Injury prevention/original research
Does Screening in the Emergency Department Hurt or Help Victims of Intimate Partner Violence?

Presented at a panel presentation at the Family Violence Prevention Fund conference, March 2007, San Francisco, CA.
https://doi.org/10.1016/j.annemergmed.2007.11.019Get rights and content

Study objective

Recent systematic reviews have noted a lack of evidence that screening for intimate partner violence does more good than harm. We assess whether patients screened for intimate partner violence on a computer kiosk in the emergency department (ED) experienced any adverse events during or subsequent to the ED visit and whether computer kiosk identification and referral of intimate partner violence in the ED setting resulted in safety behaviors or contact with referrals.

Methods

We conducted a prospective, observational study in which a convenience sample of male and female ED patients triaged to the waiting room who screened positive (on a computer kiosk-based questionnaire) for intimate partner violence in the past year were provided with resources and information and invited to participate in a series of follow-up interviews. At 1-week and 3-month follow-up visits, we assessed intimate partner violence, safety issues, and use of resources. In addition, to obtain an objective measure of safety, we assessed the number of violence-related 911 calls to participant addresses within a call district 6 months before and 6 months after the index ED visit.

Results

Of the 2,134 participants in a relationship in the last year, 548 (25.7%) screened positive for intimate partner violence. No safety issues, such as calling security or a partner’s interference with the screening, occurred during the ED visit for any patient who disclosed intimate partner violence. Of the 216 intimate partner violence victims interviewed in person and 65 contacted by telephone 1 week later, no intimate partner violence victims reported any injuries or increased intimate partner violence resulting from participating in the study. For the sample in the local police district, there was no increase in the number of intimate partner violence victims who called 911 in the 6 months after the ED visit. Finally, 35% (n=131) reported they had contacted community resources during the 3-month follow-up period.

Conclusion

Among patients screening positive for intimate partner violence, there were no identified adverse events related to screening, and many had contacted community resources.

Introduction

Although victims of intimate partner violence frequently use emergency department (ED) services, most present for non-injury-related complaints and are not screened for intimate partner violence despite recommendations for routine intimate partner violence screening by the American Medical Association and The Joint Commission.1 However, neither the United States Preventive Services Task Force nor the Canadian Task Force on Preventive Health Care found sufficient evidence to recommend for or against intimate partner violence screening.2, 3

One piece of information needed and not available for the United States Preventive Services review was an assessment of the safety of intimate partner violence screening itself. In fact, there are limited data available on the potential for harm or retaliation that might result from routine screening and intimate partner violence identification in a health care setting with either women or men.

In addition, very few studies have examined the effectiveness of intimate partner violence screening related to seeking out resources or patient outcomes. One study found that almost half of women who disclosed intimate partner violence during screening accepted case management follow-up.4 Many of these women believed that they were no longer at risk for intimate partner violence after participating in the screening. However, another study revealed that most health care providers documented intimate partner violence status after patients participated in a mandatory waiting room screen, but only 10% of these medical records included any mention of a safety plan or referral.5 These results suggest that even if screening is implemented in health care settings, it may not objectively improve referrals or outcomes.

The goals of this study were (1) to determine whether patients (male or female) who disclosed intimate partner violence victimization on a computer screening assessment in the ED would have any safety issues (ie, disruption of the visit by a partner, security involvement) compared with ED patients who did not disclose intimate partner violence; (2) to ascertain whether intimate partner violence victims had any short-term safety issues at 1-week and 3-month follow-up related to screening, including increased number of violent acts, increased severity of intimate partner violence, and other self-reported safety issues after participation or any increases in 911 calls 6 months after the ED visit from the addresses of all patients who screened positive for victimization within 1 call district; and (3) to investigate whether screening linked with automatic (computer-generated) resource information would result in intimate partner violence victims contacting referrals or taking any measures to improve their safety.

Section snippets

Study Design

We conducted an intervention study with a prospective cohort of intimate partner violence victims from February 2004 to April 2006. We identified male and female intimate partner violence victims at an index ED visit by using a touch-screen computer kiosk. The intervention consisted of computer-generated targeted referrals tailored to the health risk behaviors, specifically intimate partner violence in this study that the patient disclosed on the kiosk. We then conducted follow-up interviews

Results

Approximately 6,328 patients were triaged to the waiting room during our study hours, and 5,473 were approached to participate in the study. Four thousand four hundred twenty-five patients were eligible for survey participation and 3,083 (69.6%) consented to participate. No differences existed for race or chief complaint between participants and nonparticipants, although participants tended to be younger and women. Overall, of the initial 3,083 consenting participants: 47% were women, 88% were

Limitations

Before one generalizes our findings, there are certain factors to consider. The study recruited a convenience sample of patients who were not acutely ill or severely injured. The limited sample size at the 3-month follow-up assessment limits analysis. Many intimate partner violence victims were lost to follow-up, and these victims may have had safety issues after screening positive for intimate partner violence or these victims may not have found the resource information helpful and decided not

Discussion

We found no evidence that computer-based screening for intimate partner violence in the ED setting resulted in harm or significant adverse events for intimate partner violence victims. However, ED follow-up is notoriously poor for all manner of acute medical and surgical complaints, so adverse events may well have occurred in the group without follow-up. Nonetheless, 65% of screened intimate partner violence victim participants who agreed to participate either returned to the ED for follow-up

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      In general, whether in-person face-to-face questioning, or use of a computer-interface for screening, no harm to patients has been reported. However, none of these studies were specific to adolescents.84,85 Example screening questions are listed in Table 4 and a summary of best practices for screening adolescents for TDV are available in Table 5.

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    Supervising editors: Rita K. Cydulka, MD, MS; Michael L. Callaham, MD

    Author contributions: DH, NJK, LAM, CC, HS, and KVR developed the study design and obtained funding. DH, NJK, and RSK oversaw the study protocol and enrollment of participants. ER and CL performed statistical analyses. All authors participated in drafting and revising the article and all approved the final version. DH takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by CDC R-49 grant 4230113 (Houry), NIMH K-23 grant 069375 (Houry), and NIMH K23 64574 (Rhodes).

    Reprints not available from the authors.

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