Discussion5

THE EMERGENCY DEPARTMENT AND VICTIMS OF SEXUAL VIOLENCE: AN ASSESSMENT OF PREPAREDNESS TO HELP

STACEY BETH PLICHTA, SC.D. TANCY VANDECAR-BURDIN, M.A. Old Dominion University, Norfolk, VA REBECCA K ODOR, M.S.W. Virginia Department of Health, Richmond, VA SHANI REAMS, A.A.S. Virginia Sexual and Domestic Violence Action Alliance, Richmond, VA YAN ZHANG, M.S. Old Dominion University, Norfolk, VA

ABSTRACT The Emergency Department (ED) is a key source of care for

victims of sexual violence but there is little information available about the extent to which EDs are prepared to provide this care. This study examines the structural and process factors that the ED has in place to assist victims. A survey of all 82 publicly accessible EDs in the Commonwealth of Virginia was conducted (RR 76%). In general, the EDs provide the recommended medical care to victims. However, at least half do not have the needed resources in place to effectively assist victims and most (80%) do not provide regular training to their medical staff about sexual violence. Further, almost one-quarter do not have a relationship with a local rape crisis center. It is recommended that each ED partner with local rape crisis centers to provide training to their staff and to ensure continuity of support for victims. It is also suggested that the state government explore ways in which a forensic (SANE) nurse be made available to every victim of sexual violence that presents to the ED for medical assistance. Ideally, each ED would become part of a community-wide Sexual Assault Response Team

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(SART) in order to provide comprehensive care to victims and thorough evidence collection and information to law enforcement.

INTRODUCTION This study seeks to examine the extent to which

Emergency Departments (EDs) in the Commonwealth of Virginia are prepared to provide care for victims of sexual violence through an examination of both structural and process factors that are currently in place. Many studies indicate that sexual violence victimization has both long- term and short-term health consequences (Plichta and Falik, 2001; see also Rentoul and Applebloom 1997; Cloutier, Martin and Poole, 2002; Bohn and Holz, 1996). The ED is a key source of care for victims of sexual assault. It is one of the first points of entry to care. Competent care by professionals trained in treating sexual assault victims is critical to the timely recovery of physical and mental health. The ED also plays a critical role in the collection of evidence that may lead to the conviction of the perpetrator and a recent study found that specially trained (forensic) nurses perform this function significantly better than do other staff (Sievers, Murphy and Miller, 2003). Forensic nurses are registered nurses (R.N.’s) who have advanced training in the examination of sexual assault victims; this includes training on legal aspects of evidence gathering.

Few studies have examined the preparedness of the ED to assist victims of sexual violence and to collect evidence, and none have been completed in Virginia. Those few studies, which have examined different aspects of care offered to victims in the ED, generally find that the care is incomplete (Rovi and Shimoni, 2002) and that comprehensive training of the staff is necessary (Lewis et al., 2003). There is however some evidence that those EDs with sexual assault nurse examiners (forensic nurses) generally provide better and timelier care to victims (Selig,

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2000; see also Stermac and Stirpe, 2002; Ledray and Simmelink ,1997).

Prevalence of Sexual Violence and Care-Seeking in Virginia

There are a substantial number of victims of sexual violence in Virginia, many of whom may not be obtaining the care that they need. The lifetime prevalence of sexual violence victimization in Virginia is estimated to be approximately 27.6% for women and 12.9% for men, with a one-year rate of 1% for women and .1% for men (Masho and Odor, 2003); these rates are consistent with those found in national studies of sexual violence (Resnick et al., 2000). Using U.S. Census data for the adult population of Virginia (U.S. Census, 2000) and these incidence rates, it is estimated that about 26,000 female and 2,580 male adults will be victims of sexual violence each year in Virginia. Numerous studies have documented that sexual violence victimization is underreported (Bachar and Koss, 2001; see also Bureau of Justice Statistics, 1996). This appears to be true in Virginia, as the majority of the estimated victims are not found in the legal, social service, rape crisis service or health care system (Virginia Uniform Crime Reporting Program, 2004; see also VAASA, 2002; Masho and Odor, 2003). Masho and Odor (2003) report that only 10.8% of women and 2.2% of males sought medical care after being raped or sexually assaulted. This is significantly lower than a national estimate of 26.2% of women seeking care after an incident (Resnick et al., 2000). Some of this variation may be due to the difference in definitions of rape and sexual assault between the two studies. However, the care- seeking rate for Virginia is still low, and the reasons why so few victims seek medical care are worth exploring. One possibility is that the services may not be well prepared to assist victims.

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Existing Clinical Guidelines for the Care of Victims The evaluation of services for victims of sexual violence is somewhat challenging as there is currently no definitive standard of medical (physician) care for the treatment of victims of sexual violence. An extensive search of the Association for Health Research and Quality (AHRQ) website, which houses the majority of clinical guidelines developed and used in the U.S., only uncovered some limited guidelines from Great Britain (www.ahrq.gov). The closest approximation to medical guidelines for the treatment of sexual violence victims in the U.S. comes from the American Medical Association (AMA,1995) which has published some recommendations for the care of victims based on available evidence; however, the document is careful to point out that these recommendations should not be regarded as absolute clinical guidelines. The American College of Obstetrics and Gynecology (www.acog.org; ACOG,1997) and the CDC (2002) have also published recommendations for specific aspects of care, but the AMA report was the most comprehensive of the three. Nursing has been much more pro-active in the development of standards of nursing care for victims of sexual violence. The nursing specialty devoted to this area is the Sexual Assault Nurse Examiner or SANE nurse (also referred to as a forensic nurse) and there are currently over 100 SANE programs in the United States (www.sane- sart.com; Ahrens et al., 2000). This specialty has developed extensive nursing guidelines for both the care of victims and for evidence collection, as well as training standards for forensic nurses (Ledray, 1999). These guidelines are generally in agreement with the AMA strategies, although they are more extensive and detailed regarding evidence collection and the psychosocial care of victims.

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These authoritative sources that provide guidelines regarding the care of victims of sexual violence are generally in agreement with one another, although some sources are more comprehensive than others (AMA, 1995; see also ACOG, 2004; CDC, 2002; Ledray, 1999). Table 1 presents a list of recommended components of care based upon these sources. Recommended Linkages to Other Agencies

The care of a victim of sexual violence has medical, psycho-social and legal (evidentiary) aspects. While the ED is generally well-placed to perform medical services, it is not as well prepared to provide the array of other services, such as counseling and evidence storage that a victim may need. In order to do so, it is recommended that ED’s partner with rape crisis advocates (who can provide on-going emotional support to the victim) (Preston, 2003). A more comprehensive model of care expands this partnership to other agencies and involves the ED participating on a multidisciplinary team, such as a Sexual Assault Response Team (SART) (Heger,1999; see also Botello et al., 2003; Derhammer et al., 2000). The SART, a fairly new model of care, shows promise in providing comprehensive services to victims. The SART is a multi- disciplinary team developed to coordinate services to victims. It is comprised of advocates from the local rape crisis center, law enforcement officers, the ED and other SANE programs. SART’s have the ability to provide a full range of comprehensive services to victims, including: immediate crisis intervention, team interviews, forensic examination, and follow-up care. This partnership enables law enforcement to receive a fuller view of the facts regarding the case, and provides for better forensic evidence collect and storage for prosecution of the sexual offender (Ledray, 2001).

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Table 1 Recommended Components of ED Care for Sexual Violence Victims General Recommendations Screen all patients, or at least those with injuries of unknown origin Screen all patients when sexual assault is suspected Medically stabilize the victim Obtain a medical history Obtain a relevant sexual history Have the patient in a quiet and safe area Do not leave the patient alone Contact (with the patient’s permission) a friend or family member Offer the services of a rape crisis advocate Where medically indicated: Offer emergency contraception Offer HIV testing and prophylaxis Offer STD testing and prophylaxis Offer follow-up for re-testing for HIV and/or STD’s Forensic Exam Recommendations Know the state guidelines Obtain an informed consent Obtain a history of the sexual assault Obtain information about current pregnancy status Collect the victim’s blood for typing and DNA Collect a urine sample to screen for pregnancy, alcohol and drugs (including date rape drugs) Collect samples of the victim’s hair Examine the orifices involved for trauma and to collect sperm/seminal fluid Collect fingernail scrapings Comb the victim’s pubic hair for foreign hair and matter Collect torn and stained clothing Document all injuries on a body map Photograph injuries Examine the victim’s body for sperm/seminal fluid that might have dried and been missed on initial examination

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Structural and Process Components Related to the Care of Victims

It is clear, that to allow these processes to occur, the ED has to have a number of structural and process components of care in place, as well as linkages to other agencies. First and foremost, the ED needs a clearly written protocol on the care of victims. Second, it is necessary for the ED to have trained nursing personnel (SANE/forensic nurses) available to all victims in a timely manner. Nurses provide the majority of patient care to victims. However, other medical staff, particularly the physicians, also need some level of training in how to care for victims. Third, the ED needs the physical resources (a dedicated room, evidence collecting kits, medical equipment) in order to be able to conduct the exam. If clothing is to be collected, the ED will also need to have other clothing available for the victims so that they have something to wear when they leave the ED. Finally, the ED will obviously need linkages to rape crisis centers and other agencies that can provide extended assistance and follow- up support to victims. Ideally, the ED would participate on a community-wide sexual assault response team (SART), as the SART formalizes these linkages. This study seeks to explore the extent to which EDs in Virginia have these resources and processes in place. This study also seeks to to provide a base of information upon which a plan for improved services can be built.

METHODS

The survey questions were based primarily upon the

list of victim resources discussed in the previous section. The survey was reviewed and revised by experts from the Virginia Sexual and Domestic Violence Action Alliance, the Virginia Department of Health and by several

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practicing forensic nurses across the Commonwealth of Virginia. Survey items included questions about the ED’s characteristics (location, number of visits), screening practices, hospital resources available (SANE/forensic nurse, linkage to a rape crisis center, participation on a SART), services offered to victims of sexual assault, components of the sexual assault examination, training policies for medical staff and a self-rating of how the ED was performing in the area of providing services to victims. The survey focused on adolescent and adult victims, and did not ask questions about child sexual abuse. The survey was six pages long, and designed to be either self- administered or completed in a phone interview by the ED nurse manager or the lead forensic nurse in the ED. It took approximately 15 minutes for respondents to complete.

Sampling Frame and Survey Distribution The surveys were distributed by mail with a telephone follow-up to each of the 82 publicly available EDs in the commonwealth of Virginia. The initial contact was with the chief executive officer (CEO) of each ED. Each CEO was sent a survey with a cover letter requesting that they pass the survey on to either the lead forensic nurse or the ED nurse manager. If no response was received within two weeks, a second survey was sent out directly to the nurse manager of the ED. If a survey was not received back within two weeks of that mailing, the ED nurse manager was called and invited to participate in the survey via a phone interview. Respondent Characteristics Overall, 76% (62) of the ED’s responded to the survey (See Table 2). The respondent ED’s are similar to the entire population of EDs across the state in terms of geographic location and size. In general, the proportion of the sample from each of the five health planning regions

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across the state is similar to the proportion of EDs in those planning regions. Also, all four of the teaching hospitals in the commonwealth completed the survey. A number (n=56) of the EDs provided estimates of the number of victims they treat each year. These estimates were approximate and not necessarily precise figures derived from any data collection process at the ED. The average hospital reported seeing about 44 victims each year, although this varied greatly (0-310). The EDs reported that the majority of the victims were adult women (50%), but they also treated adolescent girls (38%), adolescent boys (9%) and adult males (4%). Since this study focused on services available to adolescent and adult victims, there is no data on the number of younger children (age 11 and under) served or any data about the services available to children.

RESULTS Policies and Available Resources

Emergency Departments varied greatly in policies and available resources (See Table 3). The majority of the EDs (86%) have a written protocol in place regarding the care of victims of sexual violence and almost all (87%) treat victims on-site. The remaining hospitals transfer victims to a sister hospital in the same system. The majority (75%) of hospitals which refer patients elsewhere do have a written protocol in place.

Approximately two-thirds of the EDs have an employee on staff that is trained to assist victims, but only half have a forensic nurse examiner (SANE) who works at the hospital. Note that not all of these actively provide forensic nursing care 24 hours a day. Overall, only 35% of the EDs have a forensic nurse who is a paid employee and who is available to all victims of sexual violence.

Linkages to other services also vary by ED. Almost one-quarter (23%) do not have a relationship with a rape

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crisis center and over half (60%) do not participate on a sexual assault response team (SART). Even among the ED’s that do have a linkage to a rape crisis center, 12% almost never use their services and 37% use their services for less than half of the sexual violence victims that they treat (the remaining 51% do work with the center for three- quarters or more of the victims that they treat).

Providing training to ED staff about the care of victims of sexual violence does not appear to be a priority for most of the EDs. Almost half (47%) of the EDs did not have a formal training plan in place and over half (56%) had not provided training to new staff in the past year. Further, the great majority (87%) did not provide any training to existing medical staff in the past year. When asked, however, almost all of the EDs rated various aspects of training as ‘very important.’ In particular, over 80% said that it was very important for them to have training in the following: collecting evidence, working with the police, testifying in court, talking with victims and their families, and working with rape crisis centers .

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Table 2 Characteristics of the Emergency Departments that Participated (n=61) Characteristic % of Sample Health Planning Region 1 (Northwest Virginia) 13 2 (Northern Virginia) 11 3 (Southwest Virginia) 40 4 (Central Virginia) 18 5 (Eastern Virginia) 18 Teaching Hospital Yes 7 No 93 ED Visits in the Past Year (all reasons) N=56 Mean (standard deviation) 34,536 (21,861) Median (inter-quartile range) 32,000 (16,000-48,000) Range % 2,900 – 15,000 23 % 15,001 – 31,500 27 % 31,501 – 48,000 25 % 48,001 – 90,000 25 ED Visits in the past year (n=48) (sexual violence)

Mean (sd) # of victims treated 44.17 (61.98) Median (interquartile range) # treated 19.5 (6-46) Range of victims treated % Treating 0-6 victims/year 25 % Treating 7-19 victims/year 25 % Treating 20-46 victims/year 25 % Treating 470-310 victims/year 25 Age/Gender of Victims treated (n=45) % of victims who are female age 12- 17

38

% of victims who are female age 18+ 50 % of victims who are male age 12-17 9 % of victims who are male age 18+ 4

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Table 3 General Policies and Available Resources Policies % Yes % No The ED has a written protocol in place regarding the care of victims of sexual violence

86 14

The ED routinely refers victims to another hospital

13 87

Resources and Linkages The ED has an employee who is trained to assist victims of sexual violence

64 36

The ED has a forensic nurse examiner (SANE) on staff

52 48

The ED has a relationship with a sexual assault or rape crisis center.

77 23

The ED participates on a Sexual Assault Response Team

40 60

Training The ED has a formal training plan about sexual violence

53 47

The ED has provided training about sexual violence to new staff in the past year

44 56

The ED has provided training about sexual violence to current members of the medical staff in the past year

13 87

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Screening Protocols Only 30% of the EDs use a standardized instrument to screen for sexual violence (See Table 4). Among those that do screen, almost 20% use screening instruments for intimate partner violence (domestic violence) and not for all types of sexual violence. Further, among those that screen, 22% do not use a question from a written form on the clinical record, but simply ask the patient verbally and then included the answer in the patient notes. The EDs are somewhat more likely to screen women for sexual violence than men. For women, 7% of the EDs screen all women for violence victimization, 38% screen all women with injuries of unknown origin, 47% only screen women when they suspect sexual violence and 8% only discuss sexual violence if the women discloses it to the provider. For men, 5% of the ED’s screen all men for violence victimization, 26% screen all men with injuries of unknown origin, 50% only screen men when they suspect sexual violence, 13% only discuss sexual violence if the man discloses it to the provider and 5% report that they do not discuss sexual victimization with male patients. Services Routinely Offered to Sexual Violence Victims

In general, the EDs provide the necessary medical care, but are less likely to offer comfort care (See Table 5). Almost all of the ED’s provide the recommended medical care to victims of sexual assault, with the exception of a follow-up phone call within 48 hours (54% do not). A minority of the EDs do not provide some of the recommended services, such as screening for date rape drugs (17%), prophylactic HIV treatment (17%) and emergency contraception (10%) do not. Comfort care (a place to shower and fresh clothes) is still not offered by a substantial minority of EDs. Most EDs do offer referrals to support services for victims, such as rape crisis centers, safe housing and counseling. It should be noted that a

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substantial minority do not have specially trained personnel to provide these services; almost half do not offer a forensic nurse, about one-quarter do not have a rape crisis counselor in the examination room with victims and one-fifth do not give victims any access to a rape crisis counselor. Table 4 Screening Protocols for Sexual Violence Victims

Uses a Standardized Instrument % The ED uses a standardized instrument to screen patients for sexual Violence

30

Screening Protocol for Women All female patients are screened 7 All female patients with injuries of unknown origin are screened

38

All female patients with suspected victimization are screened 47 All female patients who disclose victimization are screened 8 Screening Protocol for Men All male patients are screened 5 All male patients with injuries of unknown origin are screened

26

All male patients with suspected victimization are screened 51 All male patients who disclose victimization are screened 13 Sexual violence victimization is not discussed with male patients

5

Components of the Sexual Assault Forensic (Evidentiary) Exam The assessment of the contents of the forensic exam was only conducted for the 53 EDs that treat the victims on-site and do not refer to another ED; data was available for 96% of these EDs (See Table 6). On average, the EDs perform 8.69 (s.d. 2.59) of the ten components measured here, with 66% of the EDs performing all of the recommended components. The components of the exam that are performed less frequently are: obtaining an informed consent (78%), taking photographs of the injuries (78%), making a body map of the injuries (83%), collecting

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fingernail scrapings (86%) and collecting the victim’s blood for type and DNA screening (89%). All of the other components are performed by at least 90% of the EDs.

Table 5 Services Routinely Offered to Sexual Violence Victims Offered By1: Type of Service

Hospital Outside Agency

Not Offered

Medical Care Follow-up phone call within 48 hours 16 30 54 Emergency contraception 87 3 10 HIV testing 82 12 6 Prophylactic HIV treatment 63 20 17 STD testing 97 0 3 Prophylactic STD treatment 97 0 3 Pregnancy test 97 0 3 Mental health assessment 70 26 4 Blood and urine screening for date rape drugs

69 14 17

Screening for the presence of drugs or alcohol

97 3

Personnel Forensic Nurse Examiner available to all victims

41 14 46

Rape crisis advocate/companion in the room with the victim during the examination

36 39 25

Rape crisis advocate/companion available to meet with the victim

18 62 20

Comfort Care A place for the victim to shower after the exam

59 0 41

Fresh clothing for the victim 68 5 27 Referrals Referral to a local rape/sexual assault center

68 20 12

Referral for safe housing 59 34 7 Referral for follow-up counseling 73 23 3 1Services offered by an outside agency may or may not be offered in the ED setting.

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Table 6 Components of the Sexual Assault Exam

N=51

Component

% performing this component

Obtaining written consent from the victim 78 Taking photographs of the injuries 78 Making a body map of the injuries 83 Collecting fingernail scrapings 86 Collecting the victim’s blood for type and DNA screening 89 Examining the orifices involved for trauma and to collect sperm/seminal fluid

90

Combing pubic hair for foreign hair and matter 90 Collecting torn or stained clothing 90 Getting an assault history of the current assault 95 Obtaining pertinent medical information about current pregnancy status

97

Emergency Department’s Self-Rating of Performance in Assisting Victims The EDs were asked to rate themselves on how they performed on various aspects of assisting victims (the rating scale went from 1-5, where 1 was poor and 5 was excellent). The majority of the EDs rate themselves as somewhere between good and very good (average score 3.72/5.00) in treating victims of sexual violence (See Table 7). The ED’s generally rate themselves better in areas such as preserving the victims confidentiality, making the victim comfortable, and working with the police. They tend to rate themselves less positively on training staff and screening patients. They are also less sure of their performance when it comes to assisting families of the victims and working with the local rape crisis centers.

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Table 7 Self-Rating of Performance in Treating Victims % Rating themselves as: Type of Assistance Excellent /

Very Good Good Fair or

Poor Training to staff on how to assist victims

36 26 38

Screening patients for sexual assault and rape

35 28 37

Assisting the families of victims 57 19 24 Working with the local rape crisis center 62 18 20 Collecting evidence from victims 72 11 17 Working with patients victimized by intimate partners

54 27 18

Working with the police 79 14 7 Making victims feel as comfortable as possible

67 22 9

Preserving the confidentiality of the victim

91 5 4

DISCUSSION

Summary of Findings This study provides a summary of services available

to victims of sexual violence at emergency departments (EDs) in the Commonwealth of Virginia. In general, this study finds that the EDs generally provide needed medical services to victims. However, less than half are consistently doing so with specially trained personnel (e.g. forensic nurses) and the majority are not training their medical staff about victims of sexual violence on a regular basis. This study also finds that the EDs are not consistently screening their patients for violence victimization (particularly men) and may be missing an opportunity to assist some victims. Further, this study finds that the EDs are not all well situated to provide the full level of services needed by victims (such as counseling from a rape crisis center and evidence collection by a

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trained nurse) and that many lack necessary linkages to other services that care for victims.

Implications for Policy and Practice

In order to ensure consistent, high quality care for victims of sexual violence in Virginia, standard protocols for the treatment of victims and the training of medical staff need to be established. While the great majority of EDs have written protocols, little is known about their contents or how consistent they are between EDs. The General Assembly should consider supporting the Virginia Department of Health (VDH), rape crisis centers and representatives from the EDs to establish model written protocols and training materials. These protocols and training models should be based upon the strong models that currently exist in a number of the EDs in Virginia. These protocols need to include policies regarding screening for sexual violence victimization in the ED. Currently, the screening policies are varied across EDs, and it is likely that many victims are not being identified and thus not receiving all of the care that they need. Once identified, victims of sexual violence need access to forensic (SANE) nurses and trained staff, both to optimize their own medical care and to ensure the proper collection of evidence for the potential prosecution of the perpetrator. About half of the EDs in Virginia currently offer consistent access to forensic (SANE) nurses, and the funding for forensic nursing programs in individual EDs is currently declining. Within the Commonwealth, there are several models of providing this access that need further exploration. One model is to have forensic nurses employed at each hospital and on-call 24 hours a day. Another model is to share forensic nurses between several hospitals (e.g. ‘floating’ nurses). A third model is to designate a single hospital in each city/county as the forensic hospital, and refer all patients to that hospital. It is

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currently unknown how well each of these models works to provide comprehensive care and good evidence collection for victims and studies are needed. Victims also are likely to need post-hospital care (both medical and psycho-social). In order to provide the full basket of services needed by victims, EDs need to be linked to other agencies, such as rape crisis centers and law enforcement. A significant minority of EDs (23%) do not have any linkages with rape crisis centers, and less than half (40%) participate on a community-wide SART. The Virginia Department of Health and the community-based rape crisis centers may need to approach the EDs to build these linkages. It will likely take efforts at the General Assembly level to establish SARTs in every community. It is worth noting that many models for partnership with the rape crisis centers, and for SARTs, currently exist within Virginia that may be worth replicating.

Limitations

This study raised almost as many questions as it answered. In particular, this study did not measure any aspects of the quality of care from the victim’s perspective. The study relied on hospital self-report, and no attempt was made to externally validate any of the reported data. Also, the reported figures of the number of victims served are estimates made by the survey respondent (this data is not collected in any systematic way across the ED’s in Virginia). Further, this study is based in Virginia, and may or may not generalize to other regions. Finally, this study focused only on services available to adolescent and adult victims and does not provide any information about services available to victims age 12 and under.

Future Research The limitations of this study highlight the critical need for research in this area. Little is known about the

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provision of services to victims of sexual violence through the health care setting and studies that examine the quality of care from the viewpoint of the victim are especially lacking. These studies will be difficult to conduct, as they obviously need to be planned with great care and concern for the psychological and physical well-being of the victim. Another critical need is to examine the effectiveness of different models of providing emergent care to victims. Studies are just beginning to be published regarding the potential benefits of a trained forensic (SANE) nurse and of hospital based teams. Little work has been done that explores other models of care, such as hospital participation on a Sexual Assault Response Team. No studies could be found that explored the effectiveness of a hospital systems designating one hospital as the care center for all victims within a region. Solid data about the number of victims that present to the emergency department and other health care sources is also needed. Since the majority of the EDs do not screen most patients for sexual violence victimization, it is likely that the estimates provided here are undercounts of the true number of victims that present each year. Finally, it is important to have studies on services available to victims of sexual violence be conducted nation-wide to obtain a true picture of what is available to those harmed by sexual violence who are seeking help from the health care system.

NOTES We would like to thank the Virginia General Assembly for its vision and leadership on behalf of victims of sexual violence. In 2004, they passed Senate Joint Resolution 131, directing the Virginia Department of Health to provide them with recommendations for how to improve services to victims across legal, social service, sexual assault crisis and medical services. Subsequently, this study was funded by the Virginia Department of Health, and we would like to

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express our appreciation to them for choosing us to engage in this work. Finally, we would like to thank our phone interviewer, Addie Magnant, for her persistent and cheerful efforts to obtain responses from as many of the emergency departments as possible.

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