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TRIAGE: Appropriate Level of Care

Emergent Evaluation
line spacer An emergent evaluation is one that should occur on the same day as the initial contact with the family. If there is a local child abuse expert, refer the child/adolescent to that medical provider for an immediate consultation. In many places in New York State this immediate consultation is not available, and the child/adolescent must go to the local Emergency Department. In that case, proper photo-documentation and clear medical record documentation of the examination is essential so that a child abuse medical provider can interpret the findings. In some cases, the child may be medically unstable due to physical trauma and the Emergency Department is the most appropriate resource for evaluation and treatment. Indications for an emergent evaluation:
  • Imminent danger
  • Loss of consciousness
  • Bleeding or history of bleeding
  • Pain (genital or other)
  • Extensive bruising or bruises that may resolve quickly
  • Possible fractures
  • Abdominal trauma or other medical emergency concerns
  • Pregnancy possibility
  • Need for STD prophylaxis
  • Psychiatric emergency
  • Forensic evidence collection
Imminent Danger
Imminent danger refers to the risk of further abuse to the child/adolescent. When imminent danger is suspected, evaluate the child/adolescent as soon as possible. The provider must ascertain the possibility of injury and begin to access the social services system in order to protect the child/adolescent from further harm.

Medical Need
Immediately evaluate a child/adolescent who has severe pain, loss of consciousness, bleeding, possible fracture, possible abdominal trauma, extensive bruising, signs of suffocation, or other emergent medical concern.

  • Symptoms of head trauma: vomiting, headache, syncope, lethargy, visual disturbance
  • Symptoms of abdominal injury: vomiting, abdominal pain, bruising to the abdomen/flank/back, hematuria
  • Symptoms or history of recent traumatic sexual contact: bleeding from the vagina or rectum, genital pain, or other signs of injury

Evaluate immediately if there a possibility that the child/adolescent may benefit from prophylactic treatment for sexually transmitted diseases or pregnancy. Post-pubertal females with a history of exposure to semen are at risk for pregnancy and may receive prophylaxis up to 120 hours after the incident. All children/adolescents with history of exposure to bodily fluids may be at risk for a sexually transmitted disease. These situations should be considered on a case-by-case basis by collaborating with a professional trained in the examination of sexually abused children and a pediatric infectious disease specialist where appropriate.

Psychiatric Emergency
Certain situations such as a suicide attempt, parental or child emotional instability, acute psychotic crisis, or other significant mental health concern warrant an immediate evaluation.

Medical/Legal Issues
An immediate evaluation is appropriate when there is a possibility of forensic evidence collection or documentation of an injury that may resolve quickly. Collect evidence when there is a suspicion of sexual abuse within the previous 96 hours that includes the potential for exposure to bodily fluids:

  • Penile/vaginal contact
  • Penile/anal contact
  • Oral/penile contact
  • Oral/vaginal contact

Urgent Evaluation
line line Urgent evaluations should take place within 24 hours of the referral. Consider these situations carefully, as sometimes it is more appropriate to have the child/adolescent seen emergently.

Indications for an urgent evaluation:

  • Bruises or need for documentation of minor injuries that may resolve quickly
  • Vaginal discharge
  • Supportive evidence for a legal case

Documentation of an Injury that May Resolve
Genital injuries may resolve rapidly. Document them using proper photographic equipment and chart sketches. Evaluation and interpretation by a professional trained in the evaluation of sexually children may be warranted.

Non-genital injuries and bruises are variable in their resolution and should be considered on a case-by-case basis. It is sometimes advisable to perform an immediate medical evaluation if injury resolution will occur before an urgent examination can be scheduled.

Medical Concerns
Evaluate urgently if the child/adolescent complains of genital pain even though the incident of abuse may have occurred more than 96 hours ago. Genital injuries are often accompanied by a history of pain or bleeding.

If there has been an otherwise asymptomatic vaginal discharge that has been present for some time, the child/adolescent needs to be seen as soon as possible. In general, the evaluation is not an emergency.

Most situations of medical neglect require an urgent or emergency evaluation. Children suffering from injuries due to physical abuse and who do not fit the criteria for an emergency evaluation should be evaluated within 24 hours.

Supportive Evidence
Occasionally, in order to move forward with an arrest in a case, legal professionals are awaiting physical examination results on a child/adolescent who may have healed findings. Consider on a case by case basis if these situations warrant an urgent examination.

Evaluation Scheduled for a Later Date
line spacer All children/adolescents with a suspicion of child abuse and/or neglect are entitled to a medical evaluation. An examination can be scheduled for a later date when there is no urgency for documentation of injury, forensic evidence collection, treatment or prophylactic treatment.

Indications for an evaluation scheduled for a later date:

  • Abuse was not within the week
  • Nature of the abuse is not likely to result in findings
  • Family or child/adolescent needs reassurance
  • Concern is limited to a behavioral problem
  • Custody issues

Unlikely Need for Treatment or Evidence Collection
Activities such as vaginal/penile fondling over the clothes may not result in injury or need prophylactic treatment. However, children and adolescents often disclose abuse in a piecemeal fashion. The possibility of additional activity and possible healed physical findings must be considered.

Need for Reassurance
In some circumstances the nature of the evaluation may be for the psychological reassurance of wellness. Some children/adolescents without contact types of abuse may still benefit from an evaluation, including:

  • Siblings of abused children/adolescents
  • Children/adolescents with histories of exposure to pornography

Behavioral Concerns
In many cases, the only concern regarding abuse is due to "sexual acting out" or an acute behavioral change. These children should be examined with careful attention to the history of the problem and social concerns.

Family Issues
Some of the most challenging evaluations involve allegations of one parent against another concerning child abuse. In all cases, these allegations should be taken seriously. In all cases, the child is being victimized either as a pawn in a parental dispute or as a victim of emotional, sexual, or physical abuse or neglect. These children usually benefit from referral for evaluation by a medical professional with expertise in evaluating abused children.

Domestic violence impacts the entire family. A child/adolescent exposed to parents or caregivers who engage in domestic violence is a child/adolescent at risk. This situation should be reported to the child abuse hotline.

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Emergent Evaluation
Urgent Evaluation
Evaluation Scheduled for a Later Date