Don't miss abuse during your clinical assessment

Women may have completely unrelated conditions

If a 36-year-old woman came to your ED with obvious signs of a stroke, would you suspect that intimate partner violence (IPV) might be the cause? After ED nurses at a university medical center treated the woman for stroke, a nurse asked about IPV during a routine assessment.

"It turned out that the stroke was secondary to having been choked by her husband," recalls Jacquelyn Campbell, PhD, RN, a nurse researcher at Johns Hopkins University School of Nursing in Baltimore. "The No. 1 implication is that emergency nurses need to be assessing all women for IPV."

Physical and psychological effects

In addition to serious injuries, IPV has been linked to several adverse physical and psychological health effects, says Deborah E. Trautman, PhD, RN, director of nursing for the Department of Emergency Medicine at The Johns Hopkins Hospital in Baltimore. These include arthritis, chronic neck or back pain, migraine and other headaches, visual impairment, sexually transmitted infections, chronic pelvic pain, stomach ulcers, spastic colon, indigestion, diarrhea, and constipation, she says.

A computer-based health survey in the ED can identify dramatically higher numbers of women reporting IPV, as compared with verbal questioning, according to a new study. Nineteen percent of 411 women who completed a computer-based health survey reported IPV, as compared with only 1% who were asked about IPV during the nursing assessment, which was the ED's usual practice.1

Women in the study presented with various complaints including headache, viral illness, and sore throat, which underscores the fact that victims of IPV won't necessarily come to the ED with injuries from the abuse, says Trautman. One of the most common problems women will present with is severe pain, Campbell says. "Chronic pain is associated with IPV, either because of old injury or alterations in the stress response," she says. If the patient can't be screened for IPV in the ED because of the acuity of her condition, it should be flagged on the patient's chart so that an inpatient nurse can do the screening, she advises.

ED nurses still not screening

Most EDs don't routinely screen, even though there have been many calls to do so, says Campbell. Part of the reason is because ED staff lack training and don't know what interventions to offer if the patient reports IPV, says Campbell.

Prior to the new research, a personal interview was the preferred method to identify abused women, but this research found that a computer-based survey identifies more individuals, perhaps because of anonymity, says Trautman.

Because computerized screening seems to increase disclosure rates, that method is ideal to use in the ED, says Campbell. To obtain buy-in from hospital administrators to invest in this, she recommends including other types of screening as well, such as alcohol abuse. "Once the system is in place, we can use it to take care of several psychosocial issues that are so often underlying the problems we see in the ED," says Campbell.

The cost would vary depending upon the technology used, but in this case, the ED's costs were "very low," says Trautman. Expenses include developing a web-based survey, purchasing computers for patients to use, and providing dedicated printer capabilities for the results, she says.

The Johns Hopkins' ED utilized laptops and a mouse for their IPV survey, but this could also be done with a touch-screen computer, or even pencil and paper, says Trautman. Whichever method is used, the survey results should be placed in the patient's medical record for the ED nurse to review during their assessment, she says.

If the patient reports IPV, there are several simple but important interventions that can be provided, says Trautman. These include referrals to social workers or giving patients preprinted education materials, a listing of community resources, or pocket-sized cards.

"No one expects that the ED nurses should do it all," says Trautman. "Simply providing important safety and referral information is an important first step."

Reference

  1. Trautman D, McCarthy M, Miller N, et al. Intimate partner violence and emergency department screening: Computerized screening vs. usual care. Ann Emerg Med 2007; 49:526-534.

Source/Resource

For more information on screening for intimate partner violence in the ED, contact:

  • Deborah E. Trautman, PhD, RN, Director of Nursing, The Johns Hopkins Hospital, Department of Emergency Medicine, Marburg B-181, 600 N. Wolfe St., Baltimore, MD 21205. Phone: (410) 955-5246. Fax: (410) 955-0141. E-mail: dtrautma@jhmi.edu.

Pocket-sized Domestic Violence Cards are available from the American College of Obstetricians and Gynecologists (ACOG) to help patients identify whether they are in an abusive relationship and encourage them to discuss the issue with their health care provider, with space for local shelter and domestic violence resources telephone numbers, available in English (Item AA410) and Spanish (Item SA410). A pack of 50 cards costs $17 plus $12.50 shipping. To order, contact ACOG Distribution Center, P.O. Box 933104, Atlanta, GA 31193-3104. Phone: (800) 762-2264, ext. 349 or (770) 280-4184. Fax: (866) 441-2120 or (770) 280-0080. E-mail: sales@acog.org. Web: www.acog.org/bookstore.