The Children's Justice Center Multidisciplinary Puzzle: Where Does the Medical Exam Fit?

The gold standard for treatment of children who are victims of sexual assault is to provide all victims access to a forensic medical examination, preferably by medical providers trained in child abuse. Although most Children's Justice Centers (CJC) in the Utah have medical teams, there is not a consistent referral process of victims for a medical examination, and therefore most victims do not receive the recommended treatment. Safe and Healthy Family estimates that in 2014 less than 25% of child abuse victims received a medical examination by trained providers. The objectives of this project were to (a) evaluate the current CJC programs within the state to determine if there is a gap in access to medical evaluation of victims of child abuse, (b) create standardized guidelines for the CJC to utilize when referring a victim of sex abuse for a medical examination, and (c) disseminate information about the new Protocol for Sexual Child Abuse Medical Forensic Pediatric Examinations to CJC multidisciplinary teams. The Department of Justice (DOJ) released a national protocol to address pediatric medical examinations for victims of sexual abuse in April 2016: "Although the protocol's focus is on the exam process, it also speaks to the initial community response to prepubescent child sexual abuse, as it is a gateway for victims to access medical forensic care" (DOJ, 2016, p.7). Per Klenig (2012), the Children's Advocacy Center (CAC)/Children's Justice Center model encourages a commonsense approach to addressing child sexual abuse. The use of CAC has expanded worldwide. Pediatric child abuse experts are trained in the diagnosis and treatment of child abuse. These experts include pediatricians, nurse practitioners, and sexual assault nurse examiners (SANE). Tracey (2017) discusses recent studies that indicates when a child is subject to abuse or other traumatic events brain function is altered and damage. This damage to the brain can produce long term individual and social pathological consequences. This project addressed the knowledge deficit of the CJC multidisciplinary team members regarding the treatment of victims of sexual assault by analyzing data from a survey disseminated to the rural CJC centers. Of the surveys disseminated, 133 were completed. Only 12 of those surveyed had knowledge of the DOJ protocol, and 106 participants stated their CJC team did not have a protocol in place for the referral for pediatric sexual assault victims. The DOJ protocol was presented to rural CJC/CAC teams. Education on the sexual assault protocol was completed during rural CJC/CAC staff meetings and served to improve medical access for and treatment of victims of sexual assault. This project aimed to ensure that the gold standard of care is being implemented. Seven rural Utah CJC centers and two CAC representing Pocatello, Idaho and Southwest Wyoming were educated about the new standard of treatment for pediatric sexual assault victims. The new protocol is anticipated to initiate conversations about what changes could be made in these centers regarding the care and treatment of pediatric victims of sexual assault.

Running head: THE MULTIDICIPLIARY TEAM PUZZLE The Children's Justice Center multidisciplinary puzzle: Where does the Medical Exam Fit? Amy Bleak, DNP-FNP Student University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 THE MULTIDISCIPLINARY TEAM PUZZLE 2 Executive Summary The gold standard for treatment of children who are victims of sexual assault is to provide all victims access to a forensic medical examination, preferably by medical providers trained in child abuse. Although most Children's Justice Centers (CJC) in the Utah have medical teams, there is not a consistent referral process of victims for a medical examination, and therefore most victims do not receive the recommended treatment. Safe and Healthy Family estimates that in 2014 less than 25% of child abuse victims received a medical examination by trained providers. The objectives of this project were to (a) evaluate the current CJC programs within the state to determine if there is a gap in access to medical evaluation of victims of child abuse, (b) create standardized guidelines for the CJC to utilize when referring a victim of sex abuse for a medical examination, and (c) disseminate information about the new Protocol for Sexual Child Abuse Medical Forensic Pediatric Examinations to CJC multidisciplinary teams. The Department of Justice (DOJ) released a national protocol to address pediatric medical examinations for victims of sexual abuse in April 2016: "Although the protocol's focus is on the exam process, it also speaks to the initial community response to prepubescent child sexual abuse, as it is a gateway for victims to access medical forensic care" (DOJ, 2016, p.7). Per Klenig (2012), the Children's Advocacy Center (CAC)/Children's Justice Center model encourages a commonsense approach to addressing child sexual abuse. The use of CAC has expanded worldwide. Pediatric child abuse experts are trained in the diagnosis and treatment of child abuse. These experts include pediatricians, nurse practitioners, and sexual assault nurse examiners (SANE). Tracey (2017) discusses recent studies that indicates when a child is subject to abuse or other traumatic events brain function is altered and damage. This damage to the brain can produce long term individual and social pathological consequences. This project addressed the knowledge deficit of the CJC multidisciplinary team members regarding the treatment of victims of sexual assault by analyzing data from a survey disseminated to the rural CJC centers. Of the surveys disseminated, 133 were completed. Only 12 of those surveyed had knowledge of the DOJ protocol, and 106 participants stated their CJC team did not have a protocol in place for the referral for pediatric sexual assault victims. The DOJ protocol was presented to rural CJC/CAC teams. Education on the sexual assault protocol was completed during rural CJC/CAC staff meetings and served to improve medical access for and treatment of victims of sexual assault. This project aimed to ensure that the gold standard of care is being implemented. Seven rural Utah CJC centers and two CAC representing Pocatello, Idaho and Southwest Wyoming were educated about the new standard of treatment for pediatric sexual assault victims. The new protocol is anticipated to initiate conversations about what changes could be made in these centers regarding the care and treatment of pediatric victims of sexual assault. Committee members include: Dr. Julie Balk, DNP, APRN, FNP-BC, CNE, Family Nurse Practitioner Specialty Track Director; Pam Hardin, PhD, RN, CNE MS & DNP tracts; Dr. Jennifer Hamilton, DNP, PNP, Project Chair. Content experts and consultation: Jeanlee Carver, APRN, Content Expert; Julie Bradshaw, Director of Safe and Healthy Families; Laura Seklemian, Utah Attorney General's Office, Administrator of Utah CJC program; Stephanie Furnival, Iron County CJC Director; Daphne Solomon, APRN, Iron County Child Abuse Examiner; Iron County Children's Justice Center Multidisciplinary team Utah CJC Nurse Practitioners. THE MULTIDISCIPLINARY TEAM PUZZLE 3 Table of Contents Executive Summary ............................................................................................................... 2 Problem Statement ............................................................................................................... 4 Clinical Significance ............................................................................................................... 4 Purpose Statement ................................................................................................................ 6 Objectives ............................................................................................................................. 6 Review of Literature .............................................................................................................. 6 Consequences of Child Abuse .........................................................................................................7 Barriers to Child Abuse Examinations .............................................................................................7 Child Abuse Experts .......................................................................................................................8 Children Advocacy Center/ Children's Justice Center .......................................................................9 Theoretical Framework........................................................................................................ 10 Implementation .................................................................................................................. 11 Evaluation ........................................................................................................................... 12 Survey Data ......................................................................................................................... 13 Results ................................................................................................................................ 14 Recommendations .............................................................................................................. 15 DNP Essentials ................................................................................................................... 16 Conclusions ......................................................................................................................... 18 References .......................................................................................................................... 19 Appendices ......................................................................................................................... 22 APPENDIX A: INITIAL RESPONSE ALGORITHM ................................................................................... 22 APPENDIX B: CARE ALGORITHM ................................................................................................... 23 APPENDIX C: PROJECT SURVEY .................................................................................................... 24 APPENDIX D: PROJECT PRESENTATION ........................................................................................... 26 Appendix E- IRB Submission................................................................................................. 43 Appendix F: Poster Presentation .......................................................................................... 44 THE MULTIDISCIPLINARY TEAM PUZZLE 4 Problem Statement Although most Children's Justice Centers (CJC) in Utah have medical teams, there is not a consistent referral process of victims for a medical examination, and therefore most victims do not receive the recommended treatment. Safe and Healthy Family (SHF) (2016) estimates that in 2014 less than 25% of child abuse victims received a medical examination by trained providers. Law enforcement officers and Department of Child Protective Services (CPS) workers are not properly referring Utah's victims of child abuse to timely medical exams. SHF (2016) explains that historically, law enforcement officers have historically been charged with determining if and to whom they refer victims. In many cases the victim is referred to a primary care provider (PCP) to complete these examinations. "Child forensic medical exams require specialized knowledge. Most pediatricians do not have the skills to identify the subtle signs needed to make a differential diagnosis between abuse and other conditions" (Jones, Cross, Walsh, & Simone, 2005, p. 259). The timing and detail of the examination should be based on specific screening criteria available to qualified medical providers. The screening criteria can determine the need for an emergency evaluation or where and when a non-urgent examination should be conducted. Throughout the State of Utah, cases involving children are processed at the CJC. The CJC provides a safe and nonthreatening environment for the children's needs to be addressed. The purpose of this project is to educate the CJC multidisciplinary members on the gold standard of referring victims of child abuse, as defined by the American Pediatrics Association. Clinical Significance Child maltreatment includes child abuse, physical abuse, sexual abuse, and neglect. The Center for Disease Control (CDC) (2016) estimates that in 2012 an estimated 686,000 children THE MULTIDISCIPLINARY TEAM PUZZLE 5 were victims of child maltreatment and an estimated 1,740 children died from maltreatment. In Utah, these numbers are just as staggering. The Utah Division of Child and Family Services (2014) reported that over 25,000 children were investigated for potential maltreatment and just under 10,000 children were found to be victims. During an interview with the Safe and Healthy Families Director, Julie Bradshaw she indicated that in an average year, Utah's CJCs conduct 4,500 interviews, handle 5,500 cases, and serve as many as 15,000 people. However, of these 5,500 cases, approximately 1300 medical exams were completed which indicates that less than 25% of the children have received medical examinations. Beaver County CJC (2015) reported 54 cases of child abuse in 2015. Among these cases 18 were of sexual assault and 7 were physical abuse; of these cases, only 3 victims were referred for a medical examination. Kane County CJC (2015) opened 38 cases in the same year, 31 of which were victims of sexual abuse. Of the 31 sexual abuse victims and 7 child abuse victims, 20 medical exams were completed. If stakeholders are educated about the process of referring child abuse victims, perhaps the victims will receive the proper examination to ensure they are healthy and that the forensic evidence is properly obtained and secured. Within the last year, both counties opened a Children's Justice Center (CJC). The CJC is utilized to create a multidisciplinary approach to child victims. The stakeholders for this project include all interdisciplinary team members of the CJC: law enforcement, Child Protective Services (CPS), the County Attorney's Office, crime victim advocates, school officials, and social services. However, the most important stakeholders are the victims and their families. Isaac (2011) discussed the importance of the medical evaluation of a suspected victim of child abuse. The medical exam ensures that the child is healthy following the abuse, documents the injuries, and serves to aid in the collection of evidence used in successful prosecution. To THE MULTIDISCIPLINARY TEAM PUZZLE 6 properly interpret the medical findings of the exam, the American Academy of Pediatrics recommends that exam findings be peer reviewed. Access to child abuse experts gives the medical provider current and up-to-date information and recommendations. If the child abuse medical exam is not done properly, the child may be exposed to multiple unnecessary medical examinations and forensic evidence may be compromised. By providing education to the rural counties of southern Utah about the local child abuse resources, these children will be more likely to receive the proper medical screening and exam. Purpose Statement The purpose of this project is to develop and implement guidelines for the CJC multidisciplinary team on the referral of rural victims of child abuse. Objectives 1. Evaluated the current CJC programs within the state and determined there was a gap in access to medical evaluation of victims of child abuse. 2. Created standardized guidelines for the CJC to utilize when referring a victim of sex abuse for a medical examination. 3. Disseminated information about the new DOJ Protocol for Sexual Child Abuse Medical Forensic Pediatric Examinations to CJC multidisciplinary teams. Review of Literature The review of the literature followed a thorough literature search completed using PubMed, CINAHL, CALiO (a private search engine available only to CJC members), and CDC. The criterion for the search was narrowed to include the past 10 years. The terms utilized included one or a combination of the following terms: child abuse, forensic medical exam, sexual abuse, abuse, children advocacy center, children justice center, Utah child abuse, child abuse THE MULTIDISCIPLINARY TEAM PUZZLE 7 statistics, policies for child abuse, barriers to child abuse, child abuse experts, and guidelines for child abuse investigations. Consequences of Child Abuse Child abuse victims suffer short- and long-term consequences. "Child maltreatment has pronounced negative consequences for the emotional, cognitive, physical, and behavioral development of children" (Arias, 2004, p 468), including depression, anxiety, posttraumatic stress disorder, and alcohol and drug abuse. The CDC (2016) reports that in 2008, the US spent approximately $124 billion dollars, dealing with cases of fatal and nonfatal child abuse and neglect. Barriers to Child Abuse Examinations It is imperative that child abuse be confronted head on and in a timely manner. As discussed earlier, there are significant consequences related to child abuse. These consequences can increase if the abuse is not treated quickly. Delayed treatment for these victims may result in an increase in the incidence of mental health problems and increased medical costs. Child abuse is a serious problem within our communities, but it often goes undiagnosed due to a lack of resources. "A national study of primary care physicians in the United States identified several reasons for these clinicians to fail to report cases of child abuse and neglect, including familiarity with families, perceived lack of benefit to the family from Child Protective Services involvement, and use of an alternative management strategy such as close follow-up with the family" (Tiyyagura et al., 2015, p. 447). Tiyyagura et al. (2015) report that a significant number of victims present to a local emergency room (ER) and are examined by general ER physicians who have not had training in specialized pediatric services. Without specialized training of the provider, the diagnosis of child THE MULTIDISCIPLINARY TEAM PUZZLE 8 abuse may go unrecognized. "There is evidence that 20% to 30% of children who died from child abuse and neglect had been previously evaluated by health care providers, including ED providers, for unrecognized abusive injuries" (Tiyyagura et al., 2015, p. 449). A significant barrier to the diagnosis of child abuse is that the child may not present with any abnormal findings in the exam. Adams (1994) determined that most sexual assault victims have normal exams despite having a legal confirmation of an assault. Abnormal findings are extremely rare in sexual assault exams, leading practitioners to misdiagnose sexual abuse. When medical providers are not familiar with child abuse, they are not as comfortable with a diagnosis of child abuse without documented findings. "When faced with uncertainty about the diagnosis of child abuse and neglect, many providers discussed the case with colleagues before making the decision to report the case to Child Protective Services" (Tiyyagura et al., 2015, p. 451). The child may be discharged during the time it takes the physician to confer with other colleagues. If the physicians were to understand that there are child abuse experts within the community, perhaps the referral would be made while the patient is still within their care and an expert examination could be performed. Child Abuse Experts Pediatric child abuse experts are specially trained in the diagnosis and treatment of child abuse. These medical providers belong to communities devoted to the diagnosis and treatment of child abuse. They not only have medical training but have also been trained in testifying within the justice system. These experts include pediatricians specially trained in child abuse and sexual assault nurse examiners (SANE). SANE are registered nurses who have completed specialized education and clinical preparation in the medical forensic care of the patient who has experienced sexual assault or abuse. THE MULTIDISCIPLINARY TEAM PUZZLE 9 Children Advocacy Center/ Children's Justice Center In 1985, former Congressman and District Attorney Robert Cramer "saw the need to create a better system to help abused children" (National Children Advocacy Center (NCAC), 2016). Congressman Cramer recognized a gap in addressing child abuse. He envisioned a multidisciplinary team (MDT) approach that would unite the key members of child abuse investigators, thereby strengthening the response to child abuse cases. The MDT integrated law enforcement, social services, and mental health care, and medical services into one group. The CAC/CJC centers were created to meet the needs of the MDT. The CAC /CJC centers provide a place where children come and interact, with trained interviewers and medical staff, in a child friendly environment. These trained professionals include members from law enforcement, social services, and medical providers. Klenig (2012) defines the CAC model as a model that takes a commonsense approach at addressing pediatric child sexual abuse. This model is expanding in the United States, Australia, and across Europe. This system has been developed to help the victims of child abuse; it avoids further traumatizing these children and creating distrust of the system. For this reason, it is important that each victim of child abuse be treated using the MDT approach to minimize the possibility of additional trauma. MDT members are specially trained in dealing with victims of child abuse. The CAC model and NCAC (2013) define the roles of the MDT. The forensic interviewer is responsible for gathering information to obtain a legally defensible case. Forensic interviewers receive special training in the forensic interviewing techniques. These interviewers can be medical professionals, workers for child protective services, or law enforcement officers. The role of law enforcement is to determine if a crime has been committed. Social services members' role is to ensure the child is safe. Finally, the child abuse medical examiner is responsible for assuring the THE MULTIDISCIPLINARY TEAM PUZZLE 10 child receives proper medical care and a forensic exam, if warranted. Victim advocates and social services are responsible for ensuring the needs of victims are met and directing victims onto a path of healing. Theoretical Framework The theoretical framework that has been chosen for this project is the Plan-Do-Study-Act (PDSA) or Deming Cycle model. This theory was developed to address problems in a process and to create sustainable process improvement. The theory, designed by Robert Deming, includes four actions: plan, do, study, and act. The theory is very simple: there is a flaw in the process and it needs to be corrected. The theory is that if one properly considers all the possible improvements and tests them in a real setting, then it is less likely the process improvement will fail. This tool helps determine if the changes being tested will be sustainable. A change is effective only if it continues to be utilized. The problem in this study is that victims of child abuse are not always referred for a medical evaluation. A problem has been identified and needs to be addressed. By using the PDSA cycle, the process change will be evaluated for effectiveness prior to final implementation. The PDSA cycle incorporates opportunities to evaluate the process improvements prior to fully implementing the process changes. This concept allows for input from the stakeholders who are ultimately responsible for integrating the process improvement. 11 THE MULTIDISCIPLINARY TEAM PUZZLE • Administer questionnaire • Evaluate results • Objectives • Implantation • Evaluation • Disseminate new protocol • Create guidelines to present to CJC for process improvement Plan Do Act Study •Department of Justice examination of the protocol •Literature Review •Meet with CJC members to determine barriers or problems Implementation The implementation of this project included creating a survey that included multiple choice and yes/no questions. The survey was designed to provide insight into how each CJC was addressing pediatric sexual assault and if they had formal guidelines in place. The survey also assessed if the CJC programs were utilizing the Department of Justice Pediatric Sexual Assault Protocol. The University of Utah Institutional Review Board (IRB) granted approval for the study. Implementation of the project included (a) dissemination of an online survey to the CJC directors and medical staff, (b) creation of a guideline for pediatric sexual assault with a flow chart to indicate to users when a medical referral was needed after a sexual assault, (c) completion of a PowerPoint presentation (Appendix D) following approval by the faculty advisor 12 THE MULTIDISCIPLINARY TEAM PUZZLE and content expert, and (d) presentation of DOJ protocol to various CJCs throughout Utah, Idaho, and Wyoming... The information contained in the DOJ protocol was presented to the CJC medical staff January 20, 2017 during their staff meeting. The medical staff provided feedback as to what information should be included in the presentation. Since the State of Utah Attorney General's Office has oversight of the CJC, the material was also presented to the medical director and staff on January 21, 2017. Evaluation In January 2017, the IRB committee determined this project to be a nonhuman study and therefore no IRB was necessary. Data analysis followed distribution of the surveys and directed the content of the presentation. The content expert and faculty advisor approved the presentation, which was then given to the various multidisciplinary teams: Kane County CJC on February 6; Beaver County CJC February 7; Iron County CJC February 8; Cache, Box Elder, Weber, and Morgan Counties February 22; and finally, to Pocatello, Idaho and southwest Wyoming multidisciplinary teams on February 23, 2017. Objectives Objective #1 Evaluated the current CJC programs within the state to determine gap in access to medical evaluation to victims of child abuse. Implementation Created a survey, using multiple choice and yes/no questions, to determine if the new protocol was being utilized within the CJC programs. Applied for IRB approval The survey was disseminated via survey monkey to all the CJC directors and medical staff. Evaluation IRB was determined to be a nonhuman study and did not require an IRB approval. Analyzed data from the surveys. Recorded gaps within the CJC centers in the state of Utah. Presented this information to the project chair and content expert. 13 THE MULTIDISCIPLINARY TEAM PUZZLE Objective #2 Created standardized guidelines for the CJC to utilize when referring a victim of sex abuse for a medical examination. Created a guideline for all the Utah CJC teams to implement into their practice. Presented this guideline to the CJC directors and Utah Attorney General's office. The new guideline was presented and approved to the project chair and content expert for approval. Objective #3 Disseminated information about the new Protocol for Sexual Child Abuse Medical Forensic Pediatric Examinations to CJC multidisciplinary teams Presented the information in the form of a power point presentation to the CJC medical team staff meeting and then to the rest of the members of the CJC's multidisciplinary teams throughout the state. PowerPoint created and approved by the project chair and content expert. Presented the PowerPoint to multiple CJC staff meetings throughout the state. Presented the PowerPoint to the CJC Nurse Practitioners during staff meeting Survey Data Of the surveys disseminated, 133 were completed. Only 12 of those surveyed had knowledge of the DOJ protocol, and 106 participants stated their CJC team did not have a protocol in place for the referral for pediatric sexual assault victims. However, most respondents (N=70) did recognize that the initial steps included contacting the victim advocate, arranging for a medical assessment, and initiating an investigation/forensic interview. Although most respondents indicated that every victim should have access to a medical exam, 31 respondents did not think that every victim should have access to a medical exam. This survey also gathered information regarding the knowledge of guidelines within the DOJ protocol. Questions five, six, and seven specifically asked about the care of the pediatric victim. Less than half of the respondents (N=52) could properly identify the time frame in which a victim would be eligible for HIV prophylaxis. Most (N=72) recognized that an acute THE MULTIDISCIPLINARY TEAM PUZZLE 14 medical forensic exam would be completed within 72 hours' post assault, and 94 defined a nonacute medical forensic exam more than 72 hours' post assault. Results The survey identified a significant gap regarding how each CJC referred child abuse victims for a medical evaluation. In most counties, the victim is referred to a medical examination only if the law enforcement representative or CPS worker determines that the patient needs a forensic evaluation. The medical state of the victims is not a consideration when determining the need for a medical evaluation. The barrier to this objective is that not all counties in Utah were assessed in this project. Approximately one-third of the CJC multidisciplinary teams participated in this project. This project addressed mostly the rural counties in Utah, Southwest Wyoming, and Pocatello, Idaho. The primary limitation of this project was time constraints. If this project were to continue another few months, other urban counties could be included. During the presentation, each team member was given a copy of the DOJ (Appendix 6) Initial Response Algorithm. This algorithm gives direction in the initial response in sexual child abuse cases. The algorithm is a resource to aid in referring victims of sexual assault for a medical examination. The team members were also given a handout that defined the urgency of the medical examination with respect to the victim's injuries, complaints, and timing of the incident. Along with the copies of the DOJ flow chart, each multidisciplinary team member was given the link to the full DOJ protocol for future reference. Although each team member received a copy of the referral protocol, it is ultimately up to each CJC team to adopt these recommendations into their daily practice and buy-in must be achieved. In those counties that do not have a high incidence of sexual abuse cases, these THE MULTIDISCIPLINARY TEAM PUZZLE 15 recommendations may never be incorporated into their routine and the handouts may be misplaced or lost. Each presentation to the multidisciplinary teams included a question and answer session. The teams were asked if they had a protocol in place to direct child abuse victims to a medical exam. In each session, the answer was no, which was particularly concerning to the attorneys present on these teams. The attorneys stated that if the "Department of Justice thought it was important enough to have created a protocol, then each of these departments should also have a protocol in place." Each CJC team was presented with information from the DOJ to guide them in creating their own guidelines. Subsequent work meetings have been scheduled to discuss the creation of such guidelines and protocols in each county. Recommendations This project is in the initial stages. Utah CJC do not have proper protocols in place to refer victims of child abuse. This information will be presented on a state level, at the Utah CJC symposium in May 2017. The presentation will be completed in two breakout sessions during the 3-day conference, which will be an excellent opportunity to reach more CJCs throughout the state. However, this presentation is only a recommendation for each of the CJCs to create a protocol. To hardwire these guidelines into practice, the Utah State Attorney General's Office will need to mandate that all CJC's have such protocols initiated. These guidelines could also be presented to local pediatricians and practitioners who interact with victims of child abuse. If these practitioners understand the guidelines, then perhaps trained child abuse experts will refer more victims of child abuse for a medical examination. It is also important to educate the providers in each area on how to contact the THE MULTIDISCIPLINARY TEAM PUZZLE 16 local child abuse experts. These practitioners may not even be aware of the experts within their area to whom they can refer victims. For those providers who do not routinely deal with pediatric victims, it is important to know how to properly address their needs. Providers have access to the Safe and Healthy Family team at Primary Children's Hospital/University of Utah. This team has a child abuse physician always on call. The doctor of the day can be reached by calling Primary Children's Hospital, Safe and Healthy Family at [phone]. The doctor will be able to answer any questions the provider may have regarding the care and possible referral of the victims. Future Recommendation As this process moves forward, it is important to maintain the momentum. These next few months are essential to the project's success. In the upcoming months, it will be important to communicate with the CJC multidisciplinary systems to ensure that the protocol has been implemented into practice. In the future, it would be beneficial to meet with the CJC directors and develop a protocol for all the CJCs within the State of Utah to follow. Having an official protocol in the CJC should increase the sustainability of this project. The governing body of the CJC system is the Utah Attorney General's Office. It would be advantageous to meet with the system leaders to determine what further actions can be taken to ensure that the process improvement continues and will eventually reach all 22 CJC systems throughout the state. It is the intention is to continue to educate as many of the CJC multidisciplinary teams as possible. Many of the CJC centers who have not received the education will be present at the upcoming Utah CJC symposium in May 2017. DNP Essentials Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking THE MULTIDISCIPLINARY TEAM PUZZLE 17 This project embodies the importance of establishing quality improvement to improve the overall outcome of the patient care. Currently, the CJC is lacking protocol to ensure that each victim of a sexual assault receives the appropriate care in the right time frame. The medical examination is an important component in the treatment of these victims. These victims have been exposed to a traumatic experience and need to be assured they are normal. Now that the process improvement has been implemented, it is crucial that the progress be sustained. Through system leadership, the project can continue to be successful. Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes Being a victim of child abuse is a traumatic experience, and the process that follows can prevent further trauma if it is done properly. When an allegation of child abuse occurs, these children are immediately immersed into a system that is completely foreign. The justice system can be intimidating for an adult, much less an innocent child. By collaborating with law enforcement, Child Protective Services, and medical and legal services, we can help to provide a positive experience for the child. Rural areas in southwestern Utah currently do not have a uniform process for the medical treatment of victims of child abuse. It is often extremely complicated to find a practitioner who is willing to perform a forensic child abuse examination. In most cases, the child is given a well child check and is often misdiagnosed. These medical services are extremely disjointed and complicated. Multiple providers throughout the process can see a victim of abuse. Collaboration between the medical practitioners within the region is essential to improve health outcomes. By providing education about our local child abuse experts, we can help to improve the child abuse patient experience. These child abuse experts are specially trained to provide a detailed forensic examination that is peer reviewed and that reduces the need for multiple medical examinations. THE MULTIDISCIPLINARY TEAM PUZZLE 18 The elimination of repeated examinations can improve the patient experience and improve the patient outcome. Conclusions The gold standard in treatment of victims of sexual assault is that all sexual assault victims have access to a forensic medical examination, preferably by medical providers trained in child abuse. Throughout this project, efforts have been taken to ensure that this standard of treatment is adhered to. However, only a few counties have officially received information about this standard. For this project to be declared a complete success, the work must continue until all areas have been reached. The victims of child abuse deserve to receive the best care possible. "Child forensic medical exams require specialized knowledge. Most pediatricians do not have the skills to identify the subtle signs needed to make a differential diagnosis between abuse and other conditions" (Jones, Cross, Walsh, & Simone, 2005, p. 259). We not only must train law enforcement and DCFS workers but also reach out to medical practitioners. In the end, we all have the same goal: to provide the best care possible. Safe and Healthy Family (2016) estimates that in 2014 less than 25% of child abuse victims received a medical examination by trained providers. This is not enough for these victims. These victims have already sustained trauma and do not need to be further harmed by an untrained professional who may neglect to document injuries. However, as this project is implemented in other areas of Utah, these children will be more likely to receive proper medical screening and exams and possibly reduce the re-victimization and trauma that has been occurring by not following the DOJ protocol. THE MULTIDISCIPLINARY TEAM PUZZLE 19 References Adams, J., Harper, K., Knudson, S., & Revilla, J. (1994). Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics, 94(3), 310-317 8p. Arias, I. (2004). The legacy of child maltreatment: long-term health consequences for women. Journal of Women's Health, 13(5), 468-473 6p. Doi: 10.1089/1540999041280990 Child Advocacy Center (CAC), (2016). Retrieved from: http://www.smallvoices.org/what_we_do/child_expect.html Center for Disease Control (2014). Child Maltreatment, Facts at a glance. Retrieved July 21, 2016 from: http://www.cdc.gov/violenceprevention/pdf/childmaltreatment-factsat-a-glance.pdf Center for Disease Control (2016). Child Abuse and Neglect: Consequences. Retrieved July 19, 2016, From: http://www.cdc.gov/ViolencePrevention/childmaltreatment/consequences.html Children's Justice Center (2016) Interview of Utah CJC Nurse Practitioners. Department of Justice (2016) Protocol for Sexual Child Abuse Medical Forensic Examination pediatric. Retrieved September 5, 2016 from: https://www.ncjrs.gov/pdffiles1/ovw/249871.pdf A journey through Utah's Child Welfare System: Quick Facts. (2014). Retrieved from http://dcfs.utah.gov/wp-content/uploads/2013/08/Fact-Sheet-FY14.pdf Center for Disease Control (CDC). (2016). Child Abuse and Neglect: Consequences. Retrieved from: http://www.cdc.gov/violenceprevention/pdf/childmaltreatment-facts-at-aglance.pdf THE MULTIDISCIPLINARY TEAM PUZZLE 20 Isaac, R. (2011). The Physical Examination of the Child When Sexual Abuse Is Suspected. In Child Abuse and Neglect. Diagnosis, Treatment, and Evidence (9 ed., pp. 63-68). Jones, L., Cross, T., Walsh, W., & Simone, M. (2005, July). Criminal Investigations of Child Abuse. Trauma, Violence, & Abuse, 6, 254-268. http://dx.doi.org/10.1177/1524838005277440 Klenig, J. (2012). The George Jones child advocacy center: A case study on a service designed to support children who have experienced sexual abuse and their families. Curtin University of Technology, Western Australia, Australia. National Children's Advocacy Center (NCAC), (2016). Children's Advocacy Center History. Retrieved July 19, 2016, from: http://www.nationalcac.org/history/history.html National Children's Advocacy Center (NCAC), (2013) Do the right thing: The value of CACs and MDT. Retrieved July 19, 2016, from: http://www.nationalcac.org/images/pdfs/CALiO/do-right-thing-impact-and-value-cacsmdts.pdf Newlin, C. (2013). Do the Right Thing: The Impact and Value of CACs and MDTs. Safe and Healthy Families (2016) Interview with Director Julie Bradshaw. Tiyyagura, G., Gawel, M., Kozier, J., Asnes, A., & Bechtel, K. (2015, November). Barriers and Facilitators to Detecting Child Abuse and Neglect in General Emergency Departments. Annals of Emergency Medicine, 66, Issue 5, 447-454. doi:10.1016/j.annemergmed.2015.06.020 Tracey, S. (2017) Abuse is Devastating. Mending the Soul. Retrieved from: http://mendingthesoul.org/research-and-resources/research-and-articles/abuse-is- THE MULTIDISCIPLINARY TEAM PUZZLE 21 devastating/?gclid=CjwKEAjw_bHHBRD4qbKukMiVgU0SJADr08ZZMsD7nKpXSc632N1o7z neXvKcyvqVT3WMKuPpGK9hTBoCJ_Xw_wcB Utah Attorney General's Office (2014). Utah Children's Justice Center Program. Retrieved from: http://attorneygeneral.utah.gov/uncategorized/childrens-justice-centers Utah DCFS (2014). A journey through Utah's Child Welfare System: Quick Facts. Retrieved from http://dcfs.utah.gov/wp-content/uploads/2013/08/Fact-Sheet-FY14.pdf THE MULTIDISCIPLINARY TEAM PUZZLE Appendices APPENDIX A: INITIAL RESPONSE ALGORITHM 22 THE MULTIDISCIPLINARY TEAM PUZZLE APPENDIX B: CARE ALGORITHM 23 THE MULTIDISCIPLINARY TEAM PUZZLE 24 APPENDIX C: PROJECT SURVEY CJC Multidisciplinary DOJ Protocol Survey 1. Have you read the Department of Justice National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric? a. Yes b. No 2. Does your center have guidelines as to when to refer a pediatric victim of sexual assault for a medical examination? a. Yes b. No 3. If a disclosure or suspicion is first reported to child protective services or law enforcement, what are the initial steps that need to be taken? a. Activate advocate b. Arrange initial health care assessment of the child to determine urgency of care needed c. Investigative/forensic interview d. All the above e. None of the above 4. Should every victim of abuse have access a medical exam by trained professionals? a. Yes b. No 5. Within how many hours should the HIV prophylaxis treatment begin? a. 24 hours b. 36 hours c. 48 hours d. 72 hours 6. What constitutes an acute medical forensic exam? a. Within 24 hours' post assault b. Within 48 hours' post assault c. Within 36 hours' post assault d. Within 72 hours' post assault 7. What would constitute a non-acute medical forensic exam? a. <72 hours post assault b. > 72 hours' post assault c. Within 36 hours' post assault d. Within 23 hours' post assault THE MULTIDISCIPLINARY TEAM PUZZLE 25 THE MULTIDISCIPLINARY TEAM PUZZLE APPENDIX D: PROJECT PRESENTATION 26 THE MULTIDISCIPLINARY TEAM PUZZLE 27 THE MULTIDISCIPLINARY TEAM PUZZLE 28 THE MULTIDISCIPLINARY TEAM PUZZLE 29 THE MULTIDISCIPLINARY TEAM PUZZLE 30 THE MULTIDISCIPLINARY TEAM PUZZLE 31 THE MULTIDISCIPLINARY TEAM PUZZLE 32 THE MULTIDISCIPLINARY TEAM PUZZLE 33 THE MULTIDISCIPLINARY TEAM PUZZLE 34 THE MULTIDISCIPLINARY TEAM PUZZLE 35 THE MULTIDISCIPLINARY TEAM PUZZLE 36 THE MULTIDISCIPLINARY TEAM PUZZLE 37 THE MULTIDISCIPLINARY TEAM PUZZLE 38 THE MULTIDISCIPLINARY TEAM PUZZLE 39 THE MULTIDISCIPLINARY TEAM PUZZLE 40 THE MULTIDISCIPLINARY TEAM PUZZLE 41 THE MULTIDISCIPLINARY TEAM PUZZLE 42 THE MULTIDISCIPLINARY TEAM PUZZLE Appendix E- IRB Submission 43 THE MULTIDISCIPLINARY TEAM PUZZLE Appendix F: Poster Presentation 44