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Data gathered for CAADA's 2012 policy report, A place of greater safety , shows that victims identified through health services were more likely to reflect vulnerable, hard-to-reach groups, such as B&ME or younger patients and those with complex needs, including mental health and substance/alcohol misuse issues.

CAADA's Themis project, launched last November, has joined together with hospital-based services to find out more about the positive impacts of co-locating IDVAs in A&E and maternity units. One team taking part is The Bristol Royal Infirmary (BRI) Emergency Department IDVA service. As the city's main hospital, the BRI's A&E unit sees between 190 and 200 patients each day. Having an IDVA team based within this department ensures that victims are not only more readily identified, but that they are also offered a full care package: from immediate medical assistance and IDVA support, to alcohol/substance misuse services and psychiatric care, where appropriate. The majority of the service's referrals come from the Minor Injury Unit, with patients typically arriving at the hospital 24-28 hours after an incident has taken place.

Punita Morris, the BRI's Emergency Department IDVA Service Manager, speaks to CAADA about how she delivers an effective IDVA service within a hospital setting.

How do you ensure people are aware of your service?

“Our service is available 9am – 5pm, seven days a week, including bank holidays. Reports of domestic abuse to the police typically increase at weekends – Sundays are currently our busiest day for referrals - so it's important we're here to reflect this.

“Furthermore, having a set routine ensures that practitioners always know where to find us. We also publicise our work across the hospital: through leaflets, promotional products – such as lip balms - and gender neutral posters to reach as many patients as possible.

“Being based within the emergency department itself has a positive effect on referrals: during a recent refurbishment, we were temporarily located elsewhere and noticed a drop in the number of cases being referred.”

To what extent does training play a part in improving referrals?

“Referrals to our service work best when practitioners are confident in their ability to recognise the signs of domestic abuse. It's crucial that we're able to provide them with specific training on how to screen for domestic abuse in an empathetic manner: particularly as the BRI has a relatively high turnover of staff, on account of the continual rotation of clinicians in A&E. Being located on-site means ad-hoc ‘bitesize' sessions can easily take place when staff are available, and we're often invited to tag along to the compulsory site liaison study days. This awareness means that other practitioners will also mention our service when delivering training themselves: for instance, during Adult Safeguarding or Child Protection training.

“With so much training already taking place, there's a risk that domestic abuse can become a ‘take it or leave it' topic, so it's really important to get involved with mandatory training to ensure your service becomes better known.

“Training also provides a great opportunity to dispel those myths about victims of domestic abuse – for instance, that it only happens in low-income households – as well as a chance to engage directly with those practitioners who appear more reluctant to participate or are less aware of the topic.”

How else do you collaborate with clinicians?

“The BRI's Emergency Department sees such a large number of patients each day that it's simply not practical to risk assess every one; it's important for staff to understand how to ‘sift through' and identify patients who are potentially experiencing domestic abuse. They may approach us if patients' explanations of their injuries don't match up with the practitioner's professional judgement, and cooperate with us to separate the patient from the suspected perpetrator under the guise of a medical examination/procedure.

“We're also fortunate to be Trust employees, so we feel very much part of the team. Staff know our service and remit and, like other specialist services on site, we have pagers to ensure we're contactable whenever a referral comes in. We have access to the Emergency Department's patient management system, which means we can view all patients and their injuries as they come in and flag appropriate cases for screening to staff, enabling more interventions to be made.”

What happens when your team is not available to support a patient?

“As I mentioned earlier, the service doesn't run 24 hours a day, so handover procedures are very important. Staff undertake risk assessments for any patient arriving out of hours who is suspected to be experiencing domestic abuse, and these are stored in a dedicated folder. If the victim is shown to be particularly high risk, a bed in the observation unit will be offered to ensure an immediate place of safety, and allow them to speak to an IDVA in the morning. If this is not possible, where appropriate, the IDVA will contact the patient the following day by telephone to ensure they do not miss out on support.”

Who else do you work with?

“Within the hospital itself, we work across a number of departments outside of A&E: particularly maternity, alcohol and substance misuse specialist nurses, the psychiatry liaison team and adults' safeguarding services. The BRI's proximity to the Bristol Eye Hospital, Heart Institute and Children's Hospital means we often receive referrals from these services, so it's important to build and nurture links with health staff as much as possible.

“Where interventions are made and positive outcomes created, feeding this information back to staff is hugely beneficial, as it gives them the confidence to make referrals again in future.”

What other steps do you take to improve referrals?

“We're continually reviewing our referral processes. In the not-so-distant future, we hope to establish additional screening among groups which are recognised as having a higher prevalence of domestic abuse: for example pregnant women; those with mental health issues; those with self-harm injuries; and young women.

“Where possible, under certain circumstances, we also manually flag patient files. For instance, if the patient is discussed at MARAC and they are regularly visiting A&E with domestic abuse injuries, we are in the fortunate position of being able to physically stamp the patient's records. This ensures clinicians are immediately aware when the patient is in a potentially high risk situation, allowing them to offer information about the IDVA service and gently ask if they'd like a referral to be made. While the patient is within their rights to refuse, it plants that seed in their mind and makes them aware that the BRI A&E is a place of safety, with dedicated IDVAs who can act immediately on their behalf and provide personalised support.”