Screening

1
Screening

• for IPV

2
Screening Procedure

• What should physician screen patients for?
• Who should be screened routinely?
• Who should conduct screening?
• Where should screening conducted?
• How should screening occur?
• When should screening occur?
• When should screening NOT occur?
• What to do if screening does NOT occur
• Why is screening important?

3
Patients Should be Screened for

• current
• lifetime
• exposure to violence from their intimate partner

4
Who Should be Screened?

• All adolescent and adult patients
• Parents of children in pediatric care

5
Who Should Conduct Screening?

• Health Care Providers, like
• Medical staff
• Nursing staff
• Social workers
• Paramedical staff
• Mental health providers
• IPV should be
• multi-disciplinary confronted

6
The Provider Who Conducts Screening Should Be

• educated
• about the dynamics of IPV
• about issues concerning the safety of abused
  patients
• trained how
• to ask patients about abuse
• Provide information about IPV and make referrals
  to local community resources
• to intervene with identified victims
• authorized to record in the patients medical
  record
• a person who has established a trusting
  relationship with the patients

7
Where Should Screening Occur?

• In Settings of
• A E and Outpatient Departments (adult child)
• Geriatrics
• Ob/Gyn Womens health care
• Dental care
• Orthopedic health care
• Substance abuse treatment
• Mental health
• Family Planning and Pre-Natal Care
• etc.

8
How Should Screening Conducted?

• Routinely (regardless of the presence of signs of
  abuse)
• Orally in private
• Interpreter (only if needed)
• Language direct and nonjudgmental
  (culturally/linguistically approrpiate)
• Confidential

9
When Should Screening Conducted?

• As part of the routine health history
• As part of the standard health assessment
• At every encounter in Urgent Care
• During every new patient encounter
• During periodic health visits (screen for current
  IPV only)
• When signs or symptoms raise concerns

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When Should Screening NOT Occur?

• If there is not private space in which to conduct
  screening
• If there are concerns that screening is unsafe
  (for either patient or provider)
• If there is not available an appropriate
  interpreter

?
In this case
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If Screening Does Not Occur

• Note in patients record
• Schedule a follow-up appointement (if in Urgent
  Care Setting, refer patient to a primary care
  provider)
• Have available posters, referral and educational
  material in exam/waiting rooms, bathrooms.

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Why is Screening Important?

• Provides victims an opportunity
• to disclose their IPV experience
• to talk to someone who is going to listen to and
  believe them
• to get referral information and resources
• Screening
• communicate support to victims
• increase the likelihood of future disclosure of
  the abuse
• Sends a prevention message that IPV is
  unacceptable

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Screening Questions

• Within the past year, have you been hit,
  threatened, slapped, or otherwise hurt by your
  intimate partner/ex-partner?
• Are you currently in a relationship in which you
  feel afraid or threatened?
• IF Yes How do you feel unsafe?
• Is there any former intimate partner currently
  threatening you?
• IF Yes How do you feel unsafe?
• Is your current hospital contact due to violence
  or illness related to partner violence?
• IF Yes What kind/type of injury or illness?

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Assessment

• of IPV

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Health and Safety Assessment

• Goals of the assessment
• When should assessment conducted?
• What should assessment include?
• Signs of abuse
• Why victims are reluctant to reveal IPV?

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The Goals of the Assessment are

• to create a supportive environment in which the
  patient can discuss her/his abuse
• to enable the provider to gather information
  about health problems associated with the abuse
• to assess the immediate and long-term health and
  safety needs for the patient in order to develop
  and implement a plan for confronting IPV issues

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When Should Assessment Conducted?

• Immediately after disclosure (initial assessment)
• During follow-up appointment (repeat and/or
  expanded assessments)

• After disclosure (of current or past IPV) at
  least one follow-up appointment (or referral)
  should be made

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What Should Assessment Include?

• Assessment
• of immediate safety
• of the impact of the IPV (past or present) on the
  patients health
• of the pattern and history of IPV (current and/or
  past)
• of homicide/suicide trends

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Initial Assessment
of Immediate Safety
20

• Are you in immediate danger?
• Is your partner here with you, now?
• Do you want to/have to go home with your
  partner?
• Is there any safe place for you to go?
• Has your partner ever threatened to or abuse
  your children?
• Are you afraid you life may be in danger?
• As the time passes by, has the violence gotten
  worse? More often? Are you scare more?
• Is your partner using alcohol or drugs?
• Has your partner ever threatened you or used a
  weapon against you?
• Has your partner ever restrain you or your
  children against your will?
• Has your partner ever watch you closely, follow
  you or stalk you?
• Has your partner ever threatened to kill
  him/herself, you or your children?

?
If there are several YES to the last 7 questions
Homicide/Suicide Assessment
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Initial Assessment
of the Impact of the IPV on Victims Health
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Initial Assessment

• Assess
• how the IPV (current/past)
• affects the presenting health issue
• relates to other associated health issues
• if the partner controls
• patients access to health care
• the way patient care for her/himself

23
Expanded Assessment
of the Impact of the IPV on Victims Health
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Expanded Assessment (1)

• Health issues related to IPV could be
• Injuries
• Chronic pain (neck, back, pelvic migraines)
• Peptic ulcers
• Irritable bowel syndrome
• STIs
• Infections (vaginal and urinary tract)
• Multiple pregnancies
• Miscarriages and abortions

25
Expanded Assessment (2)

• Mental Health Problems
• depression
• PTSD (Post-Traumatic Stress Disorder)
• anxiety
• stress
• insomnia
• suicide risk

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Expanded Assessment (3)

• Substance abuse (by the victim)
• tobacco
• alcohol
• others
• Ability to manage other illnesses
• hypertension
• diabetes
• asthma
• HIV/AIDS

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Expanded Assessment (4)

• If forced sex occurred asses for gynecological
  problems like
• STIs (Sexually Transmitted Infections)
• anal/vaginal tearing
• sexual dysfunction
• discuss about safe sex practices and
• family planning

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Expanded Assessment (5) (if pregnant)

• Pregnancy Complications
• miscarriages
• low weight gain
• first and second trimester bleeding
• infections
• ? low birth weight babies

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Expanded Assessment (6)

• If the patient remain unconscious (choking/head
  injury)
• conduct a neurological exam
• Encourage and help facilitate
• Preventive health behaviors such as
• PAP-test
• regular mammography
• early pre-natal care, etc.

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Initial Assessment
of the Pattern and History of IPV (Current/Past)
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Initial Assessment of Current IPV

• For how long is your partner violent?
• Have you ever been hospitalized because of the
  IPV?
• Can you describe me the most violent event?
• Has your partner ever forced you to have
  sex/into sexual acts against your will/hurt you
  sexually?
• Has your partner ever hurt any other family
  member/child/pet?
• Does your partner control/wish to control your
  activities/your social relationships/your money?

32
Initial Assessment of Past IPV

• When did the abuse happen?
• Do you feel you are still in dangerous?
• Are you in contact with your ex-partner?
• Do you have children/other matters in common?
• How do you think the abuse has affected you
  physically/emotionally?

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Expanded Assessment
of the Pattern and History of IPV
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Expanded Assessment (1)

• Discuss about
• the childhood history of abuse in family of
  origin
• whether abuser is limiting access to friends,
  family, co-workers
• possible steps to be taken (separation, divorce,
  seeking consultancy and/or shelter)

35
Expanded Assessment (2)

• Assess
• the support resources (e.g. friends, family,
  community, church, etc.)
• how the victims community respond to issues like
  marriage, divorce, abuse
• how the victim responds to cultural expectations
• how the abuse has affected children (physically,
  emotionally, etc.)
• how the abuse affects the victims life, work,
  relationships

36
Expanded Assessment (3)

• Assess (for the batterer)
• alcohol abuse
• drug abuse
• Increase violent behavior?
• mental health problems
• medication
• criminal record

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Expanded Assessment (4)

• Suicidal thoughts
• Have you ever felt so bad that you didnt want
  to go on living?
• Have you ever attempted suicide?
• Have you ever thought to commit suicide?
• Are you thinking to commit suicide now? If
  YES ?
• Do you have a plan?

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Expanded Assessment (5)

• Homicidal thoughts
• What options do you believe you have for being
  safe?
• Have you ever attempted/thought to kill your
  partner? If YES ?
• Have you thought about how you would do it?
• Do you have a plan of killing your partner right
  now?
• Assess the anger expressed by victim
• and his/her intention to kill

39
High Risk of Suicide/Homicide

• Restrict the patient in order to keep him/her
  safe
• Obtain psychiatric evaluation

40
Signs of Abuse

• You might suspect IPV if you observe
• failure to keep medical appointments, or comply
  with medical protocols
• discomfort to discuss about relationship -
  secrecy
• accompanied by a possessive partner who insist to
  be present into the examining room
• repeated returns of the patient with vague
  complaints
• a patient with health problems associated with
  abuse
• injuries inconsistent with the history given or
  unexplained injuries
• delay between an injury and seeking medical
  treatment
• injury to the head, neck, chest, breasts,
  abdomen, or genitals
• bilateral or multiple injuries, especially if in
  different stages of healing
• physical injury during pregnancy, especially on
  the breasts and abdomen
• chronic pain without apparent etiology
• an unusually high number of visits to health care
  providers
• high number of STIs, pregnancies, miscarriages,
  and abortions, repeat vaginal and urinary tract
  infections.

• failure to keep medical appointments, or comply
  with medical protocols

• discomfort to discuss about his/her relationship
  ? secrecy

• accompanied by a possessive partner who insist to
  be present into the examining room

• repeated returns of the patient with vague
  complaints

• a patient with health problems associated with
  abuse

• injuries inconsistent with the history given or
  unexplained injuries

• delay between an injury and seeking medical
  treatment

• injury to the head, neck, chest, breasts,
  abdomen, or genitals

• bilateral or multiple injuries, especially if in
  different stages of healing

• physical injury during pregnancy, especially on
  the breasts and abdomen

• chronic pain without apparent etiology

• an unusually high number of visits to health care
  providers

• high number of STIs, pregnancies, miscarriages,
  and abortions, repeat vaginal and urinary tract
  infections

41
Why Victims Are Reluctant to Reveal IPV?

• They may be
• embarrassed
• ashamed and humiliated
• afraid (of more severe abuse)
• lack trust in people
• There may be
• financial issues
• issues related to immigration or other status

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You Suspect IPV but the Victim Does Not Disclose
It

• Encourage the patient (in a sensitive and
  empathetic way) to talk about his/her experience
• Provide patient with a hotline number and other
  resources
• Let the patient know that you are available, if
  s/he ever need you
• Bring the issue up during the next visit. Goal ?
  not to force the victim but to understand his/her
  concerns
• Encourage a follow-up visit and schedule it
  within a short time

43
Documentation

• of IPV

44
Once IPV is Confessed or Suspected

• Physician should make a
• complete record of his/her
• findings in the patients chart

45
Record of Findings (1)

• Describe the injuries
• Locate the injuries on a body map
• Photograph the injuries (after patients consent)
• Record
• findings of related exams
• findings of the Assessment
• referrals made /or follow-up appointments
• Maintain any physical evidence
• Quote the description of the violent incidence by
  the patients own words

46
Examination

• Neurological exam
• Gynecological exam
• Mental health exam
• Lab tests, x-rays, etc.

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Findings of the Assessment

• Cite information concerning
• Medical history (falls, accident prone
  injuries)
• Social history (Overly concerned partner, history
  of substance abuse -including alcohol- by patient
  or partner
• Sexual history (sexually transmitted diseases,
  rape)

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Record of Findings (2)

• Comment whether the explanation offered for the
  injury adequately explains it
• Describe details like cloths ripped, broken
  nails, tearful, terrified
• Name (if applicable)
• Members of staff who examined/talked with the
  victim
• Alleged abuser
• Witnesses
• Police Officer
• Any cue that will remind you the patient and the
  incidence at a later date (in case of pressing
  charges)

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Medical Record as Evidence

• For a medical record to be admitted as evidence
  should be
• Made during the regular medical examination
• Made in accordance with routinely followed
  procedures
• Stored properly and access to it should be
  limited to staff only.

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Describe the Injuries

• Type
• Extent (size)
• Age (color)
• Location

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Body Map (1)
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Body Map (2)

• Mark the area of injury
• Score the severity of each injure (in a scale 1
  6)

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Body Map (3)
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Body Map (4a)
Describe injuries
Describe injuries in detail in the space provided
below
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Body Map (4b)