A 1993 national poll found that 34% of adults in the United States report having witnessed a man beating his wife or girlfriend and that 14% of women report that a husband or boyfriend has been violent with them (1). Studies suggest that as many as 30% of women treated in emergency departments (EDs) have injuries or symptoms related to physical abuse (2). A national health objective for the year 2000 is for at least 90% of hospital EDs to have protocols for routinely identifying, treating, and referring victims of sexual assault and spouse abuse (objective 7.12) (3). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has also recommended that accredited EDs have policies, procedures, and education in place to guide staff in the treatment of battered adults (4). To assess progress toward the national health objective for the year 2000 and the JCAHO standards, all active EDs in California were surveyed during November-December 1992 about their policies and practices for the treatment of battered adults. This report presents findings of this survey.

The survey was conducted by the Family Violence Prevention Fund (FVPF) in collaboration with the San Francisco Injury Center for Research and Prevention (SFICRP). The California Office of Statewide Health Planning and Development provided a 1990 list of 414 California hospitals with EDs. Telephone calls to each hospital revealed that mergers and closures reduced the active list to 397 EDs with patient volumes ranging from 515 to 234,663 annually. Distinct questionnaires for nurse managers and for physician directors of these EDs were mailed to them by name. Domestic violence was defined as "the actual or threatened physical abuse of an individual by someone with whom they have or have had an intimate or romantic relationship." Nurse managers from 319 (80%) and physician directors from 216 (54%) of the EDs responded to the survey, representing 346 (87%) of the EDs.

Only nurse managers were asked questions about existing written policies, referral lists, and patient brochures, and they were requested to provide copies of all the hospital's written materials related to domestic violence. One hundred seventy-two (54%) nurse managers reported that their ED had written policies for treating adults suspected of being victims of domestic violence. The reported presence of a domestic violence policy was not associated with ED patient volume. Of the nurse managers who reported that their EDs had domestic violence policies, 110 (64%) submitted copies.

Fifty-nine (54%) of the policies submitted included material specifically about spouse/partner abuse; the remainder exclusively addressed other forms of abuse (elder, child, and sexual {not specific as to partner}) or general criminal assault. Of the 59 policies, 34 (58%) mentioned notification of authorities; 20 (34%) provided at least limited guidance for conducting a physical examination; 14 (24%) mentioned patient consent; 14 (24%) provided instructions for taking photographs as evidence of battering; and 11 (19%) mentioned the collection, retention, or safeguarding of specimens and other evidentiary material. Eight (14%) policies provided instructions on information to include in the medical record regarding examination, treatment, referral to other care providers and community agencies, and reporting to authorities.

Of the responding nurse managers, 295 (93%) reported having referral lists of services or resources for battered adults, and 135 (42%) submitted copies. Nine (7%) of the submitted lists were comprehensive, including at least one resource in each of the following categories: domestic violence agencies or battered women's shelters, mental health and community agencies, general social services, criminal justice system agencies, and providers of legal assistance. Fifteen (11%) lists did not include resources in any category; 111 (82%) included resources in one to four of the categories.

One hundred eight (34%) nurse managers reported having pamphlets, brochures, and other written materials on domestic violence that were appropriate for patients, and 88 (81%) submitted copies of them. Seventy-three (83%) of these 88 EDs submitted materials specifically addressing spouse/partner abuse; the others exclusively addressed other forms of abuse (elder, child, and sexual {not specific as to partner}).

Nurse managers were asked if they would use model policies for the identification and referral of battered adults. Of the 319 nurse managers, 279 (87%) said they would use them to develop and/or refine policies for their hospitals.

Physician directors and nurse managers were asked about staff education regarding domestic violence. Of the physician directors, 50 (23%) reported that their EDs had ever conducted an educational session on domestic violence for physicians, and 14 (6%) reported that such a session was conducted for residents. Of the nurse managers, 89 (28%) reported that their EDs had ever conducted an educational session on domestic violence for ED staff. Two hundred ninety-four (92%) nurse managers and 199 (92%) physician directors, together representing 331 (96%) of the responding EDs, said that they would use educational materials developed by experts in the treatment and prevention of domestic violence. Of the nurse managers, 145 (45%) reported their ED would be willing to serve as a test site during the development of model policies and educational materials.

Reported by: E McLoughlin, ScD, San Francisco Injury Center for Research and Prevention; D Lee, P Letellier, MA, Family Violence Prevention Fund; P Salber, MD, Institute for Health Policy Studies, Univ of California at San Francisco. Program Development and Implementation Br, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: EDs may provide the first opportunity for battered adults to find support, assistance, or protection. Because domestic violence recurs (5), ED identification may interrupt the cycle of violence and help prevent further abuse. The development and implementation of policies and procedures, reinforced by staff education, may increase the rate of identification of battered adults (6,7).

The survey findings suggest that most California EDs lack policies specifically addressing the identification and treatment of domestic violence. If the submitted policies were characteristic of all EDs reporting a domestic violence policy (e.g., 54% verified as specific to spouse/partner abuse) and the EDs participating in the survey were representative of all California EDs, as few as 29% of all California EDs have policies for domestic violence, well below the national health objective for the year 2000. In addition, most referral lists are not comprehensive and staff are given little education about domestic violence.

Added impetus for achieving the national year 2000 objective for hospital protocols was given when the JCAHO revised its accreditation standards. In January 1992, the JCAHO added "physical assault" and "domestic abuse of elders, spouses, partners" to the existing standards for child abuse, rape, and sexual molestation as conditions of abuse where ED patient care must be guided by written policies and procedures. For all of these conditions, the JCAHO now requires that procedures address "patient consent; examination and treatment; the hospital's responsibility for the collection, retention, and safeguarding of specimens, photographs, and other evidentiary material; and, as legally required, notification of and release of information to the proper authorities" (4). The JCAHO also requires that a list of referral agencies be kept; that the medical record adequately document examination, treatment, and referral; and that staff be educated about identifying and treating abused patients.

It is not known to what extent EDs in other states have appropriate policies for domestic violence. The California survey is being replicated by the FVPF in collaboration with the Pennsylvania Coalition Against Domestic Violence and the SFICRP in Pennsylvania, New Jersey, and a representative national sample of hospitals. Results are expected by the end of 1993.

The JCAHO standards concentrate on the hospital's generic legal responsibilities in handling abused patients but offer little guidance for the content of the policies. To provide such guidance to ED staff, the California survey's collaborating agencies are collaborating with major medical and hospital associations to develop model policies and staff educational materials for domestic violence. Field testing is scheduled for spring 1994, after which these resources will be made available to EDs in all states.

References

1. EDK Associates. Men beating women: ending domestic violence -- a qualitative and quantitative study of public attitudes on violence against women. New York: EDK Associates, 1993.

2. McLeer SV, Anwar R. A study of battered women presenting in an emergency department. Am J Public Health 1989;79:65-6.

3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:237-8; DHHS publication no. (PHS)91-50212.

4. Joint Commission on Accreditation of Healthcare Organizations. Accreditation manual for hospitals. Vol 1 -- standards. Oakbrook Terrace, Illinois: Joint Commission on Accreditation of Healthcare Organizations, 1992:21-2.

5. Stark E, Flitcraft AH. Spouse abuse. In: Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York: Oxford University Press, 1991:138-9.

6. McLeer SV, Anwar RAH, Herman S, Maquiling K. Education is not enough: a systems failure in protecting battered women. Ann Emerg Med 1989;18:651-3.

7. Tilden VP, Sheperd P. Increasing the rate of identification of battered women in an emergency department: use of a nursing protocol. Res Nur Health 1987;10:209-15.

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