The Case

A 32-year-old female with facial injuries is brought to the emergency department by her sister. She states that she was walking her dog and fell forward onto the pavement when the dog pulled on the leash. She denies injuries other than those to her face (see Figure 1). She is uncertain whether she lost consciousness and complains of a headache.

Introduction

In the United States, more than one in three women and nearly one in three men have experienced sexual violence, stalking, or physical violence by an intimate partner.¹ Among female victims of homicide committed by an intimate partner, nearly half had been emergency department patients within the two years prior to their deaths.² The majority of victims of intimate partner violence (IPV) were emergency department patients multiple times without being identified as victims of IPV, even when injury was the presenting complaint.³ Clearly, emergency department staff have a unique opportunity to identify victims of IPV and to provide safety planning and community referrals.

Figure 1: Injuries to the patient’s face.
Photos: Brandi Castro, RN, SANE-A, SANE-P

Multiple organizations, including ACEP and The Joint Commission, recommend universal screening for IPV.⁴ Studies suggest that universal screening results in higher rates of identification of IPV.⁵ However, in reality, screening is far from universal. In one study of 433 women presenting to emergency departments, only 13 percent either volunteered information about IPV or were screened for IPV.⁶ A larger study of 4,641 adult women presenting to emergency departments suggested that patients want emergency department staff to ask about IPV, but fewer than 25 percent were screened.⁷

Emergency department staff cite several barriers to screening.⁸ The physical layout of many emergency departments makes it difficult to screen patients privately. Language barriers and time constraints may impede screening as well. Many emergency department staff have preconceived notions of what a victim of IPV should look like and do not screen patients who do not fit that profile. Given the prevalence of IPV, many of those responsible for screening have a personal or family history of IPV, which may make screening difficult. Other providers do not screen because they do not know what questions to ask or they are not familiar with community resources.

Screening

The ED staff responsible for screening for IPV varies among emergency departments. Often, the IPV screen is included in the initial triage assessment. Many departments have found that triage screening is impractical due to lack of privacy and critical medical conditions requiring immediate stabilization. If this is the case, the patient’s primary nurse or physician should screen as soon as practical. Clinical decision support in the electronic medical record may help prompt screening. For screening to be performed routinely, it must be built into the standard workflow.