Computers aid EDs in violence screening
Staff, patients discuss sensitive issue
Computer screening may increase the odds that a woman at risk for domestic violence will talk to a health care professional in the ED, according to a recent article in the Archives of Internal Medicine.1 The article's authors say that such screenings help ease the discomfort that patients and ED staff members feel when discussing such matters.
"Women are willing to speak to health care providers, but they need to be asked," says Karin V. Rhodes, MD, lead author of the article, director of healthcare policy research in the Department of Emergency Medicine at the University of Pennsylvania and an emergency physician at the Hospital of the University of Pennsylvania, both in Philadelphia. "They are reluctant to initiate the conversation, but if they are asked in the context of discussing physical and emotional health issues, they are more likely to tell their story — especially if they are asked in a confidential, concerned, and nonjudgmental fashion."
The study was conducted in two EDs: the University of Chicago Hospital ED (where Rhodes worked at the time), an academic urban center, and Lutheran General Hospital, which is in the suburbs. A total of 903 women who visited the EDs between June 2001 and December 2002 participated in the study and were randomly selected to complete the computer-based risk assessment or receive the usual care. Those who participated took the screening alone in a private room off the ED waiting room.
The urban center saw mostly African American patients, while the suburban ED saw mainly Caucasian, upper middle-class patients. "Interestingly enough, although the two EDs were quite different, the rates were not that dissimilar," says Rhodes. "We found that 26% of the surveyed patients at the urban ED and 21% of those in the suburban ED indicated they were at risk for domestic violence."
The study is interesting in terms of the impact of a confidential domestic violence screening, says Sam Shartar, RN, CEN, ED nurse manager at Emory University Hospital in Atlanta. "I think the authors correctly note that it does overcome some reluctance," Shartar says.
Shartar says his ED's triage, as well as that of Emory Crawford Long Hospital, uses screening questions from an electronic medical record (Cerner Corp., Kansas City, MO.)
If an ED staffer is suspicious there may have been violence involved in a patient's injury, they can include the screening question, "Have you been hit, kicked, or abused in any way?" The provider then can manually direct a special icon to appear on the system's tracking board to identify the patient as being at risk.
"When we see the icon, we do a social services consult," says Shartar. "If appropriate, we will contact law enforcement."
Lowering the threshold
Rhodes says computer screening "lowers the threshold" for providers as well "when it functions as your doctor/patient communication source." In the study she conducted, the questions were asked in the context of an overall assessment: physical, lifestyle, and emotional.
"We told the patients that all of these things influenced their health, and that the doctor would see a copy of report," Rhodes says. "The fact they were willing to disclose such information means they want to share it, and if the doctor gets a copy of the report that indicates a risk factor, this gives them an opening to discuss the topic." (These questions not only show whether domestic abuse has occurred, but also if the patient is at risk of potential abuse. See a sampling of the questions.)
What can ED managers take from the study? "I think that as we move more and more to an EMR [electronic medical record] that allows patients to confidentially self-disclose sensitive risk factors such as domestic violence and depression, the providers will be more likely to address the issue if the patient discloses it, and they can then focus on assessing risk and referring the patient," says Rhodes.
It might be even better to flag those charts for the social workers, she says. "The ED is a busy setting, and you are still going to miss some patients," Rhodes says. ED managers need to set up a system that prevents such people from falling through the cracks, she says.
"This should be easier to do as we set up EMRs," Rhodes notes. "You should include a screening for domestic violence for both men and women."
Confidentiality remains critical, Rhodes emphasizes. "If the patient comes in with a partner, any screening should be done in a way not to alert the partner that this person might be telling," she advises. "You can do it during bedside registration — when all patients go back by themselves — or you can give the patient a [computerized] tablet."
- Rhodes KV, Drum M, Anliker E, et al. Lowering the threshold for discussions of domestic violence: A randomized controlled trial of computer screening. Arch Intern Med 2006; 166:1,107-1,114.
For more information on screening for domestic violence in the ED, contact:
- Karin V. Rhodes, MD, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Phone: (215) 421-1036.
- Sam Shartar, RN, CEN, Nurse Manager, Emergency Department, Emory University Hospital, Atlanta. E-mail: firstname.lastname@example.org.
For more information about a triage screening program that can include questions about domestic violence, contact:
- Cerner Corp., 2800 Rockcreek Parkway, Kansas City, MO. Phone: (816) 221-1024. Fax: (816) 474-1742. Web: www.cerner.com.