −  Unemployed males −  Younger parents −  Poverty generally accepted to be a “risk factor”

Disparity

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Poverty in MN 2010-2014

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1.  Report or Not Report 2.  Screen in or Screen Out 3.  Track Assignment 4.  Safety and Risk Assessment

−  Safe placement −  Treatment/Services −  Court

Potential for bias at multiple points

Decision Points in Child Protection

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• Most reports screened out

Reporting and Screening

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Accepted Reports

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Rate per 1000

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Track Assignment

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Out of Home Placement

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•  Art vs Science

The Role of Medicine in Disparity

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•  Art vs Science •  Risk vs Bias


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•  Art vs Science •  Risk vs Bias •  Prevention vs Diagnosis


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•  Art vs Science •  Risk vs Bias •  Prevention vs Diagnosis •  Over report vs Missed abuse


Case

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Mandatory Reporting • MINNESOTA • Statute: 626.556 Subd. 3 • Standard for Reporting: • To know or have reason to believe a child

is being neglected or physically or sexually abused.

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•  Presents to the ER with left sided parietal scalp swelling

6 month old male

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•  Presents to the ER with left sided parietal scalp swelling •  Mom noticed the swelling when giving a bath and washing his hair

6 month old male

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•  Presents to the ER with left sided parietal scalp swelling •  Mom noticed the swelling when giving a bath and washing his hair • When questioned about trauma she recalls that 1-2 days prior she

left the infant on a standard height bed (frame, box spring, mattress)

6 month old male

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left the infant on a standard height bed (frame, box spring, mattress) •  She heard a thump

6 month old male

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left the infant on a standard height bed (frame, box spring, mattress) •  She heard a thump •  She found the infant on the hardwood floor with his 2 yo brother

standing nearby and assumed the brother pulled him off the bed. •  No LOC

6 month old male

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6 month old male • Parietal skull fracture • Small amount of

underlying extraaxial blood • No bruises • No other injury • Admitted for observation

per Neurosurgery

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What do you think should be done at this point? 1.  Likely abuse- Skeletal survey and report to CPS 2.  Probably abuse- Skeletal survey and consider report to CPS 3.  Probably not abuse-Skeletal survey just to be sure and no

report to CPS unless other findings 4.  Probably not abuse- No skeletal survey and no report

Impression/Plan

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• Term birth to 26 yo G8 P3, ½ pack cigarettes/day

6 month old male

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• Term birth to 26 yo G8 P3, ½ pack cigarettes/day • Mom with history of depression, anxiety, HPV positive, history

of prior gestational diabetes in 2010. Mother has a history of domestic violence and back pain. Mother is on Percocet and prenatal vitamins.

6 month old male

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• Methadone secondary to withdrawal symptoms •  2 WCC- behind on immunizations

6 month old male

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• Methadone secondary to withdrawal symptoms •  2 WCC- behind on immunizations • Strabismus- multiple missed Ophthalmology appointment but

did eventually follow through

6 month old male

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• Newborn screen positive for CF- multiple missed appointments for sweat test but did follow through with the assistance of case management

6 month old male

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• Concern for neurofibromatosis- 3 missed Genetics appointments

6 month old male

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• Older sibling with history of polydactyly and TE fistula

6 month old male

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• Older sibling with history of polydactyly and TE fistula • Mom has asked for help to see if he qualifies for any social

security benefits

6 month old male

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What do you think should be the decision at this point? 1.  More nervous for abuse- want to change my plan 2.  More nervous for abuse- no change to my plan 3.  No effect on my level of concern 4.  Reassuring and decrease my level of concern

Impression/Plan

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•  Most common fracture in children less than 12 months of age •  Minimum fall height is largely unknown •  22% of infants have a fall by 6 months of age

−  Unknown how many children have unidentified skull fractures •  Skeletal survey yield 1.4-6%

−  Almost 0% when “red flags” eliminated §  No trauma history §  Other injury §  Changing/conflicting history §  Prior CPS involvement §  >72 hour delay

Skull Fractures

A Little Literature

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Missed Cases of AHT •  173 abused children over 5 year period with head injuries •  54 (31.2%) were seen by a physicians after the AHT and were

not diagnosed •  15 (27.8%) were reinjured after the missed diagnosis •  5 deaths in the missed group - 4 preventable

Analysis of Missed Cases of AHT. Carole Jenny; Kent Hymel et al. JAMA 2/17/99---v281,#7

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Missed Cases of AHT • Conditions predisposing to Dx error

− No abnormal breathing − No seizures − No facial or scalp injuries −  Intact families − White

Analysis of Missed Cases of AHT. Carole Jenny; Kent Hymel et al. JAMA 2/17/99---v281,#7

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Reporting •  Prospective observational study. 434 primary care clinicans. 15,003

child injury visits

From Suspicion of Physical Child Abuse to Reporting: Primary Care Clinician Decision-Making. Flaherty, et al. Pediatrics. 2008

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child injury visits •  Did not report 27% of injuries deemed likely or very likely from child

abuse


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abuse •  Not having private insurance increased report rate


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abuse •  Not having private insurance increased report rate •  Race: Black vs All Other when abuse suspected

−  No sig difference in lack of private insurance group −  Relative Risk 2.11 in private insurance group −  “However, having private insurance seems to protect white children

from being reported.” From Suspicion of Physical Child Abuse to Reporting: Primary Care Clinician Decision-Making. Flaherty, et al. Pediatrics. 2008

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Reporting •  974 orthopaedist (368 completed) . 10 case vignettes. Varied

race and SES

What Factors Affect the Identification and Reporting of Child Abuse-related Fractures?. Lane and Dubowitz. Clinical Orthopaedics and Related Research. 2007

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race and SES •  79% correct diagnosis, 73% correct decision to report


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race and SES •  79% correct diagnosis, 73% correct decision to report • No difference by race


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race and SES •  79% correct diagnosis, 73% correct decision to report • No difference by race • Difference by SES

− Accidental injury correct 90% pediatric nurse vs 26% cashier − Occult rib fractures correct 68% factory worker vs 57% teacher


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Workup and Reporting • Retrospective chart review 388 children less than 3 (skull or

long bone). Minority vs white.

Racial differences in the evaluation of pediatric fractures for physical abuse. Lane, et al. JAMA, October 2, 2002.

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long bone). Minority vs white. • Abusive injury 27.6% minority vs 12.5% white by expert review


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long bone). Minority vs white. • Abusive injury 27.6% minority vs 12.5% white by expert review •  <12 months little difference in skeletal survey or report


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Workup and Reporting 12 months -3 years •  More skeletal survey (control for Insurance, expert determination,

appropriateness) (OR 8.75)


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appropriateness) (OR 8.75) •  Most “missed” skeletal surveys were in white children


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appropriateness) (OR 8.75) •  Most “missed” skeletal surveys were in white children •  By likelihood of abuse

§  Abused= no difference §  Accidental= Most pronounced difference in SS and Reporting §  Indeterminate= Difference in SS and reporting, few white kids had

SS that the expert wanted


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Workup and Reporting 12 months -3 years • More skeletal survey (control for Insurance, expert

determination, appropriateness) (OR 8.75) • Most “missed” skeletal surveys were in white children • By likelihood of abuse

§  Abused= no difference §  Accidental= Most pronounced difference in SS and Reporting §  Indeterminate= Difference in SS and reporting, few white kids had

SS that the expert wanted • Minority accidental injury 3x the rate of report

§  Most pronounced in insured Racial differences in the evaluation of pediatric fractures for physical abuse. Lane, et al. JAMA, October 2, 2002.

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•  Less willingness to consider abuse in white kids?

Anecdotes

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•  Less willingness to consider abuse in white kids?

Anecdotes

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• More anxiety when white children are perceived to be treated unjustly/shelter care?

Anecdotes

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• More likely to attempt to advocate for family shelter care?

Anecdotes

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• More likely to attempt to advocate for family shelter care? • More likely to interfere with investigation?

Anecdotes

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• More likely to attempt to advocate for family shelter care? • More likely to interfere with investigation?

Anecdotes

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•  More “rule out” work up for white kids? •  8 week old infant with history of bruising and oral injury, elevate

LFTs, a clavicle fracture and 17 rib fractures •  Genetics consult •  ENT consult •  Endocrinology consult x2 •  Call from PMD suggesting this is not abuse •  3rd Endocrinologist testifies on behalf of the parents that it could be

something else •  Some “rule out” work up is likely driven by the family and some by the

medical providers

Anecdotes

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• More likely to go to court? • More likely to hire an expert?

“…. In addition there were no additional findings of other injuries that would have prompted concerns for child physical abuse. Finally, other risk factors for child physical abuse were not found in the (family) household.”

Anecdotes

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•  “Rush to judgment” • Not enough tests • Didn’t know me

Anecdotes

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• Know your reasons for reporting. • Be courageous. Upfront your implicit bias. Recuse if you must. • Pay attention to trends. Help your colleagues do the same. • Use your resources to ensure you are making the wise and

right decision. • Be part of the solution, not the problem.

Conclusion

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•  American Academy of Pediatrics. Children's health topics: child abuse & neglect. 2008. http://www.aap.org/healthtopics/childabuse.cfm. Accessed November 4, 2008.

•  Minnesota Cancer Facts and Figures 2015. Minnesota Department of Health. http://www.health.state.mn.us/divs/healthimprovement/content/documents/CancerFandF.pdf

•  Minnesota Child Maltreatment Report 2015. Children and Family Services, October 2016. https://edocs.dhs.state.mn.us/lfserver/Public/DHS-5408H-ENG •  Minnesota’s Out of Home Care and Permanency Report 2015. https://edocs.dhs.state.mn.us/lfserver/Public/DHS-5408Ha-ENG •  Warrington, S. A., C. M. Wright, et al. (2001). Accidents and resulting injuries in premobile infants: data from the ALSPAC study. 85: 104-107. •  Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013

Apr;131(4):701-7. •  Wood JN, Hall M, Schilling S, Keren R, Mitra N, Rubin DM. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury.

Pediatrics. 2010 Sep;126(3):408-14.\ •  Flaherty EG, Sege RD, Griffith J, Price LL, Wasserman R, Slora E, Dhepyasuwan N, Harris D, Norton D, Angelilli ML, Abney D, Binns HJ; PROS network.;

NMAPedsNet.. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics. 2008 Sep;122(3):611-9. •  Lane WG, Dubowitz H. What factors affect the identification and reporting of child abuse-related fractures? Clin Orthop Relat Res. 2007 Aug;461:219-25. •  Laskey AL, Stump TE, Hicks RA, Smith JL. Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures. J Pediatr. 2013

Jan;162(1):86-9. •  Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002 Oct 2;288(13):

1603-9. •  Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics. 2009 Feb;123(2):e247-52. doi:

10.1542/peds.2008-2467. •  Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999 Feb 17;281(7):621-6. Erratum in:

JAMA 1999 Jul 7;282(1):29.

References

cps and ethics final 16x9 -...

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