Developing a multidisciplinary approach within the ED towards domestic violence presentations
- 1Department of Occupational Health, Sheffield Teaching Hospitals, Northern General Hospital, Sheffield, South Yorkshire, UK
- 2Department of Public Health, Rotherham PCT, Rotherham, UK
- Correspondence to Dr Subhashis Basu, Department of Occupational Health, Sheffield Teaching Hospitals, Northern General Hospital, Sheffield, South Yorkshire S10 1SR, UK;
- Received 5 September 2012
- Revised 12 December 2012
- Accepted 20 December 2012
- Published Online First 23 January 2013
Aim To improve the detection and quality of care of patients who attend the emergency department (ED) with confirmed or suspected domestic abuse (DA).
Design A quality improvement report on the design, implementation and evaluation of a specialised service and structured training programme to detect and manage DA presentations within an emergency medicine department.
Setting The study was set in the ED at the Northern General Hospital, Sheffield, UK.
Key measures for improvement Key measures for improvement included introducing a service within the ED to help staff manage DA and coordinate responses; improve staff confidence in detecting DA; develop a structured and consistent process by which to manage DA presentations.
Strategies for change An Independent Domestic Violence Advocate service was introduced into the department in July 2011 through a multiagency agreement. A structured training and education programme was delivered to ED staff. A ‘communications form’ was developed for DA risk assessment and case management. The process was reviewed quarterly.
Results One hundred and seventy-two referrals were made to the service (121 distinct clients) over a 12-month period. Staff reported greater confidence in detecting DA, and community partners highlighted the role the service had in improving DA detection and care quality within the city.
Conclusions Strong leadership and prioritising the issue within the department has facilitated the development of the process and contributed substantially to its success. Support from community partners has been invaluable in tailoring the service and education programme to the needs of staff and patients within the department.
Despite the potentially serious impact of domestic abuse (DA) upon the physical and psychological health of its victims and their families; it has been suggested that women, on average, experience up to 35 episodes before seeking help.1 Data suggests that the annual cost of DA was around £15.7 billion in the UK in 2008, accounting for up to a quarter of all violent crime.2 ,3
Previous research has attempted to quantify the prevalence of DA in the emergency department (ED); albeit hindered through a lack of a standardised definition. Former definitions had a focus upon signs of physical abuse as a mode of presentation, although more recent definitions include psychological, sexual, verbal and emotional abuse as well. Early work in the mid-1990s suggested that DA was a relatively common problem that was often underdetected within EDs.4 One UK study administered a questionnaire to 198 consenting women attending A&E, suggesting that the prevalence of acute trauma due to physical violence was around 1%.5 Another study conducted at Addenbrooke's Hospital in Cambridge, suggested a prevalence figure of around 1.2% after interviewing over 256 patients attending the department.6
Other barriers to exploring the epidemiology of DA within the ED have included the apprehension encountered by staff in addressing the issue with patients within a busy environment. Explanations for this have included the absence of standardised tools, lack of confidence in raising the issue with patients, and fear of causing offence in more subtle cases.7 The issue of routine screening for domestic violence in the ED remains hotly debated. Although some independent studies have suggested that this is an integral component of care,8 others highlight wide variation in the sensitivity, specificity and patient acceptability of screening tools used to detect domestic violence.9–11
Recent work has explored the utility of a multidisciplinary approach towards tackling and preventing domestic violence in the UK, and healthcare services taking a lead role. The importance of Multi-Agency Risk Assessment Conferences in identifying and preventing DA, particularly in the context of revictimisation, has been recognised by the Department of Health.12 Indeed, focus groups held with DA victims have suggested that they believe healthcare professionals should receive compulsory training in DA through a rolling programme to account for high staff turnover, as well as a need for health services to promote empowerment as a tool through which to prevent violence.13 Further studies indicate that a medical record reminder to promote abuse screening; nursing participation in interprofessional training in domestic violence; anonymous data sharing with local partners, such as the police service, and provision of guidance through local interagency domestic violence policies are levers through which an ED can successfully participate in a multidisciplinary DA prevention programme.14
Despite this, domestic violence support workers or trained nurses are not commonplace within the ED in the UK, nor is the assessment of risk status among identified victims. The focus of this quality improvement report is to describe interventions introduced into the ED at Sheffield's Northern General Hospital through a multidisciplinary approach to improve detection and management pathways for patients attending with suspected or confirmed DA.
The Independent Domestic Violence Advocate (IDVA) project was born out of concerns within community safeguarding and health agencies within Sheffield over a rising burden of mortality and morbidity from DA within the city for which few robust detection systems existed. Service data showed that the identification and referral of victims was predominantly via the Police and Social Services, with health services urgently needing to take a greater role. The ED at the Northern General was a point of particular concern since this was felt to be a location where many such presentations occurred. Previous work within the maternity unit at Sheffield Teaching Hospitals had highlighted the potential benefits of an IDVA service in that area through increasing the number of referrals to specialist services from health services; increasing the overall number of referrals in the city; and reducing the numbers of attendances and admissions at ED. A further concern related to rising costs to the health economy from increasing numbers of Serious Domestic Homicide Reviews that had taken place over the previous 12–18 months in the city.
Working with community partners
Through their role as public health practitioners, the researchers were members of the Sheffield Domestic Abuse Partnership (SDAP) which included domestic violence experts, commissioners and community partners from all statutory agencies (including South Yorkshire Police, members of the criminal justice system and National Health Service (NHS) Sheffield (Primary Care Trust). SB was also a practising doctor within the ED, and thus, had an insight into how developed interventions could be delivered ‘on-the-shop floor’. These contacts established a network for engaging community service partners in the process.
Training and interventions
A number of initiatives were introduced into the department following a series of meetings and collaborative work with community partners within SDAP and senior members of the ED.
A standardised form was developed for use within the ED through a number of consultations between SDAP and senior ED staff. This document included a rapid assessment tool to determine a risk status for the patient (High or Low) which was developed from an evidence-based tool (DASH)15; clear instructions in the form of flow pathway as to the relevant actions to take (such as informing police, social services, or referral to a Multi-Agency Risk Assessment Conference in extreme cases); and supporting contact details. The document also acted as a referral form and was kept in a secure file and with the patient notes.
Funding was provided for the presence of two IDVAs in the department that case-managed referrals relating to confirmed or suspected DA. Although it was recognised that there may have been important differences between the patient case mix and service provision at each site; funding for the ED IDVAs was provided by NHS Sheffield based upon prior evidence of the cost-effectiveness of a pilot service set up previously within the maternity wing of the hospital in reducing hospital attendances and admissions.
Training for all senior nursing and medical staff was provided by the IDVAs on a rolling basis, supported by ED staff. An intensive training programme was delivered to permanent senior staff (medical and nursing) in July 2011. Rotating junior doctors received a 2 h training session as part of their teaching programme within their 4-month placement. All training was delivered by specialists in DA, each with several years' practical experience in the field. Attendance was made a mandatory part of continuing professional development for the staff involved. If required, a private interview room within the department was allocated for the assessment of any patients that staff suspected may be victims of domestic violence.
An electronic coding system was developed so that staff members were aware of previous domestic violence presentations to the department for affected patients. This was not shared outside of the department. Anonymised coding data of the number of DA presentations to the department each month was shared with South Yorkshire Police.
Data collection for outcomes
The outcomes of the interventions were measured through referrals made into the service, and staff satisfaction. Following the introduction of the IDVA service into the department and the first phase of staff training, data was collected on referrals made to community-based services within the following 12-month period beginning July 2011. Staff satisfaction was measured through informal focus groups with medical and nursing staff within the department, as well as interviews with the two appointed IDVAs.
The research was conducted in line with established ethical principles. Approval for the project was granted by the Clinical Effectiveness Assessment Unit in Sheffield Teaching Hospitals Trust. All participants provided explicit informed consent in participating in the study and were fully briefed as to its purpose and potential outcomes. No personal data was recorded. Data from the proforma was destroyed after analysis. The General Medical and Nursing & Midwifery Councils were consulted by SB prior to development of communications forms regarding data sharing in high-risk domestic violence and alcohol-related presentations with external agencies. The study was reported using the Standards for Quality Improvement Reporting Excellence framework.
Table 1 indicates the number of referrals made to the IDVA service by ED staff following its introduction in July 2011. One hundred and seventy-two referrals were made in total (including 121 distinct individuals). This is in contrast with just a single referral made to social services from the ED between July 2010 and July 2011. Data suggested that these ED referrals were also new referrals in addition to those from existing services within the city, since total IDVA referral figures from all sources within Sheffield increased from 650 to 839 between July 2010 and July 2011.
The lead author (SB) held a number of informal discussions with clinical staff working in the ED throughout the year period. In total, 22 permanent senior and junior nursing and medical staff were consulted throughout the year (12 nursing staff, 10 medical staff) both at the start of the process and at the end of their rotations, and their comments recorded. Both IDVAs were also interviewed at the beginning and end of the 12-month period.
The IDVAs highlighted satisfaction in the way their service had been received and utilised. They reported that they had developed good working relationships with a broad range of ED staff, and that the assessment facilities in the department were appropriate for their needs.
A number of key themes were noted among the comments of ED staff. All reported that greater clarity regarding what to do when DA was suspected was an important outcome. Nursing staff generally felt more comfortable enquiring around DA. Although some doctors indicated that at the start of the process, they felt that it was the responsibility of the nursing staff to enquire about DA presentations; in general, an attitude shift occurred with the result that many of the doctors felt it was their role also. Most staff also believed their training in DA not only heightened their awareness of the issue, but raised their confidence in addressing it. Importantly, many of the doctors had previously been concerned whether they would be able to disclose DA should they detect it, due to protection of patient confidentiality, and this issue was addressed clearly in the training process. All staff also reported that use of a proforma to guide decision making was invaluable.
We have included an example case presentation to demonstrate how the DA assessment system, once up and running, functioned in practice within the ED at the Northern General. A patient presented to the department with a number of injuries sustained the previous evening that staff assessing her believed could have been due to a domestic assault. The medical and nursing staff attending the patient approached the on-duty IDVA and requested an assessment while she was in A&E. The patient consented to the meeting.
The patient disclosed a 20-year history of physical, psychological and verbal abuse to her. She had presented to health services before, but had not disclosed DA, nor had medical staff enquired about a possible association between her presentations and DA in the past. She stated she had never informed the police previously.
The patient verbally stated that she wished to leave the marriage. The on-duty IDVA discussed a number of issues including safe refuge, a civil injunction, support groups as well as safety planning (which included electronic monitoring by police upon relevant addresses and safety measures put in place to protect family members’ homes known as ‘Target Hardening’). Safeguarding referrals were made to social care services, South Yorkshire Police Domestic Violence Unit and the Safeguarding Children's Board. The IDVA also supported the client's case for a priority housing application as a vulnerable adult.
The outcome of the case was that the client entered safe refuge where she received emotional and practical support through SDAP. When she was successful in securing her own tenancy, support was continued through outreach services.
The findings from this study highlight that a multidisciplinary DA service located within the ED can increase case detection rates and improve staff confidence in tackling the issue. While the importance of both suspected and confirmed DA presentations in the ED have long been recognised, few have developed integrated systems towards tackling the issue, and most studies have predominantly focussed upon detection as opposed to comprehensive management. Our findings, at the very least, may help address local concerns regarding the previous underdetection of DA within the ED environment and underuse of community referrals services designed to manage DA. Nevertheless, given the importance of DA upon the political agenda within the UK, and the enormous financial costs of DA within UK society, we would suggest that tackling the issue should be a priority within EDs across the country. This is highlighted within the Government's long-term vision in this area. The White Paper, ‘Healthy Lives, Healthy People: Our strategy for public health in England’16 and the recently published Public Health Outcomes Framework17 contain a number of domestic violence indicators against which the performance of responsible organisations will be judged.
The comments from the staff participants within our study would suggest that multiagency support towards addressing DA within this environment can help enhance confidence in performing confidential enquiry. Coordination of staff training and service implementation by senior ED members can help the integration of DA services into the emergency care environment, improving staff knowledge of available support and referral pathways, and ensuring the appropriateness and accessibility of DA services in the department.
Future work should explore the cost-savings from the introduction of such a service. While 12-month projected cost-savings for this ED IDVA service were calculated for a report for the Primary Care Trust, these were based upon actual savings attained from a pilot service set up in the maternity unit of the hospital and, thus, likely to be an overestimate due to case mix and service provision differences. We were unable to conduct a controlled trial within the ED itself due to the absence of reliable preintervention coding data for DA attendances.
Additionally, the issue of routine versus index-of-suspicion screening for DA remains hotly debated, given the inadequate evidence-base in the area. Other aspects to consider relate to patient satisfaction with the IDVA service. This is an important outcome, and provided issues of confidentiality can be addressed, can help inform our understanding of the process.
The authors would like to thank Professor Steve Goodacre for his advice regarding writing the paper, as well as the ED staff at Sheffield's Northern General Hospital for their assistance with the project. The authors would also like to thank Dr Jeremy Wight (Director of Public Health, NHS Sheffield) for supporting the project, Dr Paul Redgrave (Deputy Director of Public Health, NHS Sheffield) for his support and contribution, and the staff of the Sheffield Domestic Abuse Partnership and IDVA service.
Contributors SB acts as a guarantor of the paper, accepts full responsibility for the work, had full access to the data and controlled the decision to publish.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.