For a video that summarizes this post, check out this link!
Points to Focus upon
- The emergency department (ED) is a safe haven for many. In the COVID-19 pandemic, many of those who might fall victim to violence at home are currently being asked to stay there in isolation with their potential abusers. During this time, it is imperative that we all be on high alert for signs of violence at home.
- The current Canadian statistics on intimate partner violence (IPV) are that women will have a 1 in 6 lifetime risk for IPV, 1 in 3 for sex assault. Per the CDC, half of the patient population in urban EDs have sex assault/IPV as a PMHx. IPV is more common that aortic dissections and PEs combined. And it is very lethal, since it is highly associated with death by murder. If someone has been strangled, they are 4x more likely to be murdered in the next calendar year.
- The following tools have some levels of validity evidence behind them for screening for intimate partner violence (IPV)1. Of the two tools listed below, the PVS is most commonly used in the ED.
- Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?
- Do you feel safe in your current relationship?
- Is there a partner from a previous relationship who is making you feel unsafe now?
Have you ever been in a relationship where your partner has:
- … Slapped or pushed you?
- … Thrown, broken, or punched things?
- … Threatened you with violence?
Sensitivity 96% (with 1 point cut off)
Specificity 75% (with a 1 point cut off)
Danger Assessment Tool for Domestic Abuse4
This is a specialized tool that is usually only used by specialized sexual assault or domestic violence programs – or by forensic psychiatrists. Use this tool in female patients presenting to the ED after assault by an intimate partner or former partner.
- Has the physical violence increased in frequency or severity over the past 6 months?
- Have they ever used a weapon or threatened you with a weapon?
- Do you believe they are capable of killing you?
- Have you ever been beaten by them while you were pregnant?
- Are they violently and constantly jealous of you?
INTERPRETATION: 3 point or greater presents a high risk of lethality.
Coordinating with your local police will be useful in this situation. It should be noted that women’s shelter facilities may be functioning quite different during the COVID-19 pandemic, so it is advisable to involve your social work team to find out what might be the best plan in this dynamic situation.
There are four main steps of a robust management plan in these circumstances
- Disclosure reaction
- Injury assessment
- Specialist referral
This should be the same despite the pandemic as most of them are minimal intervention.
Step 1: Disclosure Reaction
When a patient discloses DV to us, our reaction to it has a massive impact on their morbidity. A supportive reaction has a 6 fold reduction in future PTSD, mood disorder and substance use5,6. I teach that thanking people for this disclosure is an appropriate response – something like – thank you for telling me this today, I know that was really hard, I will do my best to take care of what you need. It’s simple, establishes trust and shows empathy. People can adapt to fit their style of speech. On average, it takes 8 healthcare visits for someone to disclose IPV, so if they picked today, it is a big deal and we need to take this seriously. Saying things like “what do you want me to do?” or “we don’t deal with that here” are most definitely not helpful.
Step 2: Safety
These patients need to be in a safe area of the ED – not in the main waiting room, not in an area that is accessible by their abuser. In pandemic times, this is actually a bit easier as everything is locked down, no visitors are allowed and not a lot of people are in the waiting room. If this patient is waiting for imaging or SW or the specialty team, they should be waiting somewhere that is inaccessible to the abuser. There are many very graphic reports of the abuser showing up at hospitals to finish the job as they are enraged about someone disclosing and seeking care. This step can literally save a life. Currently in Canada, a woman is murdered every 6 days, with greater than 90% of them by partners or ex-partners7.
Step 3: Injury Assessment
You should assess these patients like you would any other traumatic injury. Just because it is IPV, it doesn’t mean that the usual rules of trauma don’t apply. So look for and document bruising, abrasions, lacerations as you normally would. You are allowed to take photos directly into an EMR if that is your local practice – just make sure they are taken sensitively. Use the typical decision tools for things like x-rays and CT heads. A specific strangulation protocol is in development by Dr. Sampsel in Ottawa – CT angiogram of the neck is the imaging modality of choice for patients that have symptoms of vascular occlusion or neurological abnormality.
As for the question of how/what to assess, there are 2 major concepts here. Adult IPV is just like child abuse – the signs and symptoms are the same; and follow the history. We have the historical features and patterns of injury are drilled into our heads from day one of medical school – it is the same stuff for adults who are being abused.
1. stories that change all the time,
2. history that doesn’t match with the injury,
3. there is a delay in seeking care.
These three features are more sensitive in my experience for picking up IPV than any screening tool out there.
Remember that patterns of injury are the same (in concealed areas, multiple injuries at a variety of stages of healing, defensive wounds etc).
Finally, let the history guide you – same as with any other disease entity – if someone says their foot hurts, examine their foot and the associated systems. You don’t necessarily need to do a full head to toe, particularly if the patient is going to see a specialized service afterwards.
Treatment is also the same, wound care, suturing, splinting, casting, tetanus, analgesia. Medical care always comes before forensic, so don’t worry about “fixing” or covering something up that would be photographed later – we can work that out.
Step 4: Specialist Referral
Most of the Canadian sex assault/IPV units are running fully during the pandemic so far. If you are unsure of your usual channels, the easiest way honestly is to Google “domestic violence services” and their province.
In Ontario – the Ontario Network of Sexual Assault and Domestic Violence Treatment Centers has all of the programs (and the areas they serve) listed with the contact numbers/info. They also have a ton of fantastic resources. Check out their website.
What you can do in the ED
We recommend that the physician managing an IPV patient call their local centre and set up further treatment with them. Navigating all of the legal and social aspects of further safety and care is very complex and time-consuming and isn’t best done in the ED setting, even in the best of times4. Plus, the standard for court documentation is high – leave that to the professionals! It is important that the doc referring to the specialty service tells the patient that seeing this services does NOT equal reporting to police – they can help facilitate this, but isn’t a necessity. There should be MOUs for all hospitals to have access to a specialized program. If someone can’t get this information, keeping this patient to see SW to help liaise with social services (and potentially police for the forensic part) is the next best option.
Recommended Reading, Videos, and Podcasts
- Danger Assessment Tool for Domestic Abuse8
- Ontario Network of Sexual Assault and Domestic Violence Treatment Centers
This post was copyedited and uploaded by Johnny Huang.
- 1.Walls R, Hockberger R, Gausche-Hill M M. Intimate Partner Violence and Abuse. In: Rosen’s Emergency Medicine-Concepts and Clinical Practice e-Book. Elsevier Health Sciences; 2017:.
- 2.Feldhaus K, Koziol-McLain J, Amsbury H, Norton I, Lowenstein S, Abbott J. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA. 1997;277(17):1357-1361. https://www.ncbi.nlm.nih.gov/pubmed/9134940.
- 3.Paranjape A, Liebschutz J. STaT: a three-question screen for intimate partner violence. J Womens Health (Larchmt). 2003;12(3):233-239. doi:10.1089/154099903321667573
- 4.Sampsel K, Szobota L, Joyce D, Graham K, Pickett W. The impact of a sexual assault/domestic violence program on ED care. J Emerg Nurs. 2009;35(4):282-289. doi:10.1016/j.jen.2008.07.014
- 5.Liebschutz J, Battaglia T, Finley E, Averbuch T. Disclosing intimate partner violence to health care clinicians – what a difference the setting makes: a qualitative study. BMC Public Health. 2008;8:229. doi:10.1186/1471-2458-8-229
- 6.Dienemann J, Glass N, Hyman R. Survivor preferences for response to IPV disclosure. Clin Nurs Res. 2005;14(3):215-233; discussion 234-7. doi:10.1177/1054773805275287
- 7.Canadian Femicide Observatory . Canadian Femicide Observatory. Canadian Femicide Observatory for Justice and Accountability. http://www.femicideincanada.ca/.
- 8.Snider C, Webster D, O’Sullivan C, Campbell J. Intimate partner violence: development of a brief risk assessment for the emergency department. Acad Emerg Med. 2009;16(11):1208-1216. doi:10.1111/j.1553-2712.2009.00457.x