Nearly half of women who are killed as a result of intimate partner violence present to the ED in the two years prior to their deaths, most with evidence of battering. Yet, only 1 in 7 emergency physicians report having a standardized intervention checklist. Let’s change that.
It is 3:20 a.m. in your busy ED. You are walking in to see a quick level 4 patient with a chief complaint of shoulder pain. Mikayla, (not her real name) is a 28-year-old woman who presents with numerous bruises and pain in the L shoulder. She also appears to be very guarded. Her answers are brief, and she seems disengaged. Mikayla is six months pregnant. Initially, Mikayla reports she fell down on the ice. However, with some support and prompting, Mikayla takes a risk.
She tearfully reports her boyfriend pushed her resulting in her falling down some stairs last night. She very quickly adds, “I don’t think he was trying to hurt me. He just was trying to get my attention.” and “I don’t want to get him into any trouble!” Both the nurse and physician are concerned that they are not hearing the entire story. There is a straight line mark on Mikayla’s shoulder. When questioned about this Mikayla becomes still, and then begins to cry. She states he pulled the window air conditioner from the window and threw it at her.
Domestic violence in heterosexual relationships is a serious issue, with 20% of women reporting they have been assaulted by their partners (IPARV, 2002). Stats are that 3 in 10 couples have had a violent episode at some point in the relationship, and 10-16% of trauma patients in the ED admit to being victims of intimate partner violence (Zakrison 2017). Nearly half of women who are killed as a result of intimate partner violence present to the ED in the 2 years prior to their deaths, and review of their charts show that most had evidence of battering at the time of ED presentation (Wadman 1999).
While most EDs have a mandatory screening policy to help identify victims of violence, only 1 in 7 report having a standardized intervention or intervention checklist. (Choo EK 2013) This is important as the majority of these victims (75%) will be discharged home (Joseph 2015). How can your ED team break this cycle of violence?
Education, screening, and a high suspicion for domestic violence are all needed. An intervention protocol or checklist should include a full assessment by someone with training in dealing with victims of violence, such as a social worker, psychologist, or advanced practice nurse.
Additionally, it should include a method to connect the patient with multidisciplinary support for long term recovery. These patients frequently require assistance from social workers, counselors, and psychologists in addition to medical follow up for their injuries. Any trauma, including assault and robbery, can cause mental health problems and socioeconomic problems. These patients may need assistance for lost work time due to injuries, damaged property, and safety assistance due to retaliation.
In a survey of teens seen in the ED for assault, 18% were assaulted again and 21% assaulted someone else within 8 weeks of their ED visit (Wiebe 2012). Rates of depression, anxiety, and PTSD after an abuse or violent episode are high (Ferrari 2016). Does your ED have a system in place to identify these patients and ensure good care and follow up?
DEVELOPING A SAFETY PLAN
A Safety Plan is the victim’s road map should he or she decide to leave the abuser. It is important to be prepared, as victims may have little to no warning of an opportunity to leave and need to act quickly or their situation is based on awareness of the danger and they need to escape immediately.
Safety plans can be elaborate or simple, and include some of the following:
• A specific plan for how to get out of the home (a window, a door, a garage)
• Packed bags each with necessities including keys to the home, car, and workplace, cash, financial documents e.g., copies of pay stubs, bills, and other financial documents, clothes and toiletries, identification documents e.g., driver’s license or passport, Social Security card or green card, visa, or other immigration papers if applicable, communication devices e.g., cell phone, phone numbers for friends, police, a shelter or agency that can help, checks or an ATM card, and a copy of a monthly checking account statement, and any legal documents like an order of protection or restraining order.
• One bag hidden somewhere the perpetrator of violence is unlikely to find, and a back-up saved by a friend in case the victim has to leave with no warning. If children are involved, prepare two similar bags packed for them. Be certain to pack items that are familiar that will provide some semblance of stability, e.g., a favorite toy or stuffed animal; one is stored where the batterer is unlikely to find it, and the other is saved by a friend. For each child, be certain to have a copy of birth certificates and school records, any medications or copies of needed prescriptions, and numbers for a friend or neighbor who will “watch out” for anything suspicious in the home.
• It is also important to have discussed this plan with a family member or friend who will respond a given way (e.g., calling the police) when the victim uses a preset “catch phrase.”
NEW PROGRAMS FOR VICTIMS OF VIOLENT CRIMES
One intervention that has proven success is referral to a multidisciplinary, trauma-centered program. This concept began with the development of the UC San Francisco Trauma Recovery Center (traumarecoverycenter.org), which reaches out to victims of violence identified in local EDs.
This program improves reporting to police, applications to victim compensation funds, and psychological recovery (Alvidrez 2008). In February of 2017, The Ohio State University Wexner Medical Center was awarded its first Victims of Crime Grant to support the development of the Stress, Trauma And Resilience (STAR) Trauma Recovery Center to provide services for Victims of Crime.
Ohio State’s STAR Program Trauma Recovery Center (STAR TRC) facilitates healing for adult survivors of trauma, violence, and loss through an innovative, evidence-based model of comprehensive care, advocacy, and outreach. The team is comprised of physicians, nurses, clinical case managers, Licensed Independent Clinical Social Workers (LICSW), and Licensed Chemical Dependency Counselors (LCDC), assertive outreach managers, and community advocates.
The team has been able to coordinate services for victims, such as transportation to and from medical appointments and counseling sessions, as well as safety provisions for those who cannot return to their home (e.g., short term housing options, emergency home repairs, emergency clothing and prescription medication assistance). The program works closely with the Attorney General’s office to assist with victim statements and to seek victim compensation. Since the program’s launch in February of 2017, it has seen increasing numbers of victims of crime.
Initially, victims were suspicious of the program, some fearing notification of law enforcement or requirement to file charges. The staff has worked diligently to support victims of crime in building a plan for recovery.
For Mikalya, the plan for recovery included safe housing, including individual safety provisions and supports for psychiatry visits and medications provided through the Victims of Crime Grant. Additionally, Mikalya attended group sessions. She was linked with community-based domestic violence services and participated in sessions of trauma-informed cognitive behavioral therapy individually tailored to address the trauma she had experienced without re-traumatizing her.
Mikalya was able to write her impact statement and to use this as the backdrop for reshaping her understanding of the events that brought her to programming. The program also helped her build her support group and to eventually move away from this relationship. She was linked with community-based mental health and case management for ongoing therapy and medication management.
Recently, Mikalya secured a full-time job within the logistics industry and is working to establish independent living arrangements.
Think about how different her story would be right now without access to recovery services or if a patient ED team hadn’t worked with her to discover the true problem. If you would like to learn more about the OSU STAR program or developing a similar program in your area, contact Dr. Lauren Southerland at firstname.lastname@example.org or Kenneth Yeager, PhD at email@example.com.