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176 WWW.JOURNALOFTRAUMANURSING.COM Volume 22 | Number 3 | May-June 2015

P I / O U T C O M E S M A N A G E M E N T

ABSTRACT The purpose of this study was to design and implement a

domestic violence (DV) screening protocol. Trauma patients

meeting inclusion criteria (hospitalized > 48 hours) were given a four question DV screen. If abuse was found, a

comprehensive DV questionnaire followed. Barriers to

screening and results were recorded. Compliance during

the pilot test showed 23 of 157 (14.6%) admitted patients

were screened. In the implementation year, 446 of 721

(61.9%) were screened. During the 10-month follow-up,

499 of 619 (80.6%) patients were screened. Lack of social

work resources was the primary barrier to screening, but

compliance increased and was maintained after the study

period.

Key Words Abuse screening , Intimate partner violence , Performance

improvement

Author Affiliations: Department of Trauma Services (Mss Day, Fox, and

Pugh, Dr Majercik), Social Services Department (Ms Redmond), and

Department of Emergency Medicine (Dr Bledsoe), Intermountain Medical

Center, Murray, Utah.

This study was approved by the Intermountain Healthcare, Urban Central

Region IRB.

None of the authors had any conflict of interest issues.

Correspondence: Suzanne Day, RN, BSN, MA, Department of Trauma

Services, Intermountain Medical Center, 5121 South Cottonwood St,

Murray, UT 84157 ( [email protected] ).

Implementing a Domestic Violence Screening Program

Suzanne Day , RN, BSN, MA ■ Jolene Fox , RN, AD ■ Sarah Majercik , MD ■ Floresha K. Redmond , MSW-LCSW ■ Mary Pugh , MSN, FNP-BC ■ Joseph Bledsoe , MD, FACEP

The biggest risk factor for intimate partner homicide is a history of prior DV. 5 About a quarter of female IPV victims will seek medical care, almost always in emer- gency departments (EDs). 6 , 7 One study showed that 44% of women who were eventually murdered by an intimate partner had been seen in an ED during the previous 2 years. 8 The great majority of these ED encounters were in- jury related. For this reason, among others, it is critical to identify victims of DV when they present to the hospital.

In 1999, the Eastern Association for the Surgery of Trauma first issued a position on DV, urging trauma sur- geons to take a leadership role in screening and provid- ing resources for victims. 9 Over the next several years, 2 different groups showed that DV on trauma services was more common than previously thought and had been drastically underreported in the past. 10 , 11 At our level 1 trauma center, prior to this study, we had a generic, hospital-wide “Healthcare Abuse Policy Statement,” but no specific protocol to identify DV victims on the trauma service. The purpose of this study was to design, imple- ment, and test the use of a DV screening protocol to ex- pand identification of DV victims and produce a more ac- curate prevalence rate in a trauma population at a single level 1 trauma center.

METHODS The procedure for DV screening was initiated using es- tablished performance improvement (PI) principles. On our trauma service, we have dedicated social workers (SWs) who see every admitted patient. At this trauma center, SWs are responsible identifying issues and for pro- viding psychological resources to patients in need. For this reason, the SW group, rather than nursing personnel, was selected to administer the screening. Involving SW as the initial screeners provides early involvement and a clear division of responsibilities. The SW group received orientation and training with the screening tool. Social worker then screened all admitted trauma patients who were 18 years or older. Patients were excluded if they had decreased mental capacity (as determined by the treating clinicians), medical extremis (unstable or severe distract- ing injury), unable to question the patient alone, primary psychiatric diagnosis as the main reason for admission, or patient unwilling to consent to the interview. DOI: 10.1097/JTN.0000000000000128

D omestic violence (DV) is the leading cause of seri- ous injury and death in women of childbearing age in the United States. 1 Worldwide, DV is responsible for 1 in 7 homicides and more than one-third of female homicides. 2 Almost 1 in 2 US women and 1

in 5 US men have experienced some form of sexual vic- timization. 3 Lifetime estimates of intimate partner violence (IPV) against women range from 25% to 49% and for men from 17% to 41%. 3 In 2003, the Department of Health and Human Services estimated that the cost of IPV against women was more than $5.8 billion each year with $1.4 billion for medical and mental health services and $0.9 billion in lost earnings over a lifetime. 4

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A previously developed 4-item screening tool 12 was used to determine whether there was a history of abuse ( Table 1 ). This tool was modified from an earlier study done on IPV in the ED by our sister hospital. If there was a “Yes” answer to any of the initial 4 questions, a 28-item comprehensive questionnaire was adminis- tered. This questionnaire was developed at our insti- tution based on others in the literature ( Table 2 ). The questionnaire was an information gathering tool and was tested for face to face validity. 9 Patient responses were entered into the medical record. On the basis of the answers, needs were assessed and specific coun- seling and/or outpatient referral resources provided.

A pilot study using the above tools was done in November and December of 2010. Early barriers to the process and PI process solutions/changes are document- ed in Table 3 . Ongoing process evaluations and PI pro- cess solutions/changes continued for the duration of the study and are documented in Table 4 . The computerized tracking process was updated in 2011 to further deline- ate patients who were successfully screened. Instead of just entering “YES” for patients who were screened, they were entered as either “YES + ” (screened and a history of abuse) or “YES − (screened with no history of abuse). This allowed for easier tracking and ensured more ac- curate results. Compliance was monitored throughout implementation (January-December 2011) and the 10 months following completion. When inadequate compli- ance occurred, monthly meetings were held to provide feedback results and discuss barriers and solutions. These meetings included the trauma program manager, lead SW, and the director and manager of social services. At this time, each patient who was identified as not having ad- equate screening or incomplete documentation was re- viewed. Informal discussion within the group revealed time, increased workload, and lack of resources as initial barriers to screening. Social Services Management was re- sponsible for proving feedback with their staff to educate on results and implement process changes. Issues with personnel (SW) who felt that the screening was burden- some were addressed by management and eventually tied to their performance evaluations.

Data were organized into 3 time frames– pilot study (November-December 2010), implementation with PI changes (January-December 2011), and posttrial evalu- ation (January-October 2012). Demographics variables collected included age and sex. The primary outcome variable was DV screening rate (adherence to the proto- col). Secondary variables were the DV screening results (abused and admitted for abuse).

Statistical Methods This study was largely descriptive. To evaluate data for se- lection bias, demographics for screened and not screened patients were compared. Continuous variables were com- pared using the 2-sided Student t test and discrete vari- ables were compared using the 2-sided Fisher exact test. Software used was Statit Software Xerox Corporation and Midas Plus, Inc, Tucson, Arizona. A P value of .05 was considered significant.

RESULTS During the pilot phase, there were 157 patients admit- ted to the trauma service. Twenty-three (14.6%) were successfully screened. During the implementation phase, there were 1107 patients admitted to the trau- ma service. Of these, 721 (65%) met inclusion criteria and were eligible to be screened. Of those eligible, 446 (62%) were screened. Screening information for each month of the implementation phase is shown in Figure 1 . Social workers were required to document reasons for unsuccessful screening to improve capture of protocol compliance. The rate of patients missed for screening declined over the last 3 months of the implementation phase.

In the posttest evaluation period, there were 932 pa- tients admitted to the trauma service ( Table 5 ). Of these, 619 (66.4%) met inclusion criteria and were eligible to be screened. Of those eligible, 499 (80.6%) were successfully screened. Screening information for each month of the after trial evaluation is shown in Figure 2 . The proportion screened remained stable and was similar to proportions during implementation. Overall, the screening tool im- proved the number of trauma patients screened for DV

TABLE 1 Four-Question Initial Screen 1. Do you feel unsafe or afraid in any current relationship?

2a. Within the last year, have you been hit, slapped, kicked, punched, shoved, or otherwise physically hurt by a partner or ex-partner?

2b. Do you currently have contact with that person?

3. Is there a partner from a previous relationship who is making you feel unsafe now?

4. Is this current hospitalization due to intimate partner violence?

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screened vs 53 ± 23 not screened, P = .062) across all 3 phases of the study. There was also no age dif- ference between those with negative screens and those with positive screens (51 ± 22 vs 43 ± 22, respectively, P = .73). Overall, 37 (3.8%) of all patients who were

TABLE 2 DV Study Questionnaire Questions

1. How were you injured? (MVC, MCC, fall, stab, GSW, assault, other)

2. Is there a family history of DV?

3. Do you have a primary MD or family MD that you see regularly? (yes/no)

4. How many times have you seen a primary MD or family MD for any reason in the last 6 months? (0, 1, > 2)

5. How many times have you been to an ED or InstaCare for an urgent problem in the last 6 mo? (0, 1, > 2)

6. How many of those times did you go because of an injury? (0, 1, > 2)

7. How many times have you been admitted overnight to the hospital for any cause in the last year? (0, 1, > 2)

8. How many of those times were you admitted overnight because of an injury? (0, 1, > 2)

9. During the past week, have you had at least 1 alcoholic drink of any kind? (yes/no)

10. During a routine week, how often do you drink alcohol? (0, 1-5 times, > 5 times)

11. Do you smoke cigarettes, cigars, or use tobacco? (yes/no)

12. Have you used illegal drugs in the past? (yes/no)

13. Are you using illegal drugs currently? (yes/no)

14. Is there a gun of any type where you are staying? (yes/no)

15. Have you been hit, kicked, punched, strangled, injured with an object, or hurt in another manner by a partner or loved one in the last year? (yes/no)

16. If the answer to the previous question is yes, who has done this to you? (husband, significant other, ex-husband, boyfriend, ex- boyfriend, neighbor, child, friends, relative, other)

17. Do you feel safe in your current situation or with your current relationship? (yes/no)

18. Is there a partner or loved one from a previous relationship who is making you feel unsafe currently? (yes/no)

19. Are you hospitalized today because of new or current injuries from a partner or loved one? (yes/no)

20. Over your lifetime, have you ever been the victim of physical or sexual violence from a partner or loved one? (yes/no)

21. What is your current marital status? (single, married, domestic partner, separated, divorced, widowed, other)

22. Who are you living with? (alone, spouse, domestic partner, friend, relative, other)

23. Do you have children? (yes/no)

24. Are your children with you? (yes/no)

25. Where are you living? (own home, apartment, homeless, shelter, other)

26. How many years of school have you completed? ( < 12, some college, college degree)

27. What is your current employment status? (not working, working, disabled, other)

28. What is your annual household income? (less than $10K, $10-$30K, >$40K)

29. Have you used IPV shelter services, safe hotlines, safe houses in the past (yes/no)

30. What DV services have you used? (fill in)

31. What DV services are most helpful to you? (fill in)

Abbreviations: DV, domestic violence; ED, emergency department; GSW, gun shot wound; IPV, intimate partner violence; MCC, motorcycle crash; MD, doctor of medicine; MVC, motor vehicle crash.

from 14.6% preimplementation to 80.6% in the posttest evaluation period ( P < .001).

For all phases combined there were 968 subjects screened. There was no difference in age between pa- tients screened and those not screened (51 ± 22 years

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TABLE 3 Early Compliance Issues Identified by Audit Findings Barriers Solutions

Delay in start-up Re-education of staff was required and was ongoing

Lack of time Evening, weekend, and holidays had insufficient social work coverage. Therefore, admissions less than 48 h were excluded.

Perceived as burdensome Weekly audit results were given to management.

Insufficient resources In July of 2011, an additional social worker was hired.

TABLE 4 Ongoing Process Evaluation Problems Solutions

An audit filter for DV domestic violence screening was developed; trauma registrars entered screening compliance into the trauma registry.

Feedback was provided to the social work staff.

There were 4 data entry errors, due to default answers in the computerized note. The computerized default was changed.

Thirty-three percent of positive screens were not given the full-length questionnaire to complete the process.

Feedback was provided to the social work staff.

Monthly evaluation for the process was ongoing and adjustments to the process were made as problems were identified.

The decision was made, by management, to link screening compliance with each individual’s performance evaluation.

Abbreviation: DV, domestic violence.

TABLE 5 Domestic Violence Identification Pilot Study PI Implementation Posttest P (PI vs Post)

Trauma admits 157 1 107 932 .57

Did not meet inclusion Unknown 386 (34.9%) 313 (33.6%) .57

Screening required Unknown 721 619 < .0001

Missed Unknown 275 (38.1%) 120 (19.4%) < .0001

Screened 23 (14.6%) 446 (61.9%) 499 (80.6%) .018

Positive (abuse history) 5 of 23 (21.7%) 22 of 446 (4.3%) 10 of 499 (2.0%) .12

Questionnaire complete 3 of 5 (60%) 9 of 19 (47.4%) 8 of 10 (80%) .57

Abbreviation: PI, performance improvement.

Figure 1. Trauma admits monthly screening rates during process implementation (2011).

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screened were found to have experienced DV. Of these, 21 (56.8%) were women. During all 3 phases of the study, 38% of patients screened were female. Up to 36% of patients who were not screened were female, which was not statistically different ( P = .06). These percent- ages reflect the overall sex breakdown of admissions to our trauma service.

Domestic violence as the sole reason for admission to the trauma service was infrequent and not different between the 2 phases—33 of 1107 (3.0%) during imple- mentation and 22 of 932 (2.4%) during posttest ( P = .41). Only 9 patients, 6 (0.5%) during implementation and 3 (0.3%) during posttest were admitted for assault by a sig- nificant other or family member.

Limitations The use of a 48-hour or longer inpatient stay was based on limited SW resources on the weekends and holidays. The intention was to expand SW resources at a later date to identify all potential cases of DV.

DISCUSSION

Process Evaluation In this study, hospital SWs drove the DV identification process with increasingly better screening rates as time went on. The primary purposes of this study, to design, implement, and test the use of a DV protocol and to ex- pand identification of abuse victims, were met.

In the first 2 months of the implementation phase of this study, more than 80% of patients were identified as not meeting inclusion for screening. In the last 10 months, the rate stabilized and dropped to about 25% not meet- ing inclusion. In the after study phase, the rate was stable at about a third. The implication is that, over time, SWs became more adept at correctly identifying patients for

screening. This improvement is the desired outcome of any PI initiative and sustaining this after the study is an important outcome.

In patients identified as eligible for screening, the monthly screening rates show a marked improvement over the implementation phase of the study, with the best rates achieved in the last 3 month of the study. This rate held through most of the poststudy evaluation phase. There was an uptick in missed patients in the last month of 2012, but it is unclear whether this represents a trend. Clearly, continued monitoring for successful screening is required.

DV Data The demographic characteristics (age and sex) were not different between those screened and those not screened. These data suggest that there was no se- lection bias in screening. However, the most severe- ly traumatized patients were largely excluded from screening. Some were interviewed later in their hos- pital, but the vast majority were unable to talk to the SWs during their inpatient stay. This is clearly a limi- tation of the current process. In this study, 9 patients who were admitted for traumatic injuries as a result of abuse were less severely injured than many trauma victims. Across the nation DV often results in serious injury and death. 13 , 14 Although our data did not show this to be the case, it most likely does not mean that our trauma center actually does admit less severely in- jured victims of DV. Instead, it highlights the fact that we need to find a way to eventually screen our most seriously injured patients.

A 2001 study in the ED at 1 of our other corporate hospitals in the Intermountain West found a 1-year IPV prevalence rate of 9.7% and a lifetime rate of 36.4%. 15 The results of that study demonstrated that IPV at that particu- lar hospital was similar to other institutions around the

Figure 2. Trauma admits monthly screening rates after process implementation (2012).

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country. 6 The reported lifetime prevalence rate of IPV for US women is reported as 35.6% and for US men as 28.5%. 1 Comparison of the lifetime prevalence rates between the above-mentioned study, which was done on patients pre- senting to the ED for any reason, and the results that we obtained from our study revealed that trauma patients at our institution have lower prevalence rates than ED patients (36.4% vs 3.4%, P < .001). This finding suggests that, despite our efforts to broadly implement a screening tool, we are probably still missing a significant portion of trauma patients who are victims of DV.

Victims of DV present at EDs for various medical and mental health reasons. In this study, less than 2% of pa- tients admitted to the trauma service that were screened were admitted for trauma resulting from DV. It is likely that the results we obtained were low, and that our screen missed trauma patients who were actually DV victims. The possible reasons for this are several. First, by excluding patients who were hospitalized for less than 48 hours in the screen, we may be letting some less severely injured patients “slip through the cracks.” These patients may ac- tually be some of the most important to catch, as the next time they suffer from DV, the injuries could be far worse. Conversely, some of the more severely injured patients who were not screened due to their inability to complete the questionnaires may also have been victims. Regard- less of reasons for hospitalization, early identification of victims is imperative to provide resources that may aid in prevention of DV recurrence. 16 Our results show that while our screening tool is a step in the right direction, we have a way to go to broaden the patients that we reach. Once we are able to do this, we may get a better handle on how many of our trauma patients are truly victims of DV, and which would benefit most from intervention.

In this study, the lifetime prevalence rate of DV in trauma patients was lower than in other reports. This is likely because we are still missing a significant portion of patients who are victims of or at risk for DV. Addi- tional research in this area is needed, particularly as we figure out ways to broaden the patient population that we screen. One obvious avenue to do this is to expand the screen to all admitted patients, not just those who are in the hospital for 48 hours or more. Although this would likely require more resources to achieve, we would al- most certainly identify more DV victims.

CONCLUSIONS The DV screening program initiated at our level 1 trauma center was a first step in providing resources to previ- ously unrecognized victims of abuse in our trauma pa- tient population. A standardized screening tool and sur-

vey process improved the ability to detect DV among patients hospitalized on a trauma service. Time, increased workload, and lack of resources were initial barriers to screening. Changes resulting from PI feedback improved compliance with performing the screening. Recognition by Social Services Department management of the need of additional resources to meet protocol compliance was beneficial to the program’s success.

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2. Stockl H , Devries K , Rotstein A , et al. The global prevalence of intimate partner homicide: a systematic review . Lancet. 2013 ; 382 : 859-865 .

3. National Intimate Partner and Sexual Violence Survey . http:// www.cdc.gov/violenceprevention/pdf/nisvs-report201-a.pdf 2010. Accessed September 24, 2014.

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5. Campbell JC , Glass N , Sharps PW , et al. Intimate partner homicide: review and implications of research and policy . Trauma Violence Abuse. 2007 ; 8 ( 3 ): 246-269 .

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10. Davis JW , Parks SN , Kaups KL , Bennink LD , Bilello JF . Victims of domestic violence on the trauma service: unrecognized and underreported . J Trauma. 2003 ; 54 : 352-355 .

11. Melnick DM , Maio RF , Blow FC , et al. Prevalence of domestic violence and associated factors among women on a trauma service . J Trauma. 2002 ; 53 : 33-37 .

12. Feldhaus KM , Koziol-McLain J , Amsbury HL , Norton IM , Lowenstein SR , Abbott JT . Accuracy of 3 brief screening questions for detecting partner violence in the emergency department . JAMA. 1997 ; 277 : 1357-1361 .

13. NCADV . Domestic violence facts . www.ncadv.org/learn/ statistics 2007. Accessed September 24, 2014.

14. Centers for Disease Control and Prevention . Preventing intimate partner & sexual violence . wwwcdcgov/violenceprevention 2012. Accessed September 24, 2014.

15. Allen TL , Stevens MH , Olson LM , et al. Prevalence of intimate partner abuse and suicidal ideation among women in a community emergency department . Utah Health Ann Rev . 2003 ; IX : 56-60 .

16. Davis JW . Domestic violence: the “rule of thumb”: 2008 Western Trauma Association presidential address . J Trauma. 2008 ; 65 : 969-974 .

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