SGEM Xtra: How To Save A Life – Screening for Intimate Partner Violence in the Emergency Department

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Date: November 19th, 2022

Reference: Khatib N, and Sampsel K. CAEP Position Statement Executive Summary: Where is the love? Intimate partner violence (IPV) in the Emergency Department (ED). CJE.M 2022 Nov

Dr. Nour Khatib

Guest Skeptics: Dr. Nour Khatib is an emergency physician in Toronto working in community sites Markham Stouffville Hospital and Lakeridge health. Dr. Khatib also works in remote Northern communities in the Northwest Territories and Nunavut. She is currently the professional development and education lead at Lakeridge Health and lead preceptor for Lakeridge Health learners. She is the VP of Finance of a not-for-profit emergency education organization creating educational events for community emergency doctors. Prior to her career in medicine, she was a financial analyst for Pratt & Whitney Canada and has a background in Finance and an MBA. Her unique work and life experiences have fueled her passion for leadership, patient education, and quality improvement.

Dr. Kari Sampsel

Dr. Kari Sampsel is a staff Emergency Physician and Medical Director of the Sexual Assault and Partner Abuse Care Program at the Ottawa Hospital and an Assistant Professor at the University of Ottawa. She has been active in the fields of forensic medicine and medical education, with multiple international conference presentations, publications and committee work. She has been honored with a number of national awards in recognition of her commitment to education and awareness. She has founded a technology/consultancy company to assist organizations in policy development, staff training, investigation and prevention of sexual harassment and assault. She is also an avid CrossFitter and believes that strength and advocacy are the way to a better world.

This is an SGEM Xtra episode. The Canadian Association of Emergency Physicians (CAEP) put out a position statement on intimate partner violence (IPV) on November 2, 2022. CAEP has several position statements including homelessness, violence in the ED, gender equity, opioid use disorder and other topics. We did an SGEM Xtra episode covering the CAEP position statement on Access to Dental Care. The key message is that CAEP believes that every Canadian should have affordable, timely, and equitable access to dental care.

TRIGGER WARNING:

As a warning to those listening to the podcast or reading the blog post, there may be some things discussed about IPV that could be upsetting. The SGEM is free and open access trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the IPV material we are going to be talking about on the show could trigger some strong emotions. If you are feeling upset by the content, then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance.

The rate of women murdered by a current or ex-partner in Canada has increased from 1 in every 6 days, to one in every 36 hours in 2022. Canada’s Emergency Departments are where survivors of violence most often seek care, and where the violence against them is not always recognized. A new position statement from the Canadian Association of Emergency Physicians, published in November 2022, during Domestic Violence Awareness Month, aims to guide Emergency Department staff in the recognition and care of survivors of violence. This statement helps guide clinicians and emergency departments on how to implement processes to identify, treat and keep survivors of intimate partner violence safe.

Questions for Dr. Khatib and Dr. Sampsel

Nour and Kari were asked a number of questions about IPV and the CAEP Position Statement. Please listen to the SGEM Xtra podcast on iTunes to hear their answers and for more details.

How do you define IPV?

IPV refers to any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. This is often an issue of power and control and could be in current or past relationships.

Why did CAEP decide to put out a position statement on IPV?

IPV patients are being seen daily in our EDs and CAEP saw the value in ensuring that this vulnerable trauma population was recognized and received good care when they came to see us.

Why did you two decide to take the lead on this issue?

Nour had presented an award-winning Grand Rounds on IPV where she noted that CAEP didn’t have a statement yet on this, despite IPV patients being seen most often in an ED setting. In my experience working in this field, I noticed that emerg docs were really comfortable with caring for trauma patients, but were less comfortable with this subset of trauma. So we decided to write a document to help our colleagues across the country.

How prevalent is IPV and what impact does it have on those exposed to IPV

World Health Organization (WHO) estimates the prevalence to be 1 in 3 women worldwide, with no significant difference between continents (WHO). Women exposed to IPV are twice more likely to suffer from depression and alcohol use disorders and 38% of all murders of women worldwide are IPV-related. In fact, a woman is murdered in Canada every 36 hours by a current or ex-partner.

Who suffer from IPV?

Women 1 in 3, men 1 in 8, but also LGBTQ+
The true rate for IPV in men is unknown given low reporting for various complex reasons
Populations who are vulnerable such as indigenous and LGBTQ+
IPV transcends economic status, gender, borders
It’s an everybody problem
Minorities

Has the COVID-19 global pandemic had an impact on IPV prevalence?

The COVID-19 pandemic has worsened the prevalence of IPV with shelter-at-home orders, increased calls to police and community support, and decreased recognized presentations in the ED. My research and that of others found that the stressors of the pandemic mirror the stressors that worsen IPV and that home can be an unsafe place for those affected by IPV.

What role does the ED have in this issue of IPV?

A 2008 study found 44% of women murdered by their intimate partner had visited an ED in the last year; 93% of these victims visited specifically for IPV-related injury. ED physicians identified 5% of IPV cases; only 13% asked about domestic violence, despite almost 40% of females presenting with violent injuries. These patients are being seen in our EDs every day but we aren’t tuned to look for this like we are for so many other disease entities. We are that port in the storm for patients seeking care or even escaping IPV because we are always open.

Can you help dispel the stereotype of the “battered woman”?

The stereotypical “battered woman” is often the only image that comes to mind when thinking of IPV, when it can encompass things like stalking, threats to take away their children, workplace sabotage, or blackmail. Additionally, multiple visits for the same presentation, chronic pain syndromes, mental health concerns and substance use are highly associated with IPV. Also, IPV affects all races, socioeconomic classes, educational levels, so for all these reasons, it may not look like that “battered woman”.

What are the Canadian statistics on IPV and do you think the incidence is over or under estimated?

Vastly underestimated. Best estimates state that one in 10 survivors of violence seek care. Even with that, Statistics Canada identified that IPV accounted for 1 in 4 police-reported crimes in 2011. Among these, ex-partners were involved 30% of the time. Between 2009 and 2017, there were a total of 22,323 incidents of police-reported same-sex intimate partner violence in Canada—that is, violence among same-sex spouses, boyfriends, girlfriends, or individuals in other intimate partnerships. This represented approximately 3% of all police-reported incidents of IPV over this time period. There is an increased risk of homicide after separation; leaving is the riskiest action patients take and they often find refuge in the emergency department during this transition period. A 2009 General Social Survey found 22% of victims report incidents to police; thus the IPV statistics discussed are significant underestimations. And like we had mentioned, a woman is murdered in Canada every 36h.

Is IPV a reportable event in Canada that emergency physicians must call the police?

In Canada, you cannot call the Police without the express consent of the patient, even if you are concerned for their safety. The only way you are allowed to break confidentiality is in cases where children are in the home (even if they are not victims of the abuse), elder abuse in a long-term care setting or gunshot wounds. We are there for the survivor of violence, to help them with what they need at the time, even if it can be difficult for us as ED physicians not to have this reported to police.

What is the economic impact of IPV?

Estimating the economic impact of a social phenomena naturally would help policy-makers with resource allocation and program funding. A Justice Canada costing study published in 2012 estimated the cost of IPV to be $7.4 billion dollars. The study estimated the cost of ED IPV-related visits were 30 x more costly than Family practice visits, and patients are three times more likely to visit the ED than their own family doctor for IPV-related health concerns.

Why is that? We are always open. You can come to the ED and no one will find out. In and out anonymously. At your family doctors office this might not be the case. So the ED is where most IPV patients seek refuge/medical care.

Comparatively, $7.4 billion dollars is equivalent to the Gross Domestic Product (GDP) of Bahamas and is more than what is spent on care of congestive heart failure patients in Canada. So clearly this is having a significant impact on the Canadian population, but isn’t getting the recognition it needs!

Why do you think the ED is the right access point for helping people experiencing IPV?

The ED is the setting for helping patients with IPV as a point of entry to the healthcare system, often seeing patients who do not regularly see a physician. IPV survivors come to the ED more often and they come at the most vulnerable times as they try to leave toxic relationships. The ED is anonymous – no one needs to know you are there and we don’t tend to have a pre-existing relationship with the patient or their abuser. And we are always open.

CAEP Recommendations

1) Universal Screening for IPV Should be Performed in the ED

Taking all of the evidence into account, screening is low cost, low risk (safe) and can detect a high prevalence of previously undetected abuse in the ED, where patients are presenting for care. Incorporating screening into medical care requires training of staff on what questions to ask and what local resources are available if someone screens positive.

2) Patients Should Get Appropriate Medical Care

Injuries should be assessed and treated in the usual manner – we tend to get worried when IPV is in play as to what to do, when we know how to evaluate patients. Signs of IPV are like the signs of child abuse – we are all familiar with them and adults behave in a similar manner. Medical care always comes before any forensic considerations. Perform a physical examination as guided by the clinical interview – a full head-to-toe exam is not necessary and can be traumatic for patients. Using a trauma-informed approach to your examination is ideal. This consists of informing the patient of what you will be doing for each step of your exam, never approaching a patient from behind, and allowing the patient full control to halt the examination at any time. Provide analgesia and tetanus updates as per the usual guidelines. Pursue imaging as you would for any other accidental trauma mechanisms. Patients presenting with a possible strangulation injury need evaluation for any signs of significant force, such as a loss of consciousness, vascular injury signs, neurological injury or changes in phonation that may indicate an airway injury. Imaging should be a CT angiogram of the head and neck. If the patient is stable, this patient can be imaged when a safe transfer can be arranged.

3) Patients with IPV Should Be Referred To A Specialized Care Centre

Specialized care services are a team who provide private and confidential trauma-sensitive medical care to any person who has experienced sexual or intimate partner violence in their region. Patients must consent to care from the specialized team – there is no assumption of implied/emergency consent in these cases. These exams take time and that is at a premium in a busy ED!

Hospitals in most provinces have a Memorandum of Understanding with a specialized Sexual Assault and Domestic Violence treatment centre. In Ontario, the locations can be found at under the “Get Help” box.

Additionally, hospital Social Work services can act as an expert consultant for managing the complex social safety aspects of the patient’s care. All of these services are recommended to be consulted for these patients, should they consent to this, as their care encompasses a multitude of social, forensic, psychological and safety aspects that are difficult to manage in a busy ED.

4) Focus On Documentation

Once an emergency doctor has identified a case of IPV, the assumption should be that the medical records may be summoned to court and documentation of the events should be clear and legible to any. With just small adjustments to medical charts, they can be much more accurate and useful in court. Here are some pointers in documentation for your charting:

Write legibly, use words like ‘patient states/reports’, do not use words ‘claims/alleges’, avoid commenting on suspected age of injuries, remain factual, have the sexual assault team take photos, and include IPV in the final diagnosis if the injuries were the reason for the visit. This helps with funding for the IPV/Sexual assualt programs that we rely on in caring for patients.

Additional SGEM Recommendation

5) Privacy

Try to keep someone as safe and anonymous in your ED as possible. Have the patient de-identified on your electronic medical record (EMR) or have the record locked – this keeps them from being “seen” on a tracking whiteboard and acts as a visual reminder for those in the circle of care that this is a high-risk safety patient. It also helps to have a script for people who are fielding phone calls or directing visitors to say when there is a locked chart so that they don’t have to improvise on the spot.

CAEP Position Statement Conclusion

IPV is prevalent worldwide and Canada is no exception. The ED is where these patients commonly seek care. Screening itself works and the idea that there is “no evidence for screening” is based on literature that never studied intervention. IPV-related injuries should be treated the same as any other traumatic injury and chronic, substance use or mental health complaints may be clues to IPV. Referral to a specialized care centre will ensure the complex needs of IPV patients are met. You will see these patients and hopefully this guideline will make you more comfortable in doing so.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Resources:

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