More than three quarters of domestic violence victims who report the incidents to police seek health care in emergency rooms, but most of them are never identified as being victims of abuse during their hospital visit. These findings, from a new University of Pennsylvania School of Medicine study, point to a missed opportunity to intervene and offer help to women who suffer violence at the hands of an intimate partner.
"Emergency departments are a safety net for women with health issues of all kinds, but our study shows we're not doing a good enough job of assessing our patients' entire situation," said Karin V. Rhodes, MD, MS, director of Penn's Division of Emergency Care Policy Research in the department of Emergency Medicine. "There is no reason in the age of information technology that we should not provide routine screening and referrals to the social services patients can use to protect themselves from future violence."
The findings, published online this week in the Journal of General Internal Medicine, revealed that women who reported domestic assaults to the police relied heavily on emergency rooms for medical care: Nearly 80 percent came to an emergency room at least once during the four years after their assault. Most of those sought ED care frequently - an average of seven times each. Although hospitals typically have policies requiring screening and intervention for domestic violence, only 28 percent of the patients studied were ever identified as victims of abuse. That's likely because most visits (78 percent) were for medical complaints, not injuries associated with the violence. Only 3.8 percent of the ED visits involved a chief complaint of assault, which the authors say underscores the importance of screening patients who don't appear to be at risk.
Previous studies have shown that as many as 20 percent of women have been victims of domestic violence in the past year, but moves toward universal screening in emergency departments have yet to be shown to be effective. To better focus on how often - and how - victims are identified when they come to the emergency room, the study authors conducted a longitudinal cohort study that cross-checked court, police and emergency department records in a semi-rural county in Michigan between 1999 and 2002.
The authors found that intimate partner violence was more likely to be identified when the ED visit occurred on the day of the police incident - assaults were four times more likely to be revealed at this point - and when patients were transported to the hospital by police. Providers were also more likely to identify abuse among patients whose chief complaints involved mental health or substance abuse issues such as suicidal behavior or overdoses.
The data showed that when abuse was identified, ED staff provided legally useful notes in the patient's chart 86 percent of the time and communicated with police about half the time. However, those steps didn't always lead to interventions to actually protect the women - fewer than 35 percent of cases where abuse victims were identified, contained any documented assessment of whether the patient has a safe place to go after discharge from the hospital. Nor were they consistent in referring victims to community-based domestic violence resources - that occurred only 25 percent of the time. Since health care workers have limited resources to devote to interventions for domestic violence, the authors point out the need to take a cross-systems approach to make it easier for providers to do the right thing.
"Most hospitals have a social work infrastructure to counsel patients with social risks and assist them in linking to needed services, but our study shows that these resources are infrequently utilized. This may be due to the fact that social workers are not always readily available in the ED," Rhodes said. "As providers, we should strive to set up our health care system to present every patient with an opportunity to feel safe and supported in disclosing instances of abuse and give them information and resources that can help."
Among strategies Rhodes and her coauthors suggest to boost the identification of women who've been abused: Use of confidential patient portals in which patients could use the Internet to link to their medical record and communicate with their providers, and development of easy-to-access interventions for victims, such as the on-site programs used to help patients with substance abuse and mental health problems. Integrated databases linking hospitals, criminal justice and social service agencies could also increase identification and tracking of abuse and use of support services.
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