Our Fight Against Human Trafficking with Improved Screening in the Emergency Department

Jun. 6, 2024

Every day, our staff at UC Medical Center and West Chester Hospital greet people coming into the Emergency Department on some of their most unexpected and challenging days.

Christa Pulvino, MD, MPH

Christa Pulvino, MD, MPH

UC Health staff can often diagnose problems by examining visible symptoms or reading test data. As part of our mission to make Cincinnati the healthiest city, our staff intentionally pursues ways to take whole-person care to the next level to better serve our patients, especially in times of crisis. One University of Cincinnati College of Medicine fellow has spent the last two years creating a new protocol for something that often goes unnoticed by the public and even some in the medical community: screening for victims of labor and sex trafficking.

Ohio consistently ranks in the top 10 states in the nation for reported human trafficking cases.

Christa Pulvino, MD, MPH is a Social Emergency Medicine fellow who also completed her residency at the University of Cincinnati College of Medicine. She says her passion for helping those potentially ensnarled in labor and sex trafficking has been building for years. The idea for updating the screening protocol came during her fourth year of residency.

“I've always been angered by injustices or instances of inequality. I think that human trafficking is the ultimate manifestation of that,” Dr. Pulvino said. “You know, just at a very basic level, everyone deserves to be free and to have autonomy over their own life,” Dr. Pulvino said. “We've been hearing more in the healthcare world lately about how, as healthcare providers, we are uniquely positioned to help address this because we are the ones encountering people being trafficked at the time when they most need help or intervention.”

“We really can't have a big impact on people's health or any other social issue without first addressing the fact that they are not free or are not in control of their own life, so it just felt to me like step one,” Dr. Pulvino said.

During her fellowship years with UC College of Medicine, Dr. Pulvino worked with an internal team and external partners, along with a small grant from the Society of Academic Emergency Medicine to create, train staff and implement the UC Health Human Trafficking Screening and Intervention Protocol.

What’s new?

Previously, Dr. Pulvino told UC Health there wasn’t a streamlined and standardized process within the UCMC and WCWH to report trafficking. Dr. Pulvino worked directly with the Early Intervention Program within the UC Emergency Department to create a new and integrated process to report trafficking better and support potential victims.

The Early Intervention Program (EIP), through the University of Cincinnati College of Medicine and funded through various grant sources, provides at-risk Emergency Department patients and populations with care during a time of great need. Through compassionate help, EIP offers screenings, interventions, and resources to UC Health patients during and after their hospital stay.

Dr. Pulvino praised the EIP team as an ideal partner to bring such a project to life.

“They’ve been here for decades, and that's part of what made it so perfect for me to implement this project here is because their infrastructure already existed,” Dr. Pulvino said of the EIP team. “They already are trained in trauma informed care and in sensitive interviewing techniques. So they're already primed to have these types of conversations.”

Dr. Pulvino and the EIP team created a tool kit as part of the protocol. The first tool is a website Dr. Pulvino created with Rob Braun, Research Data Analyst with the College of Medicine. The EIP patient-facing website is “where patients can go and visit links to a nondescript page initially in order to maintain safety and privacy. They can search for a variety of social resources, some of which are specific to trafficking and some of which are not,” Dr. Pulvino said.

The website allows patients to not only connect with resources related to labor and sex trafficking but also help with food access, substance use, and more. UC staff can then track the anonymous responses to better adapt to real-time care and resources made available to ED patients.

The second tool now in place is the implantation of the Rapid Appraisal For Training (RAFT) screening aid. RAFT is a nationally recognized tool that uses four questions to screen for potential trafficking victims in a healthcare setting. The questions center on whether someone has ever felt unsafe in a work environment felt scared to leave their work environment due to threats made to themselves or their family or exchanged any sort of goods or money for sex.

Dr. Pulvino explained RAFT training for people working in the EDs can help patients in need more efficiently.

“Now we have a system in place where if anybody is concerned for human trafficking, they can call EIP. And our Health Promotion Advocates from EIP will come and talk with a patient and have a conversation using specific screening questions that have been nationally validated for human trafficking,” Dr. Pulvino said.

The next step and third tool now available for UC Health employees is a thorough resource list compiled by Dr. Pulvino.

“Whether it's more immediate safety planning or, a lot of times, patients need help with a different social issue to extricate themselves from trafficking situations, or they need help with substance use or housing,” Dr. Pulvino said. “Our staff are trained to figure out what is going to be the most helpful and then connect them to that next step.”

Photo shows some of the updated Early Intervention Program resources now available to patients

Dr. Pulvino worked with trafficking survivors, the UC College of Medicine, UC Health internal partners and mentors like Caroline Freiermuth, MD, Associate Professor of Clinical Emergency Medicine at the College of Medicine, EIP, the Cincinnati Health Department, and local anti-trafficking nonprofits like Cincy at The Well to craft the resource list to help emergency department staff and patients best simultaneously.

““It's impactful,” Dr. Pulvino said of the new protocol created. “We’ve been able to address something patients needed without them having to come in and directly ask for it. You know, it feels like we're actually prepared to offer what patients need without them having to talk about something they don't want to talk about or tell their story and risk not being believed or risk somebody's not caring about it. I think it really helps when we're the ones to initiate the conversation because it makes patients feel like we care and we're actually willing to listen.””

Results and Responses

Dr. Pulvino said her team has already seen substantial results with the new screening protocol, especially with the RAFT questions now used daily in emergency departments across the UC Health system.

From the start of the new human trafficking protocol being implemented in December 2022-December 2023, Dr. Pulvino reports 557 people were screened, and 12 percent of those screened came back with a “positive” result. This means an answer(s) in the RAFT questionnaire was flagged as an initial sign of a patient potentially being connected to sex or labor trafficking. Dr. Pulvino said that half of those 12 percent of “screened positive” patients “accepted referrals specific to human trafficking,” but 87% “accepted some kind of social resource,” regardless of whether it was directly related to human trafficking or not.

UC Health spoke to members of the EIP team who worked to create and now implement the new protocol. They shared their gratitude and confidence in the now-standardized process.

“So this protocol has been very, very important to me since it came out because we see a lot of patients in the emergency department that have shown these red flags, these signs of trafficking,” EIP Operations Manager Elysia Smith reflected. Smith worked with Dr. Pulvino directly to help create and implement the new protocol. “We haven't had a concrete way, or protocol, in place to help them. So implementing this protocol helped train our peers to help these patients.”

Smith said she also appreciated the new resource database Dr. Pulvino assembled as a discrete way to help patients who may be in a threatening trafficking situation not continue to return to unhealthy environments after leading the ED and “fall through the cracks.” 

“We have gotten calls where providers are concerned about some risk factors for human trafficking as conversations came up, when they were talking with patients,” EIP Clinical Research Assistant Meghan Mays said reflecting on implementing the new RAFT questionnaire protocol. “But then we can go in and use our questions to really get a clearer picture of what is going on and be able to adjust.”

Dr. Pulvino reflected on the uncomfortable and tragic reality that comes when people in our local hospitals arrive at the ED showing signs of labor and sex trafficking.

“It's a hard thing to realize that many people are potentially in this situation or are at risk of becoming in that situation,” Dr. Pulvino said, reflecting on the human trafficking protocol’s first year of data involving Greater-Cincinnati-based patients. “However, trafficking is a multibillion-dollar industry, so I don’t think it’s necessarily surprising that we have identified patients who need help.”

Dr. Pulvino with Early Intervention Program members, from left to right, Cameron May, Elysia Smith and Meghan Mays

Dr. Pulvino with Early Intervention Program members, from left to right, Cameron May, Elysia Smith and Meghan Mays

Lessons Learned

Dr. Pulvino reflects on what she’s learned through this multi-year process. Among the lessons learned include the need for constant awareness for potential trafficking cases. “There's definitely not a classic patient or a classic story, or a classic chief complaint that people are going to come to the E.R. with so you really kind of have to be on the lookout for everybody, to be potentially in need of intervention,” she said.

“A lot of times, the patients also are not aware that this would be considered trafficking.” Dr. Pulvino said. “People don't come in self-identifying as saying, ‘Hey, I'm, you know, a victim of human trafficking.’ First, I think nobody likes to be identified as a victim. That's very disempowering. But also, they might just not have the words to describe their situation. They know that they don't have the freedom or the control that they would want. They know that there's a barrier to them getting the things they need, but they might not necessarily describe it as trafficking. They might not necessarily realize that anybody else cares or that it's illegal, or that there's anybody in the community who wants to help. At the very least, I think this project has hopefully been a good first step, in making that known to some patients,” Dr. Pulvino said.

This summer, Dr. Pulvino and her family are moving to Rhode Island, where she will work as an emergency physician at Brown University. She plans to continue her passion for vulnerable populations by working to create a Social Emergency Medicine fellowship.

Dr. Pulvino says she is confident that the protocol she, the EIP team, and community stakeholders worked to create is in good hands for the future.

“I think they're going to do a great job. and hopefully they'll continue to improve upon what we've started,” Dr. Pulvino said.

Looking ahead, Dr. Pulvino said she is working to equip current and future leaders within UC Health to create a next step in the protocol centered around following up with patients. She hopes to create a compassionate and compliant way to see how patients seeking social resources, including human trafficking, are doing and if the recommended resources have been helpful.

“I think the goal is not just to identify the problem and give resources and hope for the best, but to really figure out where do we need to build other resources in the community.”

Overall, Dr. Pulvino says she is proud of her team’s efforts to put a new human trafficking screening protocol into place and believes it better empowers UC Health staff with education and training and patients with better whole-person care.

“Even if what we have done is obviously not a quick fix and not going to be an immediate resolution for anybody, we have positioned ourselves as a safe place that people can come to. We have informed them that there's potentially a way out and we're here to help,” Dr. Pulvino said.