Intimate partner violence is prevalent worldwide and has a significant economic impact on our healthcare system. This post will discuss:

  • Intimate Partner Violence statistics globally, in Canada, and in Ontario
  • The economic impact of intimate partner violence cases in Canada
  • The literature behind screening guidelines and recommendations for the ED
  • Recommendations on documentation of Intimate Partner Violence cases

Definition

Intimate Partner Violence (IPV) refers to any physical, psychological, or sexual harm within a current or past relationship that causes harm to those in the relationship.

Statistics

WHO

IPV transcends socioeconomic classes, ethnicities, and physical borders, with recent unfortunate news events proving that no one is immune to IPV

  • The World Health Organization (WHO) estimates the prevalence of IPV to be 1 in 3 women worldwide
    • There is no significant difference between continents
    • North America: 29.8% of women experience violence by their intimate partner
  • Women exposed to intimate partner violence are twice as likely to suffer from depression and alcohol use disorders
  • 38% of all murders of women worldwide are IPV-related

Canada

  • According to the 2009 General Social Survey, only 22% of victims report incidents to police, and thus the IPV statistics discussed thus far are highly deflated compared to reality.
  • Statistics Canada: IPV (which included both spousal and dating violence) accounted for 1 in 4 of all police-reported crime in 2011:
    • Among these, ex-partners were involved 30% of the time
  • IPV is found across provinces but most notable in the Prairie provinces, with Saskatchewan alone having an IPV female victim rate of 1,200 per 100,000 population
  • Police-reported IPV crimes are much more prevalent in the territories, with prevalence being three times more than any other province.
  • There is an increased risk of homicide after separation; leaving is the bravest and riskiest action patients take and they often find refuge in the Emergency Department (ED) during this transition period.

Economic Impact

Estimating the economic impact of a social phenomena would help policy-makers with resource allocation and program funding.

  • In 2012, Justice Canada published an economic study with the goal of estimating the cost of spousal violence:
    • They estimated the total amount of tangible and intangible costs to be $7.4 billion dollars in 2009
    • The study estimated the cost of ED IPV-related visits were 30 x more costly than Family practice visits, and patients were three times more likely to visit the ED than their own family doctor for IPV-related health concerns.
      • There may be numerous reasons for this difference in visit numbers:
        • The ED is always open
        • ED visits can be done anonymously without anyone knowing of the visit, unlike a family doctor’s office where familiar faces are seen every visit
        • Unlike the family physician, the ED physician does not have a pre-existing relationship with the abuser which may be a major factor in patients’ choice to visit the ED.

The ED is truly the perfect (imperfect) 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. Victims of IPV come to the ED more often and they come at the most vulnerable times as they try to leave toxic relationships.

In a study by Daugherty et al. in 2008, 44% of women murdered by their intimate partner had visited an emergency department in the last year, and 93% of these victims specifically for IPV-related injury. In 2008, Director et al. found that ED physicians were only able to identify 5% of IPV cases with only 13% ever asking about domestic violence, despite almost 40% of females with violent injuries.

Screening

The literature on screening women for intimate partner violence is riddled with controversy, with studies showing strong evidence for screening and others lacking evidence to screen.

  • The largest screening study is an RCT which included over 6700 women in 12 primary care settings, 11 emergency departments and 3 OBGYN clinics in Ontario.
    • Patients were divided into two groups; those screened and those not screened.
    • The healthcare professionals seeing these women for various unrelated medical problems were informed of positive screens and the intervention was left to the judgment of the clinician; this meant that the intervention itself was not standardized and involved clinicians providing resources such as hotlines, crisis lines, and referrals.
    • The primary outcomes studied were exposure to abuse and quality of life 18 months post screening, with one of the secondary outcomes being depression.
    • Quality of life and depression symptoms did show statistically significant improvement:
      • After multiple imputation due to a very high loss to follow-up (41% and 43% in each group) the data was no longer statistically significant.
    • The conclusion was that there was no evidence that screening helped patients of IPV.
  • A systematic review published in Annals of Emergency Medicine December 2013 concluded that screening is beneficial, low risk, and low cost but intervention for screening is yet to be studied.

Screening itself works, health professionals are able to identify patients with high sensitivity/specificity using numerous validated screening tools such as the Woman Abuse Screening Tool (WAST). With regards to whether screening benefits patients, the literature lacks studies on intervention and thus the question has not been fully answered as of yet.

intimate partner violence

Documentation

Once an emergency physician 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. In a 1999 study by Houry et al. published in Annals of Emergency Medicine, a chart review of ED documentation of intentional assault showed that two-thirds of charts had no documentation of whom the patient reported the assailant to be and in over one-third of cases the object used and type of assault was not documented. With just small adjustments to medical charts, they can be much more useful in court. Here are some pointers in documentation for your charting:

  • Using words like ‘patient states’ or ‘patient reports’ remains factual and non-judgmental. Writing “patient was punched in face” may obscure the identity of who is speaking.
  • Do not use words like ‘claims’ or ‘alleges’ as they imply skepticism and are legal terms that should not be used.
  • Write legibly; if the average person is unable to read the documentation, it is unlikely to be helpful in court.
  • If your observations have clear discrepancies with the patient’s statements it is still very important to remain factual and write the HPI as per what the patient reports.
  • Have your sexual assault team take photographs of the injuries
    • Never take photos yourself as there is a specific way to take photos for them to be permissible in court
  • Record the time you see the patient, the time you examine the patient, and the approximate time the patient states the injuries/events occurred.
  • Write out patient’s vital signs and always describe the patients’ demeanour
    • Write whether the patient is tearful, shaking, crying, angry, agitated, calm, or indifferent
      • Writing “NAD” aka no acute distress does not accurately describe your patients’ demeanour
  • For the final diagnosis, if the patient came in for IPV-related injuries then one should have the Final Diagnosis as Intimate Partner Violence or Domestic Violence
    • Diagnoses like ‘assault’ or ‘social situation’ do not help the hospital’s coding process which has implications for funding, community resources and research.

 

Take-Home Points

  1. IPV is prevalent worldwide and Canada is no exception
  2. Large economic impact of over $7.4 billion in a 2009 costing study
  3. Screening itself works. The idea that there is “No evidence for screening” is based on literature that never studied intervention
  4. In documenting IPV-related charts, avoid legal words and use clear and factual statements

 

References:

  1. Section 3: Intimate Partner Violence. Statcan.gc.ca. Last accessed: December 16, 2017. https://www.statcan.gc.ca/pub/85-002-x/2013001/article/11805/11805-3-eng.htm
  2. An Estimation of the Economic Impact of Spousal Violence in Canada, 2009; Justice.gc.ca. Last accessed: December 16, 2017. http://www.justice.gc.ca/eng/rp-pr/cj-jp/fv-vf/rr12_7/rr12_7.pdf
  3. Macmillan, Harriet L. “Screening for Intimate Partner Violence in Health Care SettingsA Randomized Trial.” Jama, vol. 302, no. 5, May 2009, p. 493., doi:10.1001/jama.2009.1089.
  4. “Intimate Partner Violence Screening in the Emergency Department: U.S. Medical Residents’ Perspectives.” International Quarterly of Community Health Education, journals.sagepub.com/doi/abs/10.2190/IQ.30.1.c.
  5. Wilbur, Lee & Noel, Nicole & Couri, Gene. (2013). Is Screening Women for Intimate Partner Violence in the Emergency Department Effective?. Annals of emergency medicine. 62. . 10.1016/j.annemergmed.2013.06.012.
  6. Krimm, John, and Marjorie M. V. Heinzer. “Domestic Violence Screening in the Emergency Department of an Urban Hospital.” Journal of the National Medical Association, National Medical Association (USA), 1 Jan. 1970, www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds%5B%5D=citjournalarticle_267571_38.
  7. Cochrane Library. Screening Women for Intimate Partner Violence in Healthcare Settings | Cochrane, www.cochrane.org/CD007007/BEHAV_screening-women-intimate-partner-violence-healthcare-settings.
  8. Houry, Debra & M Feldhaus, Kim & Rohrbach Nyquist, Sara & Abbott, Jean & T Pons, Peter. (2000). Emergency Department Documentation in Cases of Intentional Assault. Annals of emergency medicine. 34. 715-9. 10.1016/S0196-0644(99)70096-X.
  9. D Director, Tara & Linden, Judith. (2004). Domestic violence: An approach to identification and intervention. Emergency medicine clinics of North America. 22. 1117-32. 10.1016/j.emc.2004.05.008. an approach to identification and intervention
Nour Khatib

Nour Khatib

Richard Hoang

Richard Hoang

Dr. Richard Hoang is a 5th year Emergency Medicine Resident at the University of Ottawa with a variety of academic interests including military medicine, trauma, simulation, and FOAMed.