One year follow-up of an emergency department protocol for abused women.

OBJECTIVE: To evaluate if the positive effects of an initially successful emergency department protocol of care for victims of partner abuse (PA) were maintained at one year follow-up. METHOD: A community intervention trial compared two public hospital EDs in Auckland, NZ, at baseline (BL), following implementation of a PA intervention (PI), and at one year follow-up (FU). The initial intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Later, an on-site protocol co-ordinator worked to ensure that new staff received training in protocol use. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff use of interventions and documentation of abuse. RESULTS: Approximately equal numbers of records were reviewed at each ED at BL, PI and FU (total n = 10,961). Significant interactions were found for classification of PA and acute management offered to victims between EDs over the different study phases. However, the increase in identification of confirmed cases and the improved acute management offered to identified victims found at the intervention ED in the PI phase were not maintained at follow-up. CONCLUSION: Although staff training in the use of protocols for victims of partner abuse can result in improved care, these effects were not maintained. IMPLICATIONS: More intensive institutional efforts are needed if protocol benefits are to be maintained.

Outcome evaluation of an emergency department protocol of care on partner abuse.

STUDY OBJECTIVE: To evaluate the impact of a protocol on partner abuse (PA) at increasing identification and improving acute management of abused women by emergency department (ED) staff. METHODS: A community intervention trial compared two public hospital EDs at baseline and following implementation of a PA intervention. The intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff documentation of abuse and use of interventions. RESULTS: Approximately equal numbers of records were reviewed at each ED, pre and post implementation (total n = 8,051). Eighty-nine per cent of ED staff were trained. No difference in the overall identification of PA was found (chi 2 = 0.13, p = 0.72), but logistic regression analyses showed other significant changes. At the intervention site, there was an increase in confirmed cases of PA (chi 2 = 7.6, p = 0.006), a trend towards increased documentation (chi 2 = 3.5, p = 0.06) and a significant increase in interventions offered (chi 2 = 13.8, p = 0.002). Changes at the comparison site failed to reach significance. CONCLUSION: Implementation of this protocol resulted in a moderate increase in confirmed cases of abuse and improved the acute management offered to identified victims. The findings reinforce recommendations for widespread implementation of training and protocols to address partner abuse.

Morbidity and death due to child abuse in New Zealand.

The purpose of this study was to explore under-diagnosis and racial bias among child abuse morbidity and mortality data from New Zealand. Computerized files of all intentional injury fatalities among children 16 years of age and under for 1978-87, and all hospital discharges for intentionally injured children 16 and under for 1988, were analyzed for evidence of physical abuse and sexual abuse. Among the 92 fatalities, only 21 of 68 deaths due to physical and/or sexual abuse were so coded. In both the mortality and the morbidity data, there was an association between the diagnosis of child abuse and race. In the case of fatalities, Maori and Samoan abuse victims were more likely to be assigned an E-code of E967 ("child battering and other maltreatment") than were "others" (p = 0.04), controlling for sex. In the case of hospitalizations, the association between E967 and whether or not the victim was European was significant for physical abuse only (p = 0.05). Assignment of N-code = 995.5 ("child maltreatment syndrome") as the reason for admission was significantly associated with race for those cases considered by us to have been abused, controlling for age (p = 0.002) or sex (p = 0.004).

Homicide in New Zealand: an increasing public health problem.

Injury purposely inflicted by other persons is a significant public health problem as well as a criminal problem. It accounts for approximately 3 per cent of all deaths from injury in New Zealand. National injury mortality data for the period 1978 to 1987, supplemented by reference to files of the Coroner's Court and the High Court, were used to identify the characteristics of victims of homicide, the nature of the injuries they sustained, and the circumstances in which the injuries were inflicted. The mortality rate from homicide for the 10-year period was 1.6 per 100,000 persons per year. A significant increase in the rate of homicide was identified. The rates for males were higher (2.0) than those for females (1.2), with those 20 to 24 years of age most at risk. Maori had higher rates than non-Maori. Homicides were most frequently committed with cutting and piercing instruments, and most commonly occurred in private homes. Homicides were most likely to occur on Fridays or Saturdays, between the hours of 6 p.m. and 6 a.m. In 55 per cent of homicides the victim and assailant were known to one another. Unemployment, membership of ethnic minority groups, availability of weapons, the private nature of interactions in the home, alcohol consumption, and stress in personal relationships were all identified as factors associated with homicide in the decade under study. The implications of these findings for the prevention of injury from assault are discussed.

Injury from assault in New Zealand: an increasing public health problem.

Injury purposely inflicted by other persons is a significant public health problem accounting for approximately 4 per cent of all injury hospitalisations in New Zealand. National injury morbidity data for the years 1979-1988 were examined. These data were used to identify the characteristics of victims of assault who were hospitalised, the nature of the injuries they sustained, and the circumstances in which the injuries were inflicted. The incidence of hospitalisations in 1988 was 73.7 per 100,000 persons per year. A significant increase in the rate of hospitalisations over the decade 1979-1988 was identified. The rates for males were higher than those for females, with males 20-24 years of age most at risk. Maori had higher rates than non-Maori. Fights or brawls were the leading cause of hospitalisation. The most common place of occurrence was private homes, followed by streets and highways, and licensed premises. The findings with regard to age, sex, employment status and use of weapons were consistent with earlier studies. A higher proportion of incidents occurring in the home was attributed to differences in selection of cases between studies. An indication of underreporting by women was attributed to concealment of intentionality, possible owing to fear of reprisal. Standard hospital reporting procedures were proposed as a means of improving identification.

Indicators of assault-related injuries among women presenting to the emergency department.

STUDY OBJECTIVE: We sought to determine whether women presenting for treatment of assault-related injuries at a public hospital emergency department differed from those presenting for unintentional injuries with regard to a variety of demographic and presentation characteristics, nature and anatomic site of injury, and admission or follow-up treatment for injury. METHODS: We conducted a random-sample retrospective medical record review of women aged 15 years and older who presented at either of 2 24-hour public-hospital emergency departments in Auckland, New Zealand. The characteristics of women identified as presenting with assault-related injuries on the basis of the record review were compared with those of women who presented for treatment of unintentional injuries. We also assessed the sensitivity and predictive value of nature and anatomic site of injury as markers of assault. RESULTS: We reviewed 8,051 records, of which 2,966 (37%) involved an injury at presentation. Two hundred sixty patients (9%) were identified as victims of assault. Of those women who presented with assault-related injuries and had known assailants, most were likely injured by a partner or former partner. Women with assault-related injuries were more likely to be younger and of Maori or Pacific Islands origin. They were also more likely to present between the hours of 6 PM and 6 AM on Friday, Saturday, or Sunday and to have a greater history of prior presentations to the emergency department. Compared with patients who presented with unintentional injuries, women with assault-related injuries had a greater likelihood of presenting with contusions (odds ratio, 3.54; 95% confidence interval, 2.57 to 4.88); ill-defined signs and symptoms (odds ratio, 3.20; 95% confidence interval, 1.95 to 5.24); internal injuries (odds ratio, 2.48; 95% confidence interval, 1.46 to 4.18); fractures of the head, spine, or trunk (odds ratio, 2.09; 95% confidence interval, 1.23 to 3.53); and open wounds (odds ratio, 1.90; 95% confidence interval, 1.39 to 2.61). Assault-related injuries most commonly involved the head (odds ratio, 12.8; 95% confidence interval, 9.33 to 17.68). Despite the strength of these associations, however, with regard to nature of injury the sensitivity and positive predictive value of these indicators were limited (sensitivity < or = 26.5%, positive predictive value < or = 24.3%). The maximum sensitivity for anatomic site as a marker for assault was found for injuries to the head (63.7%), but the positive predictive value was still low at 35.7%. Women with assault-related injuries were more likely than women with unintentional injuries to be discharged from the emergency department without referral for follow-up treatment and were more likely to leave the department without completing treatment. CONCLUSION: Women identified as presenting with assault-related injuries differ from those who present with unintentional injuries in terms of their demographic and presentation characteristics, as well as the nature, anatomic site of injury, and follow-up treatment for injuries. Although some of this information has implications for service delivery to abused women, the use of clinical indicators such as nature and anatomic site of injury have limited predictive value. Therefore we recommend that health care providers routinely screen patients for assault, particularly assault by intimate partners, so that they may respond appropriately by providing better treatment and referral.