Implementing Universal Intimate Partner Violence (IPV) Screening Utilizing a Patient-Centered, Shared Decision-Making Approach

Background and Problem Statement

• One in three women in the United States experience an episode of domestic violence (DV) at a cost of $8.3 billion annually. USPSTF and ACOG recommend screening all childbearing-age women regardless of signs or symptoms of abuse. While family practice provides an ideal setting for screening, only 10% of providers routinely screen women in primary care.
• Women who experience IPV are at increased risk for long-term negative health sequellae for a minimum of 15 years after abuse has ceased
• IPV during pregnancy increases the risk of preterm birth, LBW infants or stillbirth
• Midwives inconsistently screen for IPV and only 11% of family practice physicians routinely screen women
• Implementation of universal screening was established to improve the health and safety of women and children
• Surveyed Palouse Medical (PM) staff documented that 80% felt ill-equipped to screen for intimate partner violence (IPV) and chart audits revealed that only 40% of patients were screened.

Purpose/Objective

• The primary goal of this project was to screen 100% of eligible women for IPV within 90 days utilizing patient-centered shared decision-making.
• Eligibility was defined as women of childbearing age presenting for annual exam and pregnant women each trimester and postpartum.
• A total of 90 patients met the eligibility criteria for this QI project.
• To support the overarching goal, staff understanding and comfort with IPV screening was established at a staff confidence level of 80% with no more than five minutes required for screening.

Procedure

• Gap analysis and literature review were used for problem identification and intervention development. Staff education increased knowledge and comfort with screening. Patient engagement was maintained using visual aids, shared decision-making tools and interviews. A rapid-cycle model with four plan-do-study-act cycles was implemented. Data was entered on run charts over 90 days.
• The project followed an SBIRT model with four ramps: team engagement, patient engagement, screening for IPV with guided discussion, and referral for positive screens.
• Change was implemented by a multidisciplinary family practice team utilizing four, two week PDSA cycles over an eight week period from January to March 2018. Data was collected weekly via chart audit. Interventions included:
  • Team engagement through use of in-service education, weekly meetings and daily huddles, maintaining motivation through discussion of IPV and problem-solving with team
  • Patient engagement through guided discussion of relationship health utilizing laminated copies of the Power & Control and Equality Wheels with 100% of eligible women.
  • IPV screening and brief intervention to accurately determine women experiencing IPV and documenting need for referral and treatment 100% of the time
  • Referral and treatment included two options
    • Referral to Alternatives to Violence on the Palouse (ATVP) with documentation in EMR and follow-up phone call, or
    • Follow-up appointment two following initial screen for women declining referral. Women were provided a list of community resources, a decision-making tool to evaluate their options, and a personalized safety plan.

Outcomes regarding the four project ramps within 90 days

• Team Engagement:
  • Interventions increased staff comfort from 20% to 90%.
• Patient Engagement:
  • Guided discussion of healthy vs. unhealthy relationships utilizing visual tools increased from 0% to 100%
• IPV Screening
  • Screening for well-women increased from 40% to 100%
  • Prenatal screening increased from 57% to 100%
  • Postpartum screening increased from 0% to 100%
• Referral and Treatment for Positive Screens:
  • Referrals to ATVP increased from 20% with no follow-up to 100% with documented follow-up
  • Follow-up visit with documentation for women declining referral increased from 0% to 100%

Conclusions

• The goal of implementing patient-centered universal IPV screening was achieved, with 100% of eligible women being screened and documented by the end 90 days
• Median time utilized for screening was five minutes
• Providers in a primary care setting effectively identified women at risk
• Palouse Medical (PM) is committed to continuing IPV screening would like to expand violence screening to include other populations
• Project is easily generalizable to other clinics providing women’s health and prenatal care, utilizing the visual tools and methods implemented at Palouse Medical.

Implications for Practice or System Change

• Documented increased referral rate to ATVP
• All postpartum women are screened prior to discharge from Pullman Regional Hospital (PRH)
• Cost for IPV screening was not a significant factor. The main contributors to cost were laminated copies of the Power & Control and Equality wheels as visual tools and time required for screening.
• Sustainability is reinforced due to minimal time requirements, minimal cost, project team motivation, and Palouse Medical culture of excellence related to provision of care
• PM is implementing IPV screening for same-sex and transgender couples and elder abuse screening utilizing variations of the Power & Control and Equality wheels
• Relationship safety questions are added to PM Health History form, completed by all individuals establishing care
• Dissemination includes:
  • Work with PRH to present project and results community wide, including hospital staff, ER, and other clinics, offering project implementation methods and tools to area clinics
  • Present project results at PRH medical staff committee
  • Lecture at Washington State University’s college of nursing regarding breadth and impact of IPV
  • Work with Sacred Heart Medical Center, Spokane WA ER nurse in developing and implementing screening tools for their facility
  • Poster presentation at IHI National Forum, 12/2018