 We should go ahead and start, it's our time for setting as people try to catch water or snag before coming so that they can go back to their classes and other obligations. But I'm really delighted that we have this, this panel. My name is Dither from the chair of the Department of Operational Development and Resistivation. Today we're very lucky to have a group I'd say in collaboration in the program in public health and the Department of Emergency Medicine in the School of Medicine. And that group is here with us today in the person of Dr. Deborah Harris who is at Emory University and she's Vice Chair for Research and Associate Professor in the Department of Emergency Medicine at that university. But she also has appointments in the Department of Behavioral Science and Health Education and in the Department of Environmental and Official Health at the Rowling School of Public Health. So she has been working in the spirit of this kind of collaboration that we have at BCI also at Emory. She also directs the Center for Injury Control at the School of Public Health and teaches several courses on violence and injury prevention. She's on the board of directors for the Society for Advancement of Violence and Injury Research and the President-Elect for the Society for Academic Emergency Medicine. Please join me in welcoming Dr. Deborah Harris. Well thank you all for coming today and including this morning. So feel free to cover any questions to keep me as well. And as he said, I'm up. Sorry, maybe I knew we would have it. I don't think so. Come on in. You're kind of wrong there. Yeah, it's kind of hard to find. And people will, well, please come in. And then I just want to use the speaker. I mean, you're dead. Oh, yeah. Do I have somebody? Yes. I mean, I can use the speaker. Yeah. Yeah. This is what I was expecting. It was a little bit shocked, I think. But I really had to do with the directions of the books. So now it's a very popular topic. Now we're really ready to start. Thank you. So for those of you who just joined us, I introduced Dr. Deborah Harris. She has wears many hats at the Emory University in Atlanta. She's Vice Chair for Research and the Department of Emergency Medicine there. And she also has appointments in the Bureau of Science. I'm in the Environmental and Occupational Health at Emory University. We already clapped for her, too. But you're welcome to do it again, because I'm sure you'll call for me. And I am in emergency position, so I have short attention span. So feel free to ask questions throughout the presentation. You don't have to wait until the end. I may have what I was speaking about. I thought this today's talk was much more public health oriented on some of my research. I'm speaking with emergency medicine. It's definitely more of a clinical talk about the work I do with violence. I just got started in this research when I was a medical student, because I wanted to get into a good residency program. I didn't really know that I was going to end up one being a researcher or two. This was a field that I've done for the past 15 years. I got a combined master's in public health while in medical school. I just really found that in the emergency department, there's just so many ways that you can really impact patients from a primary intervention to a secondary intervention standpoint. That it made a lot of sense to really kind of mirror what I did from a research and academic standpoint with my clinical standpoint. So I think I'm lucky because I enjoy what I do and it's fun. And I at least don't make sense. A lot of people think what I do is get the front of them all over the place, but I think it comes together. So today what I wanted to really talk about was an intimate partner around screening and whether that's active. Talk about some of the work that I've done in the emergency department and how these results might apply to the general community. So how many of you are familiar with the rule of thumb that actually means more than I would have thought? Because I had no idea what it meant. I mean, I knew it meant something about your thumb. But I did not realize that that was the size of a switch that you could hit your wake with. That was a legal precedent. If the switch was smaller than your thumb, that was okay. I thought it had something to do with measurement or something like that. So when you talk about it, it really just goes to show that although it would come quite far because it was not that long ago that this was a legal precedent. And up until about twenty or thirty years ago, spousal rape was still legal in many states. So we often look at other developing countries but when we look at our own country, we still have a ways to go. It's only been a recent history that we ourselves allowed intimate partner violence to happen. I talk about it. It's really about coercive behavior leading to abuse. Physical, sexual or psychological can be any or all of those. And one partner by the other and the establishment of power and control can be a current or a past relationship. And this relationship doesn't have to be marital. It can be dating. It can be same sex. And in this talk today, I'm going to be using she as a victim, he as a perpetrator. I'm very aware that men can be victims and females can be perpetrators. And actually a lot of my more recent research has shown that those rates are actually equalizing to where you're seeing higher rates of female perpetration and male perpetration. When you look at dating violence, you're actually seeing higher rates of female perpetration. But today, when I'm using she as victim, I am cognizant and aware that this is not always the case. So why is it important? Because battering is the most common cause of injury to women in the United States. I mean, I think that how busy our room departments are, the impact of orbiting mortality that we could influence. I think it's highly imperative that we look at this issue. You look at almost $6 billion on the annual basis for medical expenses and work put into these losses, and over 1,000 women and 440 men killed each year from intimate partner violence. When you look at common conditions affecting women between August 1545, intimate partner violence is one of the most common risk factors that we're not supposed to. Bless you. And I didn't pull up the California stats for tomorrow, but the California Women's Population Study actually said that about 40% of women had experienced physical violence in their lifetime. So rates can really raise, depending on what your definitions are, but very, very common prevalence. When you look at the emergency department, it depends on whether you're talking about non-physical or physical. And when they talk about incidents, patients may not always be there for natural injury, might be mental health issues associated with the violence, or they might just be there in the current victim. So the rates can range anywhere from 12% to 20%. When you look at prevalence for lifetime, it can be up to half of emergency department patients have experienced violence from a partner. So from that standpoint, it made sense to me to really look at the emergency department as a place to study this. It's a point of entry into the healthcare system. If you fall or break your arm, you're going to come see me. If you don't have a primary care physician, you're going to come see me. So no matter what your socioeconomic status is, you're going to come see me at something. You may not want to hear that, but you really can see everybody from all walks of life. We do usually serve the medically and underserved and without insurance disproportionately, but anybody that has a violent injury will come see us. We see a lot of victims of trauma. The county hospital I work at, we see 110,000 patients a year, only level one trauma center in Atlanta. Just I work Saturday, I have five shooting cases. So we see this trauma all the time. Really, the important time to really develop an educational intervention, it's really the teachable moment. We also see people with substance abuse problems and mental health problems that, again, don't have regular access to healthcare or to other primary care providers. But when you look at it nationally, these have seen over 115 million visits increasing each year, the number of visits that we're seeing nationally. And at the same time, the number of hospitals are decreasing. So we're having increased volume, decreased places to go. And we've seen that 20 trauma centers recently closed. I know in California you guys are very familiar with some of the recent trauma center closures. That's because we do lose money. We see a lot of uninsured patients, trauma patients that usually generate money. But again, this is where patients go. So that's in line. This is what I see every day when I go to work. This is just during the day. So not a Friday or Saturday night. And those are parked, just waiting to bring me my patients and clients. And this is the waiting room. You can't see it as well, but it's not this big, beautiful waiting room with trees and plants. I teach comparative healthcare system course and I make my students come with me to my county hospital before we go to London. Because usually people, when they go to London, they go to healthcare facilities aren't that great. But when they see what some county facilities are in the United States, they do think that the facilities in London are quite nice. I think it's a lot of them that's what you're exposed to. So this is our waiting room. We usually have, it's gotten better. But sometimes we can have up to 12 to 15 hours waiting time to get there. I have suggested putting educational videos there instead of like the news or Oprah. But that hasn't happened yet. Because again, we've got that capture of audience where they're sitting there. And to me it's a great time to do an intervention. So I've actually put kiosks there, which I'll talk about. The other thing is, this was our fancy triage area. It went computerized two months ago. But before that, that was how we sorted the patients. Literally met the charts going in different baskets. How much of the traffic would you say cost more than you would deliver the needs of my students here? Probably about 30% of our patients. So not as high as people think. People think, you know, because we have so many of those patients that don't have access to healthcare, but those patients are easy. They're the ones that come with a medication refill. And so we can see them quickly. It's the patients that have longer, more complex illnesses. And because despite, you know, somebody's managed people having more insurance, it doesn't mean there's more in a primary care physician. So now patients want access to medical care. So they come see us. So this is, again, just a regular day for us. Our hallways, they're all marked. We have 19 on our trauma side and I think 20 on our medical side. And so patients will then come here. And you can see, again, the emergency department, I think it's a great place to do an intervention. But when you're looking at something like this, it may not be the most private, the most conducive, you know, to really talking about private and sensitive issues. Particularly, you know, when you're asking a question and the patient at the bed behind you won't answer because they've already heard the patient ask that question before and helpfully correct you. And on Halloween, we actually switched to a computerized system. But prior to that, this was our fancy ordering and tracking system. It began for 110,000 patients a year. So just paper and clipboards. And all of our charts were paper too. So when you're looking at doing studies where you're extracting data or trying to insert a surveillance system, this is what you're working with. And so we're talking about my studies. This is what I was working with. And so when I always talk about some of my research to say, you know, I was able to do it in my setting, it means that it can actually be done, I think, easily in other settings. And the other thing is, is patient experiences or two department, they come, you know, and then if it's like a car crash, we surround you, we cut your clothes off, you know, everything's happening all at once. Somebody comes in after a trauma, we just swarm over for these. And we really traumatic for our patient as well when you're trying to do psychological briefing or counseling or anything like that, this is the setting we're doing it in. So again, really kind of high stress, not as well as it was a one-on-one setting outside. So with that in mind, when you look at the first two department setting, many patients within the department present non-interrelation claims, like chronic abdominal pain, repression, suicidal thoughts. And they don't just come in with, you know, a broken leg or laceration from their partner. But when you look at how we've done in the healthcare setting, screening rates usually are about 10% where we're screening men and women for intimate partner violence. It's really invisible. But, I mean, we've got all these patients coming in with violence-related experiences. You know, a lot of people say, well, patients don't want to be asked. They do. We're serving men and women, the 85% bill is appropriate and the 85% bill requires to ask about violence. You know, we ask about some bill that you smoke and everything else, so you just ask about your kind of regular routine delivery of care. When you look at the American Medical Association, they actually say that you should be doing routine screening at the entry of health care, which is really emergency medicine. It's also your primary care physician's office, but the timeline of emergency medicine is really on the forefront of this. And J.K.O., the Joint Commission said all the rules that they may can't drink sodas, go let work, or have snacks out. They also say that you should be screening and referring patients. But when you actually look, there's a study done in California, actually, where they saw who knew what their protocols were, less than half of the possible is even new with their protocols and policies were. And when I first went to Emory, I was very excited. Incorporated triage. I was like, this is so great. I've just moved to Atlanta from Colorado where we're going to do this intimate partner vinyl screening. And unless we have the J.K.O. site visit coming up soon, we want to make sure that we had that screening question that we were incorporating because it was mandated. I'm okay with that because at least hopefully it's getting asked or recognized, but places where they don't even realize that there's the mandate and it's on a form, when you look at universal screening, screening everybody for intimate partner amounts is some people in places advocate. Greg Larkin, when he was at Pittsburgh, trained all the nurses through like a two-hour video and educational session on what to look for, how to ask the questions and what to do with that information. On the triage sheet, when every patient came in, there was the box that they were supposed to check with the assessment. And after this great educational intervention, less than a third was screened. Again, after they told us it was mandated and having a focused educational session on it. Day shift with being less sick more likely to be screened, which makes sense when you're not quite as busy, you know, somebody's coming in not having a heart attack, you might ask, but again, 70% of our patients, you know, wouldn't be explained by this and people just aren't asking. They took it a step further and actually implemented disciplinary action if you weren't screening where if they reviewed your charts and you hadn't been screening, you then got verbal counseling. Half of the nursing staff got verbal counseling, you know. I bet you reviewed your charts for the last month, it looks like you've not been screened for any of the partner miles. We had this session in October, you know, please screen this report, you know, from a public health standpoint. Next step was written counseling, you know. Hey Jack, you were giving verbal warning six months ago that you weren't going to go over what you needed to do, you've not seen any improvement in your screening. Please screen. Third step was written warning of termination. They'd actually lose their job for not screening. 10% of people got to that. The fourth step was termination. No one got to that step, but when you look at what screening increased to, 73% to still not even 100%, and that was been told you could be fired if you weren't screened. Yes. I'm sure you're going to get to this, and why these nurses didn't want to be screened. You tell me, what are your thoughts? Well, I have some thoughts as to why, but are you going to... Not specifically for this study, and I'll talk about kind of Pandora's box, as I call it, but at least some of your initial thoughts. Well, I mean, I guess my first question would be, what did they do if somebody screened kindly, what was the step that they were supposed to follow? And that's the big, what it, I mean, if you ask a question and you say, yes, and you're already busy, and you're supposed to stop everything, you know, refer to social work, maybe there's kids involved, and you just really open up this huge box. Sometimes it hits too close to home, or you don't think it's necessarily important, because you might think there really aren't many effective interventions, or you've seen where you referred to before, they still keep coming back. And so I think all of those really come in play, but the biggest one is, you get that yes answer. And what's amazing is, is a lot of times, when you see screaming, you can see how people can look at someone and say, you know, I don't think she smokes, and I don't think she experiences violence, because they can just check to know, like, all the way down a chart without ever having looked at their pen. And sometimes I'm not really sure that people are actually screaming, versus just looking at people and determining yes or no. When I've gone back and on the chart audits, you can see clear histories where patients really weren't there with suspicious injuries, and there's more to know, because it was never asked. But yeah, because in general people don't want to take that extra time to follow through. Which is why I developed the kiosk intervention. You know, and so it should be screened. The U.S. Preventative Services Task Force has given it both a C and an I for insufficient evidence. For instance, the president's partner about screening. And several recent systematic reviews have just said that, you know, there's really not enough information around the harm or benefit of identifying and treating these women. But I think it matters, because if you don't ask, you're not going to detect it. People don't volunteer the sensitive information to you. If we don't pick up on it, they're going to come back with the worst injuries, or they're going to be injured, or a family member is going to be injured, or they're going to come back dead. It's low cost to ask. And if we do it in a safe manner, it's low risk. You know, so does it predict future violence? Well, my first no-dub studies took several journals to get it published because they all kept saying, well, we know this. But we actually didn't throw this. It was looking at the predictive validity of screening. We looked at women who screened positive and negative at 0.0 and followed them over four months of time period. And what we found was anyone that had screened positive initially, 11 times more likely to experience physical violence during that time period, and 7 times more likely to experience verbal aggression. The studies that sought medical treatment in that time period for injury had all screened positive. So you are picking up patients who are experiencing violence and by recognizing, hopefully, you can prevent some of that future injury. You know, is there an easier way to identify and really educate? So my own personal bias is computer kiosks. It takes the really embarrassment off of one of the somebody asking that personal question, really, that your going to pick you at home. People don't want to tell me that after I've just asked them their name and checked their blood pressure. That's the next question I ask. You know, we don't have a long-standing relationship. They're able to do targeted resources or intervention on the kiosk based on what people screen. And in my mind, it's great for environments with a long waiting time. I mean, I've got a greater 80% acceptance rate of my kiosk because people go up and do them because it gives them what I've actually done is put other public health measures on there, like sensitive use mental health issues to really give them referrals and help identify any issues that they have while they're there. And physicians and nurses are really unlikely to screen. And so this takes the burden of screening off of the healthcare providers. And if you get that yes, it automatically links their gifts to targeted reports. So you don't even have to worry about what happens if you now give the physician the kiosk automatically will do that. So what I did was I wanted to see what the safety of screening and identifying and referring victims as part of this ED-Kiosk system work to really look at future incidents of violence and patient-reported outcomes over a six-month period. And again, this was in my county hospital. And I was supported by both CDC and NIH. And this is what our initial touch screen kiosk looks like. Now I'm on a newer study. It actually looks like an ETM machine and there's very nifty looking to where you can't miss it. My initial request for kiosk was something that they couldn't pull through the registration window because we can't even have, like, things to look in your ears in our hospital because, like, they walk off. I mean, so, I mean, they couldn't pull through the window. And something really heavy and indestructible. And that lasted for three years. So, you know, it cost $2,000. So, in my mind, very cost-effective. I was also in a semi-private registration booth. That way the person sitting next to them couldn't see what they were putting in. So they felt like they were private. I also positioned it right by on the security guards when people came in after they'd been screened through the metal detector. So there were any issues. Again, security was right there. We had no issues, but these were all the things I was thinking about when I developed it. Not sectioned on a patient, either. My deputy's director who I asked to pose for it. And what we looked at was harm for participation in screening. Because one of the arguments against intimate partner violence screening is that it's going to increase your harm. You know, she might feel empowered and go home and shoot him, or he might hear she participated and then retaliate. And my thought was always, if you do it or you don't label intimate partner violence, give them safe instructions. You know, tell them if they're going to keep the referrals, put them in a shoe or a small safe place and just don't say, you know, you have these issues it's safe. And to really look and see what did they do with this information. Did they follow the resources, contact the hotline. Did they develop a safety plan? And how many incidents and violence did they experience after participating? So what we did is we approved to be emergency department waiting. I had research staff that since we've walked up to every single person after they've been triage met and women and say, we've got a general health survey we'd like you to take. They were not told it was violence because again, we didn't want to predispose people or increase their risk by taking them. They've done things in the computer screen where they would do their consent and then we got a print out if anybody is screen positive for intimate partner violence for the research staff for something, enroll this patient in the study and so then we would follow them up at three months. The other thing we did was because in general follow-up is really difficult and people experiencing violence and in our county patient population. So we looked at 911 calls for their addresses before and after. That way we never got a hold of people again. We had a general staff for what was going on. Yes. Were the patients aware of the number anyone was sending? At that point we didn't call anyone. Yes. Well, we didn't call about 911 calls. Remember anybody who wanted to do the screen? They were all consented to this general public questionnaire. And we got their address and all that information at that time. If they screen positive for intimate partner violence then they did a second consent because we had them come back to the personality follow-up. And what we did was there was 120 questions but they didn't answer 120 questions. We had skip patterns in there so if you answered yes or no to something, you might skip 20 questions. It really took about 15 minutes and we saw the booth that it was conducted in. We used validated scales which I'll cover. And we also had demographic information of height, weights. We were calculating their BMI so we can give nutrition information, primary care referrals and everything. And again, although this was a research study I thought it was really a service to our patients that they were doing this. And the way I got people to rule too was I offered them a healthy snack and they got the peanut butter crackers or the cheese that weren't really healthy but I just didn't feel good giving them candy bars and when we did the roll of bars no one was interested. So that was kind of my compromise. And that was their total payment. If they did the follow-up reviews they got paid $20 to come back but they got a package of crackers to do the 15 minute computer survey. And again when we found people had screened positive the research staff would get a printout and then they would know their contact information. I also had suicide questions on there and if somebody was suicidal we wanted to know so we had that printout because we didn't want them to sit in the waiting room for 12 hours after having this close suicidality to our computer. I thought that was a big risk to have somebody perhaps leave after having documented that. So that patient then we moved out of the waiting room and brought back sooner to be assessed by a physician. Because mind you, new patients weren't coming in for suicidal ideation and they went through our psyche arc initially. These are patients that were there for like an ankle pain and then they were actually suicidal. So how common was that? So that was one of the lessons learned actually hold that thought for two minutes. So this is what we used for intimate partner violence because the universal violence prevention screening protocol and I liked it because we validated in our Grady population before and these are the questions. Because I asked about physical, sexual and non-physical violence and so I thought it was important because many only asked about physical violence and this, is it a perfect test? No, is it, you know, 20 questions? No, but again I just want something simple to really pick up for their issues. For depression we used the back depression inventory and I just broke it off by none to mild or moderate to severe. So PTSD we actually added a square about dramatic events. That way they hadn't experienced anything. They didn't go on to ask the whole PBS. And then with suicide what we did was we looked at the back scale and I looked at all the literature and it rained from 2 to 11. We initially had a lower range, I think maybe 3 or 4 with very high rates of suicidal thoughts in our patients whereas this roughly patient was low and it was not very good for our clinical practice and so I contacted Dr. Beck and looked at all the studies and found what the highest cutoff of use was and that was 11. And so that's what we went with and I'll show you the results in a few minutes about what our general population rates still were with the highest cutoff. But yes, I modified the output highlighting it because we had extremely high rates in our population. And then at the fall just with those who were exposed to victimization we did a conflict packet scale assessment, danger assessment, stages of change, short form 12 to look at physical and mental health issues as well as some victim desired outcomes like safety plan, leaving their partner telling family and friends and follow up questions about the violence they experienced. And these were the main victim desired outcomes that we looked at. So over a 17 month period we approached about 5,000 people and 4,000 were eligible. They had to be English speaking between the ages of 18 to 55. It was really during the high peak hours of them I had people screening. And we had 70% participating in screening. This is just our general population. A little over half were male ages about 35. Education levels actually higher than I thought would be. 59% had at least gone to high school. And usually our medical literacy rate is around 5 or 6 grade in this population. So all of our tools and information was also tailored to that educational level. The majority of our patients were African-American, 87%. Snow cigarettes regularly. 21% abused drugs in the past month. Or yeah, in the past month. IV drug used less common among my patients. It's crack cocaine is what's used in Atlanta. It's used in Illinois and Colorado. It was more heroin. Here it's all crack cocaine that you see. Half abused alcohol in the past month which isn't a big deal except when we look at the problem drinking questions and a third to 40% are problem drinkers. So this gives you a sense for again, the general patient population and when you look at their mental health symptoms 25% are experiencing moderate to severe depression. 13% moderate to severe PTSD symptoms. And 7% suicidal. And this really opened a lot of eyes to my own because I'm in the air dock at heart. I treat them and street them as I always say and I live off one patient complaint because I'm not that complex of a person. But then I realized that everybody has it's really multi-factorial and multi-level. And that there's all these mental health components going on and our patients are constantly exposed to traumatic events around them. To where I actually don't and we'll talk about it and I don't recommend asking them questions do you feel safe at home? Because many of my patients don't feel safe at home and that has absolutely nothing to do with their relationship. It has to do with there's a lot of crime there though. And that's why you see such high rates of mental health issues. So we then looked at people who were in a relationship in the past year about a third war and 46% disclosed intimate partner violence in the past year. Majority were female tend to be younger and unemployed compared to those who did not disclose it. And when you look at associations with intimate partner violence you can really see significance with oppression, PTSD suicidality, drinking and street drugs. All were significant. What I don't have today is my perpetrator information but it looked essentially the same as well. Whether you're a victim or a perpetrator of violence high risk associations with mental health systems that abuse the mental health again you can't just scream for one thing without considering everything else. So there were no males in this pool? Well in this pool it was about 67% of females among the victims. But I'm pretty close to that for the perpetrators. I mean I think it was close to 50-50 but you really just saw this breakdown. The other thing I did is have more power and control to see where people fell on the spectrum. I did find that females with disclosed victimization felt greater loss of power and control than men who were victims. So there was really kind of a different battering level that was going on with it. And what I should, oh sorry, yes. On the last slide, what were the other versus? Oh, those that were not victims. So 39% of victims disclosed that they were depressed versus 11% of people who were not victims. Okay, so you knew that they were a victim or perpetrator from how they responded to the CTS? Everybody was asked whether they were in a relationship in the past year then everybody got asked the Universal Violence Prevention Screening Protocol and I had a perpetration screener on there too. Okay, and you asked only the patient or could anybody in the way know? Anonymous, anonymous, few. So, and I did not ask for validation from anybody whether or not they thought the person was a perpetrator. And what we found too is if you look at the types of violence and mental health symptoms, you can really see this huge dose response ratio to where if you experience both non-physical, physical, and sexual violence up to the 18-fold risk that you disposed suicidal ideation compared to somebody that had no exposure to violence. You can really see each type of violence is very additive. And so, our follow-up was not as great as we would have liked and I'll talk about lessons more in a second, but of the 548 who screened positive 430 agreed to participate in the follow-up and it was interesting reasons for not wanting to participate were usually I'm not a victim. When you look at what they screened positive to you know, if they were being hit so we did education around that time too. We did get 62% for one week follow-ups and we added the phone number to be there because many people just didn't want to come back so we tried to at least capture the safety information. No one had any problems in the emergency department after they were given the information, targeted around violence their partners didn't try to interfere or remove security incidents and they didn't like that. Two didn't like the questions that we asked because particularly at the top of the tactics scale they thought theirs was very personal but there were no violent incidents after participating. 95% felt they benefited and 83% kept the information and I am aware this is self-report so they might be telling me what I want to hear but when you look at what happened a fourth made a safety plan 15% actually contacted the public resources and this is the patient population that when they come in with chest pain and we scheduled for an outpatient stress test there's about a 10% follow-up rate so they have this high of results when people are entering substance abuse treatment common resource knowledge is very impressive but one thing we did have to change in the script when we did our first interim analysis was kids are carrying weapons and I didn't think any of my federal funders would appreciate participating in my studies sort of carrying weapons so when we were going over safety plans or appropriate responses we put in there that carrying a weapon was not recommended and could actually increase the risk of harm so after the first couple months where this went up I think we only had one or two people carry weapons after participating I was very alarmed when I first saw that at three months we found it was interesting to look to see who was following up whether this would more significant mental health symptoms or the ones that were coming it was actually the population that we wanted to capture there were the ones that had less social support as well and so there were the ones that were coming back for our referrals and again at three months we found that a third had contacted a resource 20% had called a life duty group and a third had moved down so a couple of these cameras did a show on my program when I was worried because we just wanted to grab one of your participants and talk to her and I was thinking it was okay I wasn't getting the picture and I had no idea what they were going to say when they get to be on TV and fortunately it worked out very well the woman said I've been in abusive relations for seven years I got coming to the emergency department no one ever asked me about it and I was wrong I didn't know there were resources I didn't know there was health and after getting the information she joined the support group and left her for her so that was a good story for TV but I think that was just really clear that I mean no one is asking about it and just saying this is not this is not right if you grow up around it you might think that all that there is and you don't realize that there are other resources when you said that you're partly after the interviews and you made a safety plan was that your social workers or research staff and it was just solely off the printed out information because we wanted to do something very low key and the study we have to do now is we're taking the research staff completely out of it because we don't want to even have that counseling aspect because that costs money to have people there staffing it was just slowly taking a piece of teamwork I think there are graphs about what they can do and then additionally there were given numbers on like these are hotline numbers they can call here in the United Way here's legal aid it's the only track to see what they did so the professional care education rate between the 20th and the 23th was that largely due to not being able to find the people or was it due to their refusal not being able to find them hold that for one second and that's how we did these 901 calls and we found no difference six months before or six months after to any of the participants that participated in the study so we didn't see any increase in 901 but when we did lessons learned I had increased the cutoff score for suicidality because we had such a huge volume we ended up doing two computers that way we could run people through it multiple times to get people to come for one week we had a daily phone call or minus the follow up pre-arranged schedule times and that was to get like the 60 to 70% at one week and what I did was I told them here's your appointment to come back to us but then they also knew when we were screening patients so by chance they were there for a follow up or half of an hour they could also just drop by then and page us for three months we'd start doing weekly phone calls we'd send them postcards but I think half the people had disconnected phone after a couple of days and we tried looking through registration to get from phone numbers and this could never find a lot of our patients we also did part of tokens that's our public transportation because for a lot of our patients it was cost-permitted to come back to see us we didn't give them the tokens until they came then they got reimbursed for both ways we also were going to do exit interviews after the ED visit to the missile how long my name the patients were there like 18 hours sometimes they weren't filling out paper surveys we couldn't get staff to do it so we just took that part out one of the other aspects we initially hoped to do was there were going to be three printouts one for the patient very detailed with safety plan resources one for the staff saying enroll this person and one for the physician to say they should be positive for sexually transmitted disease risk factors alcohol files and they would just get a prompt these are paper charts at the time we found that some of them didn't make the paper charts they did it was like maybe five pages back behind you know the ambulance form or something else so they weren't getting read or noted even noted half the time we felt that was probably even worse because of the patient's soft positions new more askings and then we just took all of that away and just really had kind of very kiosk based you know other ways to screen exam questionnaire screened by a triage nurse or someone else modifying it on the chart on our paper charts we had a box for domestic violence which I think is good to prompt you to ask but again you have to be in the mindset to even ask about it and the other thing I'll say is if you're going to have that box like on a pre-exam questionnaire you have to follow up on it I was just curious to see what happened when I was going to my OV for my visit I checked the box because this is what you wanted to get information on and I was curious to know what information they had so I checked domestic violence and triage nurse didn't ask me a thing and doctor didn't ask me anything and then once you came right at this chart to me I just said well you know I checked the domestic violence box I was like oh yes you did doctor how are you is there anything you'd like to talk to me about and I said well this is my little area of research and if I truly had been experiencing violence and I checked yes and you never followed up with me about it you are endorsing this and saying it's okay so then I asked it made it worse I asked you the information they couldn't find the pamphlet at that time and I didn't have a little star because every prenatal visit I had after that I was asked about my situation at home which has always been fine but I didn't want to know so I think if you have any of these mechanisms in place you have to ask and that's why with the kiosk if you automatically get a print out whether or not it gets disclosed to the physician because my hope was to really involve providers in this I think in our healthcare system of increasing visits decreasing places for people to go it would be great if it could be done but it's not going to happen every time when I worry about the person that is there that needs health that doesn't get that referral so I think it's really important to at least have a fail-safe mechanism in place so why don't we screen because this is my Pandora's box lack of education around it people are comfortable asking the questions and aren't really sure what we can do for our patients and not realizing too that you can't just refer to social work they may need the mental health referral they might need to help with their substance abuse issues lack of time although I would say lack of time is if you get the guess because it really doesn't take that much time to ask a single question lack of effective interventions I think many people get frustrated because it can take half to seven times before somebody leads a relationship so you don't know where they are on the spectrum and we look at stages of change 80% or pre-contemplation I'm realizing that they were having any issues on what intimate partner violence was a problem in their life and so you don't know where you are on that spectrum of moving people and I think it's frustrating for providers and something like me where I'm very I see, okay, I've discussed this with them I've given their options or are they still in their relationships because that might not be the outcome that they need just by asking in itself really is a benefit they're defending the patient privacy concerns they come in they're asking all these detailed questions and we look at the numbers a lot of us have been exposed to violence it is too personal and people aren't comfortable asking about it so why bother because if you don't ask about it I really think it sends a message it's amazing how a lot of our patients think we're able to tell by the way we're talking with them when we really may not know what's going on the cycle will not stop you know the injury will get worse the violence will escalate it can involve other people I really think that it's really that educational moment somebody comes in for a car crash I say, where you wearing your seat belt they say, thank you that's why you look as good they say, no I'm like this is your lucky day you were so lucky you really needed to wear your seat belt again and that's the time you can talk to people when they come into the emergency department or anywhere else disclosing violence or some sort of associated problem that you can talk to at that time because that might be one of our most receptive to it and not talking about it today I am tomorrow with emergency medicines there's legal responsibilities too depending on what state California is a mandatory reporting state so wrapping up one of the type of questions again my personal bias I think if the partner mind screening is safe and that's related to referrals it might prevent future incidents we found that most of the patients were satisfied with this computer process and that many contacted follow-up referrals and in general I think computer kiosks can be really helpful for providing brief educational interventions and medical settings or other settings where you've got a large group of people with a waiting time where you can put them through before we talk to them about anything else resources there's always the 1-800-799-safe number which will link you up with the most local shelter there's the California hotline as well and that is with the internet you can pretty much find anything just by googling into partner violence and referrals the 1-800-799-safe number it's a really important number to always know because again it can link you no matter where you are with your local resources so that's it questions and comments just to be expected we have some chance of attrition for our patients we've got the analysis on those who are there that might want to be followed up for those who might call us we're back where I'm going to wrap your factors and we're going to go and follow up with those who want to what can be done with violence we're talking about no difference from them in rapid factors but a lot of that is because most of our patients already were low income those with the most severe violence and those with the most mental health who are the ones that need that yes yes what would be the second one it was all moderate severe I think it was like a 20 when it came back not really came back but those that came back were more likely to be suppressed it's kind of good for the thing where those who are probably the most that need to be helped but they're coming back and that would be more so you describe them to a guest I think the kiosk was the referral intervention in terms of the part of violence my question is you're thinking about given the limited resources in the emergency department many physicians are likely to go through this could the kiosk itself serve as some beneficial function I'm just thinking if going in the system it has nothing we have an ideal that validation not the referral, not the whole social worker everything called the best person but just the validation which could also be in this amount of setting so have you if you look at just the effect not if that's what you intended to do in my first place because you have such an amazing potentially nice intervention how about just the bare bones kiosk and that's what we're looking at now is kind of what level does it take if it's sitting in a waiting room if it needs signs to go up to it will actually contact anything on our own they get from the printed information it's really even the translational component of it now how are we going to make it most effective so we're studying that now and the other thing we're looking at we've called 200 administrators hospital administrators to see wouldn't you be interested in a technology like this a new medical facility we'll say yes if it's free and then sort of maintenance and then you found too we're doing a three day hospital systems now there's different firewalls different internet issues even just physical layouts like if they're not going to be supportive of it it was amazing I've gone to some where the chairs were moved around different they were over the kiosk like a sheet to where like you wouldn't even know where to find it even just having the kiosk itself requires a little bit of maintenance these boards are mandatory for many people and can you tie into your answer you're simply thinking that this being good it's certainly not high enough perhaps that we want to start calling the policing well you know the law is for if you're there for an injury from intimate partner violence then it's a medical provider that's supposed to support it so kiosk is a survey so it's not a medical provider and they're not asking about the injury that you're there for today they're asking about experiences within the past year and at that same point it wouldn't fall if there were a reporting Georgia is not technically a mandatory reporting state there's 45 states that have like laws for injuries from firearms and so what Georgia's law is that if you believe somebody is there for an injury from a non-accidental range you're supposed to report to the person in charge of the facility who will then notify the law enforcement so you think in California we could do the same thing as long as we don't ask particular questions that go with what they're for today yeah so what I'm actually going to do is looking at the link between child maltreatment and intimate partner violence and I try to navigate the IRB about if I just ask more general type questions you can ask some of those if you're looking at and for things like imminent harm like I had some homicide and suicidal questions that's why I had to print out in my consent form too, cases were told that if it disclosed you know significant suicidal ideation it would be what we call 10-30 from a mental health poll and go to our son ED so we didn't have to do that with some of our patients yes I was going to say a few questions the first kind of thing you guys on some of these I mean you've seen in this protocol right now you're having a lot of really positive outcomes including a few or none of the one calls do you think that the that seems that that's kind of you're not exactly ready to do so you're not making money by doing that do you think that that would be the sort of support for this sort of program in the future? that was my hope, I had gone towards several foundations that were initially interested because I was willing to just develop this program as a questionnaire to have an internet based where different facilities could deploy but I wanted to really pilot test it in a few other settings and different languages first in my mind it makes sense although it's a secondary convention and I do think we need to focus on primary convention as well because it's great that we're finding people now but if we could even stop the miles before it happened that would be wonderful but no I mean I think something like this is easy to do which we did more of it I guess I could do you have any ideas against the penetrance of the of the people who took the survey I don't know if they mentioned specifically how many people who were in the ED that took the survey who were positive against the if you are in the ED with an IDB related injury and your partner is right there and you probably won't like it well they wouldn't if they knew that's what it was about but we asked everybody to kind of talk about general health questions and we separated from our partner whenever we did that we did document there was any partner that seemed kind of controlling and I think we had two or three cases of that in general but you know people are used to and I had my staff work coats too because initially no one wanted to talk to them but when there were white coats everybody wanted to talk to them and so you know they would pull people aside and say you know you want to do this and so about you know 70-80% of people would do it I'm sure we missed them and we also did the waiting room so I mean it was really sick you know like shooting or stabbing or anything like that they weren't screening we talked about doing like a tablet to where we could go around but you know we made it some point I was just worried about the printer and to be honest losing all the tablets but there was a kind of key keeper like one of your staff but I guess going forward we mentioned a lot of this when you anticipate any sort of problems where it's just kind of you know you're in the waiting room you're just assigned to do the survey and you know it's not not complete privacy there you know I think probably people will be less likely to do it unless you can build it as a triage where they say like Southwestern you can actually the emergency department Dallas you do your own like red strip your chief complaint and stuff like that so if you can link it to something like that to where your primary care physician gives you your checklist where he's like go do this and then we'll see you then I think you'd have you know higher rates yeah the partner definitely could be there for and help them fill it out which would give the information you need but I think you're still going to get enough people to do it so I was unclear at the end of the survey because they were told it was just a general right survey and at the end it was we had talked to all sorts of help yeah but if they go to print out about the resources for an IPV then they've given some sort of explanation about like person contact as opposed to hand out well whatever you screen positive for you've got resources to work so if you screen positive for you're not having a smoke detector in your house you can give them information on how important is that the smoke detector in your house so anything like that but if there were IPV I think we'd call it relationship issues comfortable for patients exposed to violence that you can have on a piece of paper and like with perpetrators called it anger management they were then told that they could enroll in the second part of the study for follow up so if people didn't want they still got the violence information it was in more than just smoke detectors more than all of these it was like two paragraphs on like developing safety plans a general paragraph about what you know what was kind of normal relationship behavior things like that we kept it as basic as possible because we didn't want to give people a huge stack of papers that they weren't going to read so it was like a paragraph with resources by issue and then for the follow up interviews of the women by taking action with all of the CDC planning you should have noticed were there any significant procedures between the women and actually the women having not really but our sample size was small and did having children and all those things you know it's a great I don't recall that off hand my guess is it probably didn't because I don't remember anything that predicted one way or the other yes how did the women through data follow up with the services how effective were the women and that's a great question we didn't ask that because we were only following like even after three months because we knew by six months we'd have asked if they kind of contacted resources if they found them helpful but we didn't ask specifically like from that did you do this but we also could look at the other outcomes that they had so we couldn't look at it people using hotline were they more likely to have a safety plan you know change their locks etc but again at that point I think at three months we only had 130 people so probably like 20% contacting one resource so we just didn't have the numbers so about your sample which contested at least one resource and then contacted multiple rather than not necessarily but you know if we're then trying to compare we'd have like 20 who contacted the hotline I mean maybe 15 people that went to support group 10 that went to a mental health counselor and so just not large enough numbers to really look at it other than saying you know of these 10 8 did this your sample has been a great change that just did not as much as I had hoped and when I actually I said I don't really dance we didn't have people along the continual I said actually you know these measures sometimes you know don't pick up on more on smaller movements and the desired outcomes could actually be considered more movement along that continual but yeah we did not move many people like we had hoped we didn't have a movement plan but it did but people were still taking some actions but I think just globally they had to do the stages okay thank you thank you guys this is great to be here thank you