Project Description Routine intimate partner violence (IPV) screening in healthcare settings is a common

Transcription

1 Organization Johns Hopkins Hospital Department of Gynecology and Obstetrics Solution Title Improving Intimate Partner Violence Screening and Referrals Project Description Routine intimate partner violence (IPV) screening in healthcare settings is a common policy recommendation (Dagher, Garza, & Kozhimannil, 2014). The American College of Obstetricians and Gynecologists (ACOG) recommends IPV screening for women of all ages (Moats, Edwards, & Files, 2014). Healthcare providers have the unique opportunity to reduce and prevent IPV through patient screening and referrals. Research has shown that healthcare provider screening and intervention for IPV can benefit patients (Leibschutz & Rothman, 2012). Furthermore, routine screening of all women assures that patients are screened regardless of whether abuse is suspected (Moats et al., 2014). Yet few providers routinely screen unless there are obvious injuries (Alotaby, Alkandari, Alshamali, Kamel, & El Shazly, 2013). To reduce the prevalence and negative impact of IPV, it is critical to screen all women presenting for healthcare and to make appropriate referrals. A validated instrument should be consistently employed during the history-taking portion of the exam for the targeted audience to assess for IPV (Dagher et al., 2014). Equally important is for healthcare providers to know how to respond to a positive screening in a caring appropriate manner that includes timely safety planning and referrals (Sutherland, Fontenot, & Fantasia, 2014). Once abuse is confirmed through screening, the patient s safety must be assessed, available resources provided, and appropriate referrals completed according to the patient s wishes (Dagher et al., 2014). Women with positive IPV screens should be provided referrals to local and national resources to meet their safety desires and needs.

2 This study seeks to answer the question if education and utilization of a validated IPV screening tool adapted for use in the Electronic Medical Record (EMR) will improve provider knowledge and practices regarding IPV screening and referral as well as increase the number of patients seeking assistance from resources provided? The goals of this initiative are as follows: 1. To develop an IPV screening tool for an electronic medical record (EMR). A validated IPV screening tool will be adapted for use in the EMR. 2. To improve provider knowledge and practices regarding IPV screening and referral. We will measure provider knowledge and screening practices at baseline and after an educational training session. 3. To monitor the numbers of patients who call our newly created clinic resource line. We will measure the number of times that patients call our resource line. Process In alignment with recommendations from the American College of Obstetricians and Gynecologists, the outpatient Gynecology and Obstetric (GYN/OB) clinics of Johns Hopkins Hospital (JHH) will facilitate improved IPV screening of all women presenting for care through the implementation of a validated IPV tool in the EMR. No single IPV screening tool has been well established as the standard or top IPV screening tool; however, five tools have been studied most commonly (Rabin, Jennings, Campbell, and Bair-Merritt, 2009). After review of the five commonly studied IPV screening tools, it was determined that the Abuse Assessment Screen (AAS) was established and best suited for use in a GYN/OB clinic. The AAS is a five item clinic administered tool developed by the American Medical Association (AMA) in 1992 used to assess frequency and perpetrator of physical, sexual, and emotional abuse by anyone. It may be used in abused pregnant and non-pregnant multicultural

3 women in health and prenatal clinics. The sensitivity and specificity of the AAS is 93% and 55%, respectively. Any question answered affirmatively, i.e. yes, constitutes a positive screen (Centers for Disease Control, 2007). A pre- and post-test provider survey was identified to assess provider readiness for IPV screening. Permission for use of the survey was obtained. Data on provider type (i.e. physician, social worker, advance practice provider, nurse), demographics, years of training, and clinic location was also collected. The questionnaire, The Domestic Violence Health Care Provider Survey Scale (DVHCPSS), uses a 5-point Likert scale to assess providers training needs for IPV screening (Maiuro, Vitaliano, Sugg, Thompson, Rivara, & Thompson, 2000). Solution After obtaining permission from the AMA, the AAS was submitted to the electronic charting system Epic for integration into the patient s history for use by healthcare providers in the GYN/OB clinics. This screen should take less than five minutes to complete. Any positive answer in the AAS screen opens a screen in Epic that lists the pertinent next-steps for the provider, which includes a list of referral resources. The IPV screen released into the Epic EMR of the GYN/OB clinics at JHH in October of Prior to introduction of the AAS into Epic, providers including physicians, advance practice nurses, social workers, and nurses, were surveyed using the DVHCPSS. After the initial survey, providers were educated regarding IPV screening, utilization of the AAS in Epic, and provided with an appropriate response to positive screens. Establishing an effective response to a positive screen is a critical portion of the care for patients who are experiencing IPV. There must be a consistent approach for reliable referral and follow-up in place (Moats et al., 2014). It is not desirable to provide the patient with any materials/brochures that have the word violence written on it. In our experience, patients may not

4 want to accept such documents out of fear of their partner discovering the materials. For these reasons, an automated telephone number has been set up for patients to call at any time, and included on the clinic business card. This dedicated line lists the telephone numbers to local and national resources. Clinic business cards are given to all patients and told that the second number on the card is the IPV resource line. When called, this line provides patients with local and national resources for their safety and care. This recorded line is available in both English and Spanish at any time. A positive AAS screen instructs the provider to give the patient the business card if the patient does not desire to report the situation immediately. Before discharge from the clinic, the provider gives the patient a current clinic business card with the resource number on the card. If the patient desires to report the situation immediately, the positive AAS screen instructs the provider to have the patient call 911 and to provide the patient with social work follow up. Measurable Outcomes The DVHCPSS consists of six domains arising out of 41 questions: perceived selfefficacy, system support items, blame victim items, professional role resistance/fear of offending the patient, victim/provider safety, and frequency of domestic violence inquiry. The scale is scored from 1 to 5 with 1 representing the minimum score and 5 representing the maximum score. Three stands as the neutral middle score. Only in the domain of blame the victim is a lower score desirable (Maiuro et al., 2000). Results of initial survey: Domain Average response rate Result Perceived self-efficacy System support items

5 Blame victim items Professional role resistance/fear of offending the patient Victim/provider safety Frequency of Domestic Violence Inquiry Three months after provider education and implementation of the AAS, providers will be resurveyed regarding their IPV screening practices. Pre- and post-test survey scores are expected to reveal an improvement in provider knowledge and increase in screening practices. The Epic charts will be reviewed for utilization of the AAS and the resource line will be assessed for incoming calls. Sustainability It is generally accepted that IPV screening will likely increase identification of IPV but assessment of referrals for positive screens is weak (Taft, O Doherty, Hegarty, Ramsay, Davidson, & Feder, 2013). It is therefore unclear if screening actually improves effective referrals (O Doherty, Taft, Hegarty, Ramsay, Davidson, & Feder, 2014). This project not only strives to improve IPV screening in the local population but also to improve referrals. The project will be shared across the JHH community and made available for use not only by the GYN/OB department but also by all departments. The AAS will be easily available to anyone in the system through EPIC. Any of these providers will be directed to give their patients the resource line number. Ultimately, this will stand to provide a blueprint for IPV screening and referral across this community and others. Role of Collaboration and Leadership In 2010, the World Health Organization (WHO) defined interprofessional collaborative practice as multiple healthcare workers from different professional backgrounds working

6 together with patients, families, caregivers, and communities to provide quality healthcare (WHO, 2010). Also in 2010, the Institute of Medicine (IOM) released their publication The Future of Nursing: Leading Change and Advancing Health. This document challenged nursing to collaborate with physicians and other health care professionals to redesign healthcare in the United States (IOM, 2010). Research has demonstrated that interprofessional collaboration results in increased coordination of care and more effective communication. By allowing team members to function as a unit, the cumulative skills and experience of the group results in overall improvement in quality and safety of patient care (Robert Wood Johnson Foundation, 2011). As healthcare evolves, collaboration among healthcare providers and healthcare researchers becomes increasingly important (Naylor, 2011). Charged by leadership with the task of increasing nurse involvement in research at Johns Hopkins Hospital, a small departmental nursing research committee considered the importance of interprofessional collaboration. The nurse led committee elected to open the committee up to all professional disciplines in the department. The response included nurses, advance practice providers, social workers, physicians, lactation consultants, and financial advisors. The remarkable committee outcomes are producing practice-changing projects throughout the hospital that are improving the quality of patient care and overall patient safety. This committee identified IPV screening as a need for women in our care and set out to improve screening and referrals. The resulting project evolved through the support of departmental leadership, the hard work of all committee members, and the persistence of the notion that the world around us can be better for those women who are charged to our care. Without interprofessional collaboration,

7 these results could not be achieved. This research group is a model for collaborative interprofessional care. Innovation IPV screening is not a new recommendation. Offering healthcare providers a reliable consistent option for IPV screening and referral through the electronic medical record however is an innovative utilization of the newest and most effective technology available to meet that recommendation. Not only are providers easily able to access and use a validated screening tool, referral resources are immediately provided. Women in our care can be screened and safely referred for help. Healthcare providers can comfortably achieve the recommendation to screen all women while providing the resources those women need. Related Tools and Resources ABUSE ASSESSMENT SCREEN 1. Have you ever been emotionally or physically abused by your partner or someone important to you? YES NO 2. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? YES NO. If so, who? 3. Since you ve been pregnant, have you been slapped, kicked or otherwise physically hurt by someone? YES NO. If so, who? 4. Within the last year, has anyone forced you to have sexual activities? YES NO. If so, who? 5. Are you afraid of your partner or anyone you listed above? YES NO. If so, who? Copyright (c) 1992, American Medical Association. All rights reserved. Journal of the American Medical Association, 1992, 267, (CDC, 2007)

8 DVHCPSS: Provider type: Resident Physician Attending Physician Advanced Practice Provider Registered Nurse Social Worker Age of provider: and over Gender of provider: Male Female Highest degree obtained: Associate s Degree Bachelor s degree Master s Degree Doctoral degree Years of clinical practice after completing education: 5 or less or more DOMESTIC VIOLENCE HEALTH CARE PROVIDER SURVEY In answering the following questions, circle the appropriate number: 1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree 1. I don t have the time to ask about DV in my practice. 2. There are strategies I can use to encourage batterers to seek help. 3. There are strategies I can use to help victims of DV change their situation. 4. I feel confident that I can make appropriate referrals for batterers. 5. I feel confident that I can make the appropriate referrals for abused patients. 6. I have ready access to information detailing management of DV. 7. There are ways I can ask batterers about their behavior that will minimize risk to the potential victim. 8. I have ready access to medical social workers or community advocates to assist in the management of DV. 9. I feel that medical social work personnel can help manage DV patients. 10. I have ready access to mental health services should our patients need referrals. 11. I feel that the mental health services at my clinic or agency can meet the needs of DV victims in cases where they are needed.

9 12. A victim must be getting something out of the abusive relationship, or else he/she would leave. 13. People are only victims if they choose to be. 14. When it comes to domestic violence victimization, it usually takes two to tango. 15. I have patients whose personalities cause them to be abused. 16. Women who choose to step out of traditional roles are a major cause of DV. 17. The victim s passive dependent personality often leads to abuse. 18. The victim has often done something to bring about violence in the relationship. 19. I am afraid of offending the patient if I ask about DV. 20. Asking patients about DV is an invasion of their privacy. 21. It is demeaning to patients to question them about abuse. 22. If I ask non abused patients about DV, they will get very angry. 23. It is not my place to interfere with how a couple chooses to resolve conflicts. 24. I think that investigating the underlying cause of a patient s injury is not part of medical care. 25. If patients do no reveal abuse to me, then they feel it is none of my business. 26. I am reluctant to ask batterers about their abusive behavior out of concern for my personal safety. 27. There is not enough security at my work place to safely permit discussion of DV with batterers. 28. When challenged, batterers frequently direct their anger toward health care providers. 29. I feel there are ways of asking about battering behavior without placing myself at risk. 30. I feel I can effectively discuss issues of battering and abuse with a battering patient. 31. I feel I can discuss issues of battering and abuse with a battering patient without further endangering the victim. 32. I feel it is best to avoid dealing with the batterer out of fear and concern for the victim s safety. 33. There is no way to ask batterers about their behaviors without putting the victims in more danger. 34. I am afraid if I talk to the batterer, I will increase risk for the

10 victim. 35. In the past three months, when seeing patients with injuries, how often have you asked about the possibility of domestic violence? 36. In the past three months, when seeing patients with chronic pelvic pain, how often have you asked about the possibility of domestic violence? 37. In the past three months, when seeing patients with irritable bowel syndrome, how often have you asked about the possibility of domestic violence? 38. In the past three months, when seeing patients with headaches, how often have you asked about the possibility of domestic violence? 39. In the past three months, when seeing patients with depression and/or anxiety, how often have you asked about the possibility of domestic violence? 40. In the past three months, when seeing patients with hypertension and/or coronary artery disease, how often have you asked about the possibility of domestic violence? 41. In the past three months, when seeing patients requiring pregnancy or OB/GYN care, how often have you asked about the possibility of domestic violence? Maiuro RD, Vitaliano PP, Sugg NK, Thompson DC, Rivara F, and Thompson RS. Development of a Healthcare Provider Survey for Domestic Violence: Psychometric Properties. American Journal of Preventive Medicine, 19 (4), Contact person Amy S. D. Lee, DNP, ARNP, WHNP, BC Title Nurse Practitioner alee48@jhmi.edu Phone

11 REFERENCES Alotaby, I.Y., Bader, A.A., Khalil, A.A., Kamel, M.I., & El Shazly, M.K. (2013, June). Barriers for domestic violence screening in primary health care centers. Alexandria Journal of Medicine, 49(2), Centers for Disease Control and Prevention. (2007). Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare settings (Version 1). Atlanta, GA: Centers for Disease Control and Prevention. Dagher, R.K., Garza, M.A., & Kozhimannil, K.B. (2014, June). Policymaking under uncertainty: Routine screening for intimate partner violence. Violence Against Women, 20(6), Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from Change-Advancing-Health.aspx Maiuro RD, Vitaliano PP, Sugg NK, Thompson DC, Rivara F, and Thompson RS. (2000, November). Development of a Healthcare Provider Survey for Domestic Violence: Psychometric Properties. American Journal of Preventive Medicine, 19 (4), Moats, C.C., Edwards, F.D., & Files, J.A. (2014, March). More than meets the eye: The importance of screening for intimate partner violence. Journal of Women s Health, 23(3), Naylor, M. D. (2011). Viewpoint: Interprofessional collaboration and the future of healthcare. The American Nurse Today, 6(6). Retrieved from

12 Robert Wood Johnson Foundation. (2011). What can be done to encourage more interprofessional collaboration in healthcare? Retreived from O Doherty, L.J., Taft, A., Hegarty, K., Ramsay, J, Davidson, L.L., & Feder, G. (2014, May 12). Screening women for intimate partner violence in healthcare settings: Abridged Cochrane systematic review and meta-analysis. BMJ, 348(g2913), Sutherland, M.A., Fontenot, H.B., & Fantasia, H.C. (2014, October). Beyond assessment: Examining providers responses to disclosure of violence. Journal of the American Association of Nurse Practitioners, 26(10), Taft, A.,O Doherty, L., Hegarty, K., Ramsay, J., Davidson, L., & Feder, G. (2013, April 30). Screening women for intimate partner violence in healthcare settings. The Cochrane Library, doi / CD pub2 World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. Retrieved from