Ensuring the safety of the abused individual and children is the foremost goal. "Placing the patient in a shelter" or "having the attacker arrested" may not be congruent with the individual's goals. Ultimately, the abused individual must make the determination of whether it is safe to return home. By providing information about intimate violence, risks, and options, the physician can help the patient decide what is best for themselves and their family members. The patient's decision making may be very complex, because depression, lack of self-esteem, lack of support, social isolation, financial dependence on the perpetrator, and fear make it difficult to leave the relationship.
Patients must be told that violence, abuse, and intimidation are not a part of normal, healthy relationships. For some, this may be the first time they have heard such information. The abused individual's reports and experiences should be acknowledged and believed. Let the patient know that you take the situation seriously and that you are concerned about the health and safety of her (or him) and the children. Emphasize that he or she has done nothing to warrant violence and abuse. It is the perpetrator whose behavior is unacceptable. Clarify that ED personnel can help patients contact trained social workers or intimate violence advocates, who can then help develop logistical plans either for safety or for ending the relationship. Respect the abused individual's wishes about the future of the relationship. Screening and validation may be the stimulus needed by the patient to begin planning for change.
Indicators of a high-risk and potentially lethal situation include escalation in the frequency or severity of violence; the threat or actual use of weapons, in particular firearms; obsession with the abused individuals; hostage taking; stalking; and homicide or suicide threats or attempts and evidence of violent behavior outside the home. Another risk factor for serious injury or death is substance abuse by the perpetrator, which can increase violent behaviors.2,11
The most dangerous periods for abused individuals are during the time of abuse disclosure and during attempts to leave the relationship. Some patients feel safer remaining in the violent relationship than leaving without adequate planning for a safe departure.13
Refer survivors to intimate violence experts, such as hospital social workers or community-based advocates, who can help the victim assess the situation, understand options, plan for safety, and arrange safe shelter. Community advocates are typically on call or available by telephone. If the patient can be safely discharged from the ED and personal contact with an advocate cannot be made before discharge, give the patient up-to-date information about available services in the community. Intimate personal violence advocates should not be asked to call the patient directly unless the patient agrees, because calls to the home could jeopardize the patient's safety.
Resources for healthcare providers to assist in preparing their practices for optimal response to victims of intimate personal violence are available from a number of organizations (Table 294-5).
TABLE 294-5Resources for Healthcare Providers
If lethality risk is high, consult with experts before ED discharge. Hospital admission of the abused individual or children is an option in high-risk situations in which there is no other way to ensure safety. Use of a 24-hour safe room, a location established by some hospitals and communities to provide a safe place for the patient to stay while arrangements for safe disposition of the patient and family members are made, is another option. Use of an alias name on admission and screening of incoming phone calls may also be of benefit.
Documentation in the ED should be clear and legible. Voluntary descriptions of intimate personal violence should be quoted and described in the patient's own words. Do not use the word alleged because it implies that the person recording the incident does not believe the complaint. A complaint of "sexual assault" is no more alleged than is a complaint of "ear pain" or a "sore throat."
Record past and current abuse, with details of date, time, location, witnesses, and specific injury. Describe the patient's health complaints, injuries, appearance, and demeanor. Annotated body maps and photographs can supplement written notes.
Obtain relevant forensic evidence, and follow the appropriate chain of custody of evidence. If sexual assault has occurred, document ED testing and treatment.
Record safety assessment and disposition. A safety assessment form or referral notes from an expert are helpful adjuncts. Discussion of a safety plan with the patient is an important discharge function and also requires documentation.
Most states in the United States have laws that require healthcare providers to report injuries resulting from firearms, knives, or other weapons. Twenty-three states have reporting requirements for injuries resulting from crimes (intimate personal violence is a crime in all 50 states); seven states have statutes that specifically require health providers to report injuries resulting from intimate personal violence. The specifics of the reporting requirements vary from state to state, and the adequacy of response by the police to reporting varies by jurisdiction.15 Inadequate or inappropriate response to the reports (e.g., informing the perpetrator of the report without providing for the safety of the abused individual) can increase the risk of harm to abused individuals. ED personnel should be aware of reporting requirements and police response in their area. Patients must be informed if there is an obligation to make a police report and should also be told about possible ramifications.
ED PREPARATION FOR OPTIMAL RESPONSE
The Joint Commission requires, and the Institute of Medicine recommends, that staff receive initial and ongoing training about intimate partner violence and abuse. This should include education related to cultural competency, victim perspective, and consequences of violence, as well as how to assess, intervene in, support, and document care. Employees should also be informed of their options for assistance if they or someone they know is in an abusive relationship.
A routine screening protocol should be implemented that addresses training of ED personnel, confidential interviewing, and appropriate interventions, including validation and referral.
Multicultural and multilingual information about interpersonal violence and effects on abused individuals and family members should be made available to the public and employees. This may consist of posters and/or brochures in areas of the hospital such as public areas, examination rooms, and restrooms. Community resources that provide services to victims should be a part of the shared information.
Implement a continuous quality improvement program that assesses adherence to recommended screening and intervention strategies.
Form professional relationships with hospital- and/or community-based experts to ensure appropriate referral practices.