- Email: [email protected]
Detection of Domestic Violence by a Domestic Violence Advocate in the ED
The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 860 – 865, 2012 Published by Elsevier Inc. Printed in the USA 0736-4679/$–see front matter
http://dx.doi.org/10.1016/j.jemermed.2009.07.031
Violence: Recognition, Management, and Prevention
DETECTION OF DOMESTIC VIOLENCE BY A DOMESTIC VIOLENCE ADVOCATE IN THE ED Jessica A. Hugl-Wajek,
MD,
Deborah Cairo,
MD,
Shruti Shah,
MD,
and Barbara McCreary,
MD
Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois Reprint Address: Jessica A. Hugl-Wajek, MD, Department of Emergency Medicine, Sacred Heart Hospital, 900 West Clairemont Ave., Eau Claire, WI 54701
e Keywords— domestic violence; detection of domestic violence; domestic violence advocacy coordinator
e Abstract—Background: The current domestic violence (DV) literature has evaluated the incidence and prevalence of DV via written surveys and verbal questioning performed by a variety of health care professionals. Objectives: We sought to examine the prevalence of DV as obtained by a full-time, trained DV advocacy coordinator using direct patient interviewing in our emergency department (ED), and to compare our results with the published literature. Methods: The DV advocacy coordinator randomly selected and interviewed female patients presenting to the ED with various complaints during daytime hours. Participation was voluntary, and patients were excluded if they were too ill or injured to answer questions. We performed a retrospective review of data obtained through our DV advocacy coordinator’s screening interviews of female patients presenting to the ED over a period of 1 year. Acute incidence and lifetime prevalence of DV was determined and compared to results reported in the literature. Results: The domestic violence advocacy coordinator screened a total of 1550 patients over the study period. Domestic violence incidence and lifetime prevalence as detected by the coordinator was determined to be 4.8% (95% confidence interval [CI] 3.9 – 6.0%) and 27.5% (95% CI 25.3–29.8%), respectively. Conclusions: Although the lifetime DV prevalence of 27.5% uncovered by our trained DV advocacy coordinator is similar to other reports, the acute incidence of 4.8% is higher than most other reported results using personal interviews. The use of a trained DV coordinator may improve detection rates of domestic violence in the ED. Published by Elsevier Inc.
RECEIVED: 23 January 2009; FINAL ACCEPTED: 10 July 2009
SUBMISSION RECEIVED:
INTRODUCTION Domestic violence is a health care epidemic. The Centers for Disease Control and Prevention reported that over 4.8 million cases of intimate partner-related physical assaults and rapes in women and over 2.9 million in men occur yearly (1). The Department of Justice reported that domestic violence or intimate partner violence resulted in the deaths of 1544 people in 2004. Physical trauma, though obviously important from the perspective of those in the field of emergency medicine, is not the only consideration. Domestic violence also underlies many other aspects of health, including chronic pain syndromes, depression, substance abuse, and sexually transmitted diseases. Routine screening for domestic violence in health care settings, particularly in the emergency department (ED), can be an important preventive measure toward reducing the consequences of this type of violence. The ED presents a unique opportunity for health care providers to identify victims of domestic violence; it has been asserted that as many as 54% of all women who seek care in hospital EDs have been affected by domestic violence at some point in their lifetime (2). However, there are numerous barriers to adequate screening, de-
9 April 2009; 860
Domestic Violence Detection
tection, and support in the ED that may affect actual rates of detection. Health care providers are often untrained or feel uncomfortable dealing with patients who present with complaints secondary to domestic violence (3). Additionally, there are arguments that there is simply too little time for nurses or physicians to adequately address the important issue of domestic violence during the patient’s ED visit (4). Many attempts have been made to determine the overall incidence and prevalence of domestic violence through a variety of means. Although there is a good deal of existing literature on the prevalence and incidence of domestic violence, most of the previous studies have utilized a written survey or interviews by ED staff (registered nurse, physician assistant, or emergency physician) (2,5–15). Our hospital engages the services of a dedicated domestic violence advocate brought in from the community through an outside agency. This individual performs random screening examinations on ED patients and inpatients, evaluating for domestic violence and providing support and advocacy materials to identified victims. She is able to focus exclusively on the topic of domestic violence, freeing the physician and nursing staff to focus on the acute medical problems at hand. We sought to add to the existing literature by examining the incidence and lifetime prevalence of domestic violence as detected by a dedicated domestic violence advocate in a busy ED over 1 year.
MATERIALS AND METHODS Study Design A retrospective review of data was performed over a period of 1 year, from January through December 2006. This was the first full year in which the trained domestic advocacy coordinator had initiated data collection. This advocacy coordinator was the single interviewer and data collector in this study. The hospital’s Institutional Review Board approved this review.
Setting Data were collected in the ED of our hospital, a Level I trauma center with an emergency medicine residency training program, with over 80,000 patient visits yearly. The trained domestic violence (DV) advocacy coordinator is the coordinator of a community agency’s hospital advocacy program. Her title is Certified Domestic Violence Professional, with certification obtained through Illinois Certified Domestic Violence Professionals, Inc.
861
She has more than 3 years of experience as a DV advocate and maintains full-time employee status (40 h per week) screening female patients on site in the ED and in the Labor and Delivery unit, working with DV victims through a referral process, and providing DV training to medical professionals at the hospital.
Selection of Participants Female patients between the ages of 18 and 60 years presenting to the ED were eligible for screening. The exclusion criteria included patients either too ill or too injured to participate in the screening interview, and those who declined the screening examination. Patients were selected by the DV advocate via the IBEX computer system in the ED, which was used in this study to identify rooms occupied by female patients.
Data Collection Data on incidence and prevalence of DV were collected via direct interview by a single trained DV advocacy coordinator. During the interview, each patient was initially informed that a health screening regarding safety concerns would be performed. Other members in the room were asked to step out. An unscripted interview then began with a reintroduction of the DV advocacy coordinator as a crisis worker, and an assurance that the interview was confidential. The DV advocacy coordinator did not read from a script or written survey, but asked each patient the same basic questions: 1) “Have you ever been in a relationship in which you felt afraid or unsafe?” 2) “Have you ever been in a relationship in which you were hurt or threatened, physically, verbally, or sexually?” 3) “Are you currently here (in the ED) because of an abusive or violent relationship or do you feel stress or anxiety about a relationship you are currently in?” If the patient responded in the affirmative to any of the above questions, further questions were posed to determine whether the relationship was a former or current relationship, as well as the nature of the abuse. Informational pamphlets, referral numbers, and support were offered to every patient. Information obtained was incorporated into an Excel database spreadsheet (Microsoft Corporation, Redmond, WA). The DV advocate used a standard screening form from her agency’s Hospital Advocacy Program to record data during the examination. Data included were general identifiers such as the patient’s name, room number in the ED, date, day, and time of day. Other information included whether the patient was identified as a current or past victim of DV, whether a follow-up was requested,
862
J. A. Hugl-Wajek et al.
and whether a release was signed regarding the conversation. Finally, the type of informational materials given, as well as contact information for each patient, including safe telephone numbers and addresses for use in followup, were recorded. Safety and lethality assessment tools developed by the DV agency were used to help guide the patient in a current DV situation to develop a safety plan during the interview process. Elements of the safety plan included offering to call the police; determining a safe place to go immediately or in the future should the violence escalate; making an escape plan from the home for the victim and any children involved; packing a bag with those items and important documents that would be needed by the patient and the children after escape; finding a safe place to hide those items and important documents until needed; and advising the victim about her legal rights and options for protection through the courts. The DV advocate also offered to assist the patient in making telephone calls necessary to establish safety, gave assistance with immediate clothing needs if necessary, and provided a follow-up care telephone call, if desired by the patient, within 48 h of discharge, to a safe telephone number given by the patient.
Data Analysis The advocacy coordinator tracked the total number of women screened, the number of women who never experienced a DV relationship, the number of women currently in a DV relationship, the number of victims who suffered DV in their past relationships, and the total number of victims identified (sum of women currently in and those previously in DV relationships) (Table 1, Figure 1). Care was taken to prevent any identifying information from being released regarding the patients
screened, to preserve the confidentially agreement made between the DV advocacy coordinator and each woman screened. The data were separated into monthly and yearly totals. Percentages of the totals for lifetime prevalence and acute incidence of DV were calculated and confidence intervals were determined using the Wilson Score Method. Additionally, a chart review was performed, on a randomly selected day in the ED, for all patients presenting over a 24-h period, to identify documentation of DV screening on the IBEX computerized system used in the ED. These charts were examined for evidence of DV screening being performed by other members of the health care team, to gain perspective on who was performing additional DV screening in the ED.
RESULTS Of the 1550 women screened, 75 women were found to be in current abusive relationships, and 351 women had experienced abuse in the past (Table 1, Figure 1). Both the incidence and lifetime prevalence of DV were analyzed from the data collected. The incidence was calculated by taking the number of women who were in current abusive relationships (75), divided by the total number of women screened (1550); it was found to be 4.8%, with a 95% confidence interval (CI) of 3.9 – 6.0%. The lifetime prevalence was calculated by taking the total number of victims identified as having experienced abuse in the past or being in current abusive relationships (426), and dividing that number by the total number of women screened (1550); it was 27.5%, with a 95% CI of 25.3–29.8%. On reviewing a random day in the ED, consisting of a full 24-h time period, we found that out of 107 women who were seen, only 4 had documentation of screening for DV by other personnel. All 4 patients were screened
Table 1. Monthly and Yearly Gross Number and Percentage of Women Screened for Domestic Violence (DV) for the Year 2006 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2006 Total
Women Women Not in a DV Women in Past DV Women in a Current Total DV Victims Total DV Victims Screened Relationship Relationship(s) DV Relationship Identified Identified (%) 153 160 160 108 124 135 97 113 115 143 122 120 1550
108 120 123 71 87 92 63 88 86 107 92 87 1124
37 38 30 24 29 39 26 19 26 29 26 28 351
8 2 7 13 8 4 8 6 3 7 4 5 75
45 40 37 37 37 43 34 25 29 36 30 33 426
29% 25% 23% 34% 30% 32% 35% 22% 25% 25% 25% 28% 27%
Domestic Violence Detection
863
Figure 1. Monthly and yearly gross number and percentage of women screened for domestic violence (DV) for the year 2006.
by the trained DV coordinator, and none of the women was screened by any other member of the health care team in the ED.
DISCUSSION Extensive studies, both within emergency medicine and in many other fields of medicine, have demonstrated the physical and mental health risks and the long-term sequelae of DV. The current body of literature has demonstrated that DV is a significant concern—the incidence and prevalence has been documented repeatedly as affecting a large number of female patients who visit EDs. The published literature has examined the efficacy of detecting the incidence of DV by the use of written surveys, computer-based surveys, and by screening conducted by health care professionals, including physicians and nurses. Comparing our results to published prevalence data (11.3–54.2% with written or computerized surveys and 10.9 –36.9% with interviews performed by various ED personnel), our results were found to fall within the same range as found in the published reports regardless of the method of detection (2,5–15). When compared with existing published acute incidence data (1–19% when obtained by written or computerized survey and 1–2.2% when obtained by interview), our results suggest a higher rate of detection than most previous reports of results obtained by personal patient interview (2,5–15).
We studied the incidence and prevalence of DV as detected by a trained DV advocacy coordinator. Although our findings fell within the range of DV patients detected by previous studies utilizing various methods, in comparison to the existing literature reporting detection rates just from personal interviews, our findings suggest a higher rate of detection of acute incidence of DV from personal interviews conducted by our dedicated DV advocate. Additionally, on chart review of a random 24-h period, it appears that adequate screening by other health care providers is not being conducted. There are many potential barriers to screening that may contribute to a lack of consistency in screening methods and frequency, including a lack of standardized training for ED staff in DV detection. Self-reported screening frequency by staff and perceived barriers to screening have been studied. Inadequate preparation, both in education and experience, emerged as a key barrier to routine screening, as did the importance of “real world” constraints associated with providing emergency medical care, such as time and resources needed (4). Our DV advocate’s detection method is systematic, conducted regularly, but still individualized for each patient’s personal needs. Limitations We recognize the limitations of our study. As our DV advocate was available only during weekday daytime hours, we were unable to obtain data on the incidence of DV in patients presenting to the ED during night, early
864
J. A. Hugl-Wajek et al.
morning, or weekend hours. In addition, we did not include women who were critically injured or those cared for by the Trauma service; indeed, these women may have been injured by DV, and probably would have a higher incidence of DV as a group than other women screened in the ED. The DV advocate’s method of screening was not standardized; the same basic questions were asked of each patient, but subsequent investigation was then dependent on the responses to those initial questions and was not the same for each patient. Legal and safety requirements made it impossible to determine whether any of the four women screened on the chart review of a random day in the ED were actual victims of DV, thus, whether this is clinically relevant is unknown. Male patients were also excluded from this study. The protocol used by the DV advocate focuses on high-risk populations; according to the most recent US Bureau of Justice Statistics, 85% of victims of DV are women. Due to personnel and time constraints, the DV advocate in this study focused on women.
CONCLUSION It is clear that more research needs to be done to find better ways to detect DV victims in the ED and to intervene in the lives of these women. Having a trained domestic advocacy coordinator may offer the advantage of higher rates of detection than other health care professionals achieve, with the added benefit of designated training and a focus that is dedicated only to this aspect of a patient’s health care. The extensive training and experience of the trained DV advocate implies a more comprehensive intervention and thus may improve the effectiveness of ED detection of and intervention with patients identified as DV victims. Future studies might address such issues as who is actually performing DV screening of patients in the ED, a controlled comparison of incidence and prevalence obtained by the DV advocate vs. other health care professionals at the same institution, as well as studies that evaluate for incidence and prevalence in high-risk groups such as trauma patients.
Acknowledgments—Special thanks to Lori Kennedy and the Crisis Center for South Suburbia (a not-for-profit domestic violence agency) for their help on this research. Their time and commitment to this project and their continued dedication to the care and well-being of these patients is invaluable and greatly appreciated.
REFERENCES 1. Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence: findings from the National Violence against Women Survey. Washington, DC: US Department of Justice; 2000. 2. Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against women. Incidence and prevalence in an emergency department population. JAMA 1995;273:1763–7. 3. Gerbert B, Gansky SA, Tang JW, et al. Domestic violence compared to other health risks: a survey of physicians’ beliefs and behaviors. Am J Prev Med 2002;23:82–90. 4. Gutmanis I, Beynon C, Tutty L, Wathen CN, MacMillan HL. Factors influencing identification of and response to intimate partner violence: a survey of physicians and nurses. BMC Public Health 2007;7:12. 5. Anglin D, Sachs C. Preventive care in the emergency department: screening for domestic violence in the emergency department. Acad Emerg Med 2003;10:1118 –27. 6. Ernst AA, Weiss SJ, Nick TG, Casalletto J, Garza A. Domestic violence in a university emergency department. South Med J 2000;93:176 – 81. 7. MacMillan HL, Wathen CN, Jamieson E, et al. Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA 2006;296:530 – 6. 8. Roberts GL, O’Toole BI, Raphael B, Lawrence JM, Ashby R. Prevalence study of domestic violence victims in an emergency department. Ann Emerg Med 1996;27:741–53. 9. Sethi D, Watts S, Zwi A, Watson J, McCarthy C. Experience of domestic violence by women attending an inner city accident and emergency department. Emerg Med J 2004;21:180 – 4. 10. Lo Vecchio F, Bhatia A, Sciallo D. Screening for domestic violence in the emergency department. Eur J Emerg Med 1998;5: 441– 4. 11. McCloskey LA, Lichter E, Ganz ML, et al. Intimate partner violence and patient screening across medical specialties. Acad Emerg Med 2005;12:712–22. 12. Boyle A, Todd C. Incidence and prevalence of domestic violence in a UK emergency department. Emerg Med J 2003;20:438 – 42. 13. Dearwater SR, Coben JH, Campbell JC, et al. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA 1998;280:433– 8. 14. Sixsmith DM, Weissman L, Constant F. Telephone follow-up for case finding of domestic violence in an emergency department. Acad Emerg Med 1997;4:301– 4. 15. Biroscak BJ, Smith PK, Roznowski H, Tucker J, Carlson G. Intimate partner violence against women: findings from one state’s ED surveillance system. J Emerg Nurs 2006;32:12– 6.
Domestic Violence Detection
ARTICLE SUMMARY 1. Why is this topic important? Domestic violence affects millions of women, many of whom present to the emergency department (ED) with injuries. Research has shown that many emergency physicians do not feel adequately trained or do not have the time to properly screen for this health problem. A trained domestic violence coordinator may help improve detection rates. 2. What does this study attempt to show? A trained domestic violence advocacy coordinator aids in the detection of domestic violence in female patients presenting to the ED. 3. What are the key findings? The findings of this study fall within the range of domestic violence detected by previous studies utilizing other methods. However, in comparison to previous studies reporting personal interview detection rates, our findings suggest a higher rate of detection of acute incidence of domestic violence from personal interview conducted by our dedicated domestic violence advocate. Additionally, on chart review of a random 24-h period, it was found that adequate screening by other health care providers is not being conducted. 4. How is patient care affected? By utilizing a trained domestic violence advocacy coordinator in the ED, a higher percentage of patients affected by acute domestic violence are detected. These are the patients for whom ED intervention can then potentially be offered.
865
http://dx.doi.org/10.1016/j.jemermed.2009.07.031
Violence: Recognition, Management, and Prevention
DETECTION OF DOMESTIC VIOLENCE BY A DOMESTIC VIOLENCE ADVOCATE IN THE ED Jessica A. Hugl-Wajek,
MD,
Deborah Cairo,
MD,
Shruti Shah,
MD,
and Barbara McCreary,
MD
Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois Reprint Address: Jessica A. Hugl-Wajek, MD, Department of Emergency Medicine, Sacred Heart Hospital, 900 West Clairemont Ave., Eau Claire, WI 54701
e Keywords— domestic violence; detection of domestic violence; domestic violence advocacy coordinator
e Abstract—Background: The current domestic violence (DV) literature has evaluated the incidence and prevalence of DV via written surveys and verbal questioning performed by a variety of health care professionals. Objectives: We sought to examine the prevalence of DV as obtained by a full-time, trained DV advocacy coordinator using direct patient interviewing in our emergency department (ED), and to compare our results with the published literature. Methods: The DV advocacy coordinator randomly selected and interviewed female patients presenting to the ED with various complaints during daytime hours. Participation was voluntary, and patients were excluded if they were too ill or injured to answer questions. We performed a retrospective review of data obtained through our DV advocacy coordinator’s screening interviews of female patients presenting to the ED over a period of 1 year. Acute incidence and lifetime prevalence of DV was determined and compared to results reported in the literature. Results: The domestic violence advocacy coordinator screened a total of 1550 patients over the study period. Domestic violence incidence and lifetime prevalence as detected by the coordinator was determined to be 4.8% (95% confidence interval [CI] 3.9 – 6.0%) and 27.5% (95% CI 25.3–29.8%), respectively. Conclusions: Although the lifetime DV prevalence of 27.5% uncovered by our trained DV advocacy coordinator is similar to other reports, the acute incidence of 4.8% is higher than most other reported results using personal interviews. The use of a trained DV coordinator may improve detection rates of domestic violence in the ED. Published by Elsevier Inc.
RECEIVED: 23 January 2009; FINAL ACCEPTED: 10 July 2009
SUBMISSION RECEIVED:
INTRODUCTION Domestic violence is a health care epidemic. The Centers for Disease Control and Prevention reported that over 4.8 million cases of intimate partner-related physical assaults and rapes in women and over 2.9 million in men occur yearly (1). The Department of Justice reported that domestic violence or intimate partner violence resulted in the deaths of 1544 people in 2004. Physical trauma, though obviously important from the perspective of those in the field of emergency medicine, is not the only consideration. Domestic violence also underlies many other aspects of health, including chronic pain syndromes, depression, substance abuse, and sexually transmitted diseases. Routine screening for domestic violence in health care settings, particularly in the emergency department (ED), can be an important preventive measure toward reducing the consequences of this type of violence. The ED presents a unique opportunity for health care providers to identify victims of domestic violence; it has been asserted that as many as 54% of all women who seek care in hospital EDs have been affected by domestic violence at some point in their lifetime (2). However, there are numerous barriers to adequate screening, de-
9 April 2009; 860
Domestic Violence Detection
tection, and support in the ED that may affect actual rates of detection. Health care providers are often untrained or feel uncomfortable dealing with patients who present with complaints secondary to domestic violence (3). Additionally, there are arguments that there is simply too little time for nurses or physicians to adequately address the important issue of domestic violence during the patient’s ED visit (4). Many attempts have been made to determine the overall incidence and prevalence of domestic violence through a variety of means. Although there is a good deal of existing literature on the prevalence and incidence of domestic violence, most of the previous studies have utilized a written survey or interviews by ED staff (registered nurse, physician assistant, or emergency physician) (2,5–15). Our hospital engages the services of a dedicated domestic violence advocate brought in from the community through an outside agency. This individual performs random screening examinations on ED patients and inpatients, evaluating for domestic violence and providing support and advocacy materials to identified victims. She is able to focus exclusively on the topic of domestic violence, freeing the physician and nursing staff to focus on the acute medical problems at hand. We sought to add to the existing literature by examining the incidence and lifetime prevalence of domestic violence as detected by a dedicated domestic violence advocate in a busy ED over 1 year.
MATERIALS AND METHODS Study Design A retrospective review of data was performed over a period of 1 year, from January through December 2006. This was the first full year in which the trained domestic advocacy coordinator had initiated data collection. This advocacy coordinator was the single interviewer and data collector in this study. The hospital’s Institutional Review Board approved this review.
Setting Data were collected in the ED of our hospital, a Level I trauma center with an emergency medicine residency training program, with over 80,000 patient visits yearly. The trained domestic violence (DV) advocacy coordinator is the coordinator of a community agency’s hospital advocacy program. Her title is Certified Domestic Violence Professional, with certification obtained through Illinois Certified Domestic Violence Professionals, Inc.
861
She has more than 3 years of experience as a DV advocate and maintains full-time employee status (40 h per week) screening female patients on site in the ED and in the Labor and Delivery unit, working with DV victims through a referral process, and providing DV training to medical professionals at the hospital.
Selection of Participants Female patients between the ages of 18 and 60 years presenting to the ED were eligible for screening. The exclusion criteria included patients either too ill or too injured to participate in the screening interview, and those who declined the screening examination. Patients were selected by the DV advocate via the IBEX computer system in the ED, which was used in this study to identify rooms occupied by female patients.
Data Collection Data on incidence and prevalence of DV were collected via direct interview by a single trained DV advocacy coordinator. During the interview, each patient was initially informed that a health screening regarding safety concerns would be performed. Other members in the room were asked to step out. An unscripted interview then began with a reintroduction of the DV advocacy coordinator as a crisis worker, and an assurance that the interview was confidential. The DV advocacy coordinator did not read from a script or written survey, but asked each patient the same basic questions: 1) “Have you ever been in a relationship in which you felt afraid or unsafe?” 2) “Have you ever been in a relationship in which you were hurt or threatened, physically, verbally, or sexually?” 3) “Are you currently here (in the ED) because of an abusive or violent relationship or do you feel stress or anxiety about a relationship you are currently in?” If the patient responded in the affirmative to any of the above questions, further questions were posed to determine whether the relationship was a former or current relationship, as well as the nature of the abuse. Informational pamphlets, referral numbers, and support were offered to every patient. Information obtained was incorporated into an Excel database spreadsheet (Microsoft Corporation, Redmond, WA). The DV advocate used a standard screening form from her agency’s Hospital Advocacy Program to record data during the examination. Data included were general identifiers such as the patient’s name, room number in the ED, date, day, and time of day. Other information included whether the patient was identified as a current or past victim of DV, whether a follow-up was requested,
862
J. A. Hugl-Wajek et al.
and whether a release was signed regarding the conversation. Finally, the type of informational materials given, as well as contact information for each patient, including safe telephone numbers and addresses for use in followup, were recorded. Safety and lethality assessment tools developed by the DV agency were used to help guide the patient in a current DV situation to develop a safety plan during the interview process. Elements of the safety plan included offering to call the police; determining a safe place to go immediately or in the future should the violence escalate; making an escape plan from the home for the victim and any children involved; packing a bag with those items and important documents that would be needed by the patient and the children after escape; finding a safe place to hide those items and important documents until needed; and advising the victim about her legal rights and options for protection through the courts. The DV advocate also offered to assist the patient in making telephone calls necessary to establish safety, gave assistance with immediate clothing needs if necessary, and provided a follow-up care telephone call, if desired by the patient, within 48 h of discharge, to a safe telephone number given by the patient.
Data Analysis The advocacy coordinator tracked the total number of women screened, the number of women who never experienced a DV relationship, the number of women currently in a DV relationship, the number of victims who suffered DV in their past relationships, and the total number of victims identified (sum of women currently in and those previously in DV relationships) (Table 1, Figure 1). Care was taken to prevent any identifying information from being released regarding the patients
screened, to preserve the confidentially agreement made between the DV advocacy coordinator and each woman screened. The data were separated into monthly and yearly totals. Percentages of the totals for lifetime prevalence and acute incidence of DV were calculated and confidence intervals were determined using the Wilson Score Method. Additionally, a chart review was performed, on a randomly selected day in the ED, for all patients presenting over a 24-h period, to identify documentation of DV screening on the IBEX computerized system used in the ED. These charts were examined for evidence of DV screening being performed by other members of the health care team, to gain perspective on who was performing additional DV screening in the ED.
RESULTS Of the 1550 women screened, 75 women were found to be in current abusive relationships, and 351 women had experienced abuse in the past (Table 1, Figure 1). Both the incidence and lifetime prevalence of DV were analyzed from the data collected. The incidence was calculated by taking the number of women who were in current abusive relationships (75), divided by the total number of women screened (1550); it was found to be 4.8%, with a 95% confidence interval (CI) of 3.9 – 6.0%. The lifetime prevalence was calculated by taking the total number of victims identified as having experienced abuse in the past or being in current abusive relationships (426), and dividing that number by the total number of women screened (1550); it was 27.5%, with a 95% CI of 25.3–29.8%. On reviewing a random day in the ED, consisting of a full 24-h time period, we found that out of 107 women who were seen, only 4 had documentation of screening for DV by other personnel. All 4 patients were screened
Table 1. Monthly and Yearly Gross Number and Percentage of Women Screened for Domestic Violence (DV) for the Year 2006 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2006 Total
Women Women Not in a DV Women in Past DV Women in a Current Total DV Victims Total DV Victims Screened Relationship Relationship(s) DV Relationship Identified Identified (%) 153 160 160 108 124 135 97 113 115 143 122 120 1550
108 120 123 71 87 92 63 88 86 107 92 87 1124
37 38 30 24 29 39 26 19 26 29 26 28 351
8 2 7 13 8 4 8 6 3 7 4 5 75
45 40 37 37 37 43 34 25 29 36 30 33 426
29% 25% 23% 34% 30% 32% 35% 22% 25% 25% 25% 28% 27%
Domestic Violence Detection
863
Figure 1. Monthly and yearly gross number and percentage of women screened for domestic violence (DV) for the year 2006.
by the trained DV coordinator, and none of the women was screened by any other member of the health care team in the ED.
DISCUSSION Extensive studies, both within emergency medicine and in many other fields of medicine, have demonstrated the physical and mental health risks and the long-term sequelae of DV. The current body of literature has demonstrated that DV is a significant concern—the incidence and prevalence has been documented repeatedly as affecting a large number of female patients who visit EDs. The published literature has examined the efficacy of detecting the incidence of DV by the use of written surveys, computer-based surveys, and by screening conducted by health care professionals, including physicians and nurses. Comparing our results to published prevalence data (11.3–54.2% with written or computerized surveys and 10.9 –36.9% with interviews performed by various ED personnel), our results were found to fall within the same range as found in the published reports regardless of the method of detection (2,5–15). When compared with existing published acute incidence data (1–19% when obtained by written or computerized survey and 1–2.2% when obtained by interview), our results suggest a higher rate of detection than most previous reports of results obtained by personal patient interview (2,5–15).
We studied the incidence and prevalence of DV as detected by a trained DV advocacy coordinator. Although our findings fell within the range of DV patients detected by previous studies utilizing various methods, in comparison to the existing literature reporting detection rates just from personal interviews, our findings suggest a higher rate of detection of acute incidence of DV from personal interviews conducted by our dedicated DV advocate. Additionally, on chart review of a random 24-h period, it appears that adequate screening by other health care providers is not being conducted. There are many potential barriers to screening that may contribute to a lack of consistency in screening methods and frequency, including a lack of standardized training for ED staff in DV detection. Self-reported screening frequency by staff and perceived barriers to screening have been studied. Inadequate preparation, both in education and experience, emerged as a key barrier to routine screening, as did the importance of “real world” constraints associated with providing emergency medical care, such as time and resources needed (4). Our DV advocate’s detection method is systematic, conducted regularly, but still individualized for each patient’s personal needs. Limitations We recognize the limitations of our study. As our DV advocate was available only during weekday daytime hours, we were unable to obtain data on the incidence of DV in patients presenting to the ED during night, early
864
J. A. Hugl-Wajek et al.
morning, or weekend hours. In addition, we did not include women who were critically injured or those cared for by the Trauma service; indeed, these women may have been injured by DV, and probably would have a higher incidence of DV as a group than other women screened in the ED. The DV advocate’s method of screening was not standardized; the same basic questions were asked of each patient, but subsequent investigation was then dependent on the responses to those initial questions and was not the same for each patient. Legal and safety requirements made it impossible to determine whether any of the four women screened on the chart review of a random day in the ED were actual victims of DV, thus, whether this is clinically relevant is unknown. Male patients were also excluded from this study. The protocol used by the DV advocate focuses on high-risk populations; according to the most recent US Bureau of Justice Statistics, 85% of victims of DV are women. Due to personnel and time constraints, the DV advocate in this study focused on women.
CONCLUSION It is clear that more research needs to be done to find better ways to detect DV victims in the ED and to intervene in the lives of these women. Having a trained domestic advocacy coordinator may offer the advantage of higher rates of detection than other health care professionals achieve, with the added benefit of designated training and a focus that is dedicated only to this aspect of a patient’s health care. The extensive training and experience of the trained DV advocate implies a more comprehensive intervention and thus may improve the effectiveness of ED detection of and intervention with patients identified as DV victims. Future studies might address such issues as who is actually performing DV screening of patients in the ED, a controlled comparison of incidence and prevalence obtained by the DV advocate vs. other health care professionals at the same institution, as well as studies that evaluate for incidence and prevalence in high-risk groups such as trauma patients.
Acknowledgments—Special thanks to Lori Kennedy and the Crisis Center for South Suburbia (a not-for-profit domestic violence agency) for their help on this research. Their time and commitment to this project and their continued dedication to the care and well-being of these patients is invaluable and greatly appreciated.
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Domestic Violence Detection
ARTICLE SUMMARY 1. Why is this topic important? Domestic violence affects millions of women, many of whom present to the emergency department (ED) with injuries. Research has shown that many emergency physicians do not feel adequately trained or do not have the time to properly screen for this health problem. A trained domestic violence coordinator may help improve detection rates. 2. What does this study attempt to show? A trained domestic violence advocacy coordinator aids in the detection of domestic violence in female patients presenting to the ED. 3. What are the key findings? The findings of this study fall within the range of domestic violence detected by previous studies utilizing other methods. However, in comparison to previous studies reporting personal interview detection rates, our findings suggest a higher rate of detection of acute incidence of domestic violence from personal interview conducted by our dedicated domestic violence advocate. Additionally, on chart review of a random 24-h period, it was found that adequate screening by other health care providers is not being conducted. 4. How is patient care affected? By utilizing a trained domestic violence advocacy coordinator in the ED, a higher percentage of patients affected by acute domestic violence are detected. These are the patients for whom ED intervention can then potentially be offered.
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