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Health Care Professional’s Response to Intimate Partner Violence

Health Care Professional’s Response to Intimate Partner Violence. Sheryl Heron, MD, MPH, FACEP Associate Professor/Associate Residency Director Assistant Dean – Clinical Education Associate Director Education & Training, Center for Injury Control Emory University School of Medicine

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Health Care Professional’s Response to Intimate Partner Violence

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  1. Health Care Professional’s Response to Intimate Partner Violence Sheryl Heron, MD, MPH, FACEP Associate Professor/Associate Residency Director Assistant Dean – Clinical Education Associate Director Education & Training, Center for Injury Control Emory University School of Medicine October 2011

  2. Disclosure Statement I have no financial relationship in any amount with a commercial interest to disclose

  3. Introductions • Who you are? • Why are you here?

  4. Objectives Review the Health Consequences of IPV Describe Strategies to Improve the health professional’s response Demonstrate a Systemic Response to IPV

  5. Intimate Partner Violence (IPV) Centers for Disease Control & Prevention - 2000 • Physical, sexual, or psychological harm by a current or former partner or spouse. • heterosexual or same-sex couples • does not require sexual intimacy • IPV can vary in frequency and severity

  6. Patient 1 20 yo female presents s/p GSW to the head. On presentation she is in traumatic arrest US notes IUP at 3 months.

  7. Patient 2 30 yo female presents to the ED, c/o “being tired, recently unemployed”. Her 2 kids are with her. On exam, she is febrile at 38.2 and on auscultation of her lungs, she has bruises to her chest.

  8. In the literature

  9. By gender • Male and female perpetration of violence is equalizing, but: • Women tend to report victimization more • Men tend to perpetrate more severe violence in most surveys, incl. homicide • Women tend to sustain more injuries and 3x more like to report more fear/ battering Houry D: J Interpers Violence. 2008; 23(8):1041-55.

  10. Medical settings • Obstetrics/gynecology- 12.7% • Pediatrics- 8.4% • Primary care- 8.6% • Addiction recovery- 36.2% • Emergency department- 16.5% McCloskey: Acad Emerg Med. 2005;12(8):712-22

  11. Pre-hospital • DV victims more likely to call 911 for any reason (77% vs. 47%) (Datner 1999) • DV-positive patients more likely to refuse EMS transport (23% vs. 7%) (Husni 2000) • More DV patients presented during the EMS night shift

  12. Associations with IPV • Young (mean age 32) • Female (62%) • Unemployed (60%) • Street drug use (29%) • Cigarette smoking (59%) • Depression (36%) • PTSD (21%) • Suicidal (10%) • Houry D Does Screening In The Emergency Department Hurt Or Help Victims Of Intimate Partner Violence? Annals of Emergency Medicine 2008;51:433-42

  13. Physical Morbidity • Physical injuries • Disfigurement or disability • Chronic body pain (e.g., abdominal, headache)

  14. Physical Morbidity • Miscarriage or abortion • Sleep and appetite disturbances • Recurrent vaginal infections (e.g., STDs) • Other complaints (gynecological, cardiac, central nervous system)

  15. Homicide

  16. ED Use Prior To Death • 139 homicide victims (5 years, 12 hospitals) • 34 (25%) were IPV victims • 15 (44%) presented to the ED < 2 years • 14 had injuries • 8 head lacerations; 2 perineal lacerations; 2 rapes; 1 suicide attempt • Medical records suggestive of abuse in 8 • IPV documented in 2; no intervention • Arbuckle J et al: Ann Emerg Med. 1996 Feb;27(2):210-5.

  17. What questions to ask? HITS Scale • Hurt; insulted; threatened with harm; screamed at you • Danger Assessment Scale • Increasing risk of lethal events with each “yes” answer • Frequency/severity of violence, presence of weapon, substance use, suicidal or homicidal intent, violence towards children

  18. What questions to ask? SAFE • Safety; afraid/abuse; family/friends; emergency plan • Abuse assessment screen/ Index of Spouse Abuse/ Conflict Tactics Screen • Utilized in research • Labor intensive

  19. What questions to ask? Partner Violence Screen (Feldhaus 1997) • Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom? • Do you feel safe in your current relationship? • Is there a partner from a previous relationship who is making you feel unsafe now?

  20. Patient attitudes about screening • 78% favored routine screening (Friedman 1992) • 85% of patients feel it’s appropriate for health providers to ask questions about violence (Houry 1999) • 36% of DV victims would tell a physician only if asked directly (Hayden 1997)

  21. So… what do you do with this information? How effective is screening for and identifying victims? Does it prevent or predict future violence? Is it safe?

  22. Why does screening matter? Women who screened positive for IPV in the ED • Re-interviewed 4 months later about violence in the interim: • 11.3 times more likely to experience physical violence • 7.3 times more likely to experience verbal aggression • All women who sought medical treatment for injuries had screened positive for IPV Houry D et al: J Interpers Violence. 2004 Sep;19(9):955-66

  23. Is it safe? 2,134 screened for IPV • 281 victims followed up at 1 week & 131 at 3 months • No problems in the ED • No problems from participating in the study at 1 week • All were satisfied with the screening • 1 “reminded her of the violence” Houry D et al Annals of Emergency Medicine 2008; 51(4):433-42

  24. Is it Enough? Paucity of evidence for effective treatment and services (MacMillan – JAMA 2009) Lack of evidence that screening alone improves health outcomes (Moracco – JAMA 2009)

  25. Responses of Health Professionals to IPV • Identification • Evaluation • Treatment • Documentation • Safety Planning • Referral

  26. Identify & Evaluate • First you have to get there! • If it doesn’t make sense……………… • THINK IPV or SEXUAL ASSAULT!!!

  27. Presentations • Traumatic injury • Suicidal/ depression • Vague complaints

  28. Presentations • Abdominal pain (no determined etiology) • Chronic pain • Headaches • Multiple visits

  29. Patterns of Injury

  30. Injury patterns • Incompatible with history • Multiple injuries in various stages of healing • Defensive injuries • “Central Pattern” of injury

  31. Injury locations Muellemann et al: Annals of Emergency Medicine - 1996 9,057 women (280 acute IPV) • Neck (OR 15.9) • Abdomen (OR 9.8) • Face (OR 8.9) • Thorax (OR 5.5) • Head (OR 4.9)

  32. Physical Examination • Physical Exam - • Injury pattern: head, neck, torso, genitalia • “Central Pattern of Injury” • Look for bruises, throat injuries • Wounds in various stages of healing • Evaluate patient’s emotional state • Pregnant Patients – FHT’s

  33. Treatment – Medical Team • Treat injuries • Treat other physical complaints • Create safety plan • Secure legal advocacy

  34. Documentation • Medical records • Police reports • Protection orders • Witnesses

  35. Safety Planning/Advocates/Referral • Ensure Patient Safety • Involve Advocates EARLY • Marshall support • Spiritual • Family • Social Services

  36. Benefits to Trained Medical Personnel • Collaboration and involvement with community leaders and resources • Relate medical needs of victims to community members and groups • Advocacy • Learn about impact of violence on other aspects of a patient’s life • Knowledge of community laws and responses

  37. How does the community engage the medical community? • ASK! • Solicit Universities • Challenge your physician during visits • Note Authors of papers/ lecturers and invite them to participate

  38. How to involve “Medical Professionals” with the task force • What’s in it for me?? • Your expertise • Medical aspect of IPV • Fatality reviews • Medical-legal issues (mandatory reporting)

  39. Georgia statute (31-7-9) • Physicians, licensed registered nurses, and other medical personnel “having cause to believe that a patient has had physical injury or injuries inflicted upon him other than by accidental means” must report this to the person in charge of the medical facility; this person in turn shall notify local law enforcement

  40. Challenges for Medical Involvement • Lack of DV education • Lack of time • Lack of effective interventions • Powerlessness • Fear of offending the patient • Privacy concerns • Personal history of abuse

  41. Other Challenges? • On-call emergencies • Night and weekend shifts • May not understand community or local priorities • Time commitment

  42. How do we Address these Challenges? • Educate health professionals – go to Grand rounds, lectures • Reiterate the seriousness of IPV • Understand the time constraints, give them something to work with

  43. How do we Address these Challenges? • Reinforce it’s not a medical rather a societal issue • Family/Friends are affected • It’s the right thing to do

  44. Benefits To Medical Involvement Medical Personnel: • Direct access to survivors of IPV • Bring a relevant perspective on the realities of health and mental health issues facing survivors • Potential financial strength to assist lobbying efforts

  45. Benefits To Medical Involvement • Medical Personnel: • Builds a scientific data base which can be used to leverage funding (i.e. track injuries, etc.) • Strengthens the collaborative community response • Demonstrates Leadership

  46. Patient Discussions • Patient 1: • Patient 2:

  47. Patient 1: IPV & Pregnancy • Assessment • Approach • Documentation • Referral

  48. Patient 1 • IPV HOMICIDE/PREGNANCY • http://www.ajc.com/news/no-bond-for-man-117116.html • Partners are responsible for >50% of homicides during pregnancy in U.S. • Increased risk of miscarriage and LBW infants • HOW DO YOU APPLY THIS CASE TO OTHER PATIENTS?

  49. IPV in Adolescents (n= 570)* • Prospective study Adolescent girls • IPV highest at 3 months post partum (21%), lowest at 24 months (13%) • Highest in African American & Mexican Amer. • 78% at 3 mos post partum did not report IPV prior to delivery. • High risk period, important to screen Harrykissoon et al. Arch Pediatr Adolesc Med. 2002; 156: 325-330

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