Abigail Hankin-Wei and Debra Houry
The term interpersonal violence implies violence between two people with some relationship (partner, family, acquaintance, gang-related, patient, etc.). This chapter focuses specifically on intimate partner violence (IPV) and provider exposure to violence in the emergency department (ED) setting. Specific information on sexual assault (Chapter 135); trauma in older adults (Chapter 53); and pediatric physical and sexual abuse and neglect (Chapter 290) can be found elsewhere in this textbook.
Also known as domestic violence, spousal abuse, or battering, IPV can present in the form of physical, sexual, or psychological abuse, or a combination of multiple forms of abuse—perpetrated against a former or current partner. A recent population-based study reported that 29% of women have experienced physical, sexual, or psychological IPV in their lifetime (1). IPV results in nearly 2 million injuries and 1,300 deaths nationwide every year (1).
The incidence of IPV victimization within the past 12 months among female ED patients has been reported to range from 11% to 20% (2–4). Many victims of IPV seek medical care for their injuries in EDs (2,5,6), while others present to EDs for treatment of complaints related to IPV, such as depression, posttraumatic stress disorder, substance abuse or complications of pregnancy secondary to abuse (7,8). In many cases, the ED is the primary access to health care for these patients. The lifetime prevalence of IPV exposure in ED patients has been estimated to be as high as 50% (9). In a recent report, the Institute of Medicine issued a recommendation that screening and counseling for IPV for all women, as part of standard preventative services, noting that such screening should be done in a “culturally sensitive and supportive manner” (10).
Violence within the ED is a problem that is underreported. The ED lends itself to promotion of a violent environment as a result of the volume of sick patients, long wait times, availability of drugs, 24-hour accessibility, and potentially violent psychiatric patients awaiting medical clearance. In one survey of emergency physicians in Michigan, 74.9% of those surveyed reported a verbal threat in the prior 12 months, while 28.1% reported that they had been physically assaulted in the workplace in the same interval. Among physicians, female gender and fewer years in practice were significantly associated with risk of assault (11).
Multiple studies have shown that, while workplace violence is common, victims often suffer in silence, with severe consequences for their mental health. Gates et al. (12) reported that 65% of assaulted ED workers did not report the assault to hospital authorities. Kowalenko et al. (6) reported that 81% of emergency physicians were occasionally fearful of workplace violence and 9% were frequently fearful. In one study, 42% of emergency physicians sought various forms of protection including obtaining a weapon to protect their personal safety (11).
The American College of Emergency Physicians (ACEP) developed a policy statement on protection from physical violence in the ED (5). ACEP stated that hospitals must ensure the provision of adequate security personnel, coordination of hospital security with local law enforcement agencies, the development of written protocols for violent situations in the ED, and education of staff on violent situations.
CLINICAL PRESENTATION
Intimate Partner Violence
IPV risk crosses all societal categories. However, studies have shown that risk of IPV victimization increases among patients with poor mental health (including depression and increased suicide risk), poor physical health and concurrent medical comorbidities, low income and low level of educational attainment, as well as race/ethnicity (although differences in ethnicity disappear when socioeconomic status is controlled for) (7,13,14).
IPV victims may present to the ED for treatment of an injury from IPV, evaluation of a chief complaint exacerbated by their situation (headache, anxiety, chronic pain), evaluation of nonspecific general medical complaints such as mental illness, substance use, or poorly controlled comorbid conditions, or a history of IPV that is elucidated via standard screening. Common presentations of battered women are listed in Table 383.1.
TABLE 383.1
Common Presentations of Women Experiencing Intimate Partner Violence
Violence in the ED
Patient-based factors that predict agitation and risk for violent behavior include substance abuse and intoxication, explosive or unpredictable anger, intimidating behavior, hostile and threatening verbal behavior, a history of self-harm, and resistance to medical care (15). At a facility level, interventions that reduce risk of violence in the ED include the use of metal detectors, security staff presence in the ED, and structural changes including panic buttons, improved lighting and visibility, and surveillance camera monitoring of the entire department (16).
DIFFERENTIAL DIAGNOSIS
IPV should be considered in the differential diagnosis of every ED patient, particularly in patients with nonspecific symptoms, or complaints associated with substance abuse or mental health. Patients with recurrent visits to the ED for vague, somatic complaints should be asked about IPV, as this may be the underlying etiology. Patients with traumatic injuries should be questioned specifically about how the injury occurred, especially if the physical examination findings are inconsistent with the stated mechanism. Without asking specifically about IPV, the diagnosis of abuse may not be made in these cases (17). It is important to ask about and identify IPV, as women who disclose IPV are at risk for incurring future injury (3).
With respect to the violent patient in the ED, it is important that clinicians evaluate for medical causes of the patient’s agitation after securing patient and staff safety. Metabolic abnormalities, infection, and trauma are life-threatening causes of altered mental status and agitation that must be ruled out. Table 383.2 lists key diagnoses to be considered.
TABLE 383.2
Organic Causes of Violent Behavior
ED EVALUATION
Intimate Partner Violence
Studies have reported that patients will not disclose IPV unless prompted by a health provider (17). Thus, ED patients should be routinely screened for IPV. This can be done as part of the nurse’s triage intake or during the physician’s history and physical examination. Questioning should always be carried out in private and with a nonjudgmental manner.
Physicians have several specific areas of responsibility in the evaluation and management of patients who are experiencing IPV: to screen for IPV; to provide medical treatment; to document findings and utterances; to facilitate appropriate referrals and follow-up; and to ensure the patient’s safety.
Patients thought to have injuries resulting from IPV should be interviewed in a quiet, secure area of the ED without their partner, family, or friends present. Patients should be asked in private whether they want their companion to accompany them into the treatment area, to minimize the chances that they will feel coerced into silence by an abusive companion. If there is a concern for the patient’s safety or a companion refuses to leave the patient in private, hospital security or police should be involved. A history of previous trauma, chronic complaints, psychological symptoms, or other red flags for IPV (inconsistent story, injury not consistent with chief complaint, multiple injuries in various stages of healing, partner who will not leave the patient’s side) should be sought when obtaining the history. If there is a language barrier, an interpreter should be provided. It is inappropriate to use a family member as an interpreter when IPV is suspected.
Multiple approaches to universal, standard screening for IPV are available, and can be implemented via face-to-face screening, paper screening, or computerized screenings. The Partner Violence Screen is one option, which has been previously validated in healthcare settings (18). It is a simple, three-question screen for IPV that is easy and quick to administer. The screen is as follows:
1. Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is making you feel unsafe now?
If a patient discloses IPV, the physician’s first task is to assess the patient’s safety. It is important to determine whether the patient has a safe place to stay and has a safety plan if she chooses to return home. Regardless of the severity of the presenting complaint or injury, the best indicator of danger is the patient’s own assessment. The frequency and severity of previous attacks, as well as verbal threats of violence are also good guides to current risk. Presence of a weapon in the home, prior battering episodes, and partner substance use may increase risk of harm. Additionally, IPV victims are most likely to be killed when they are in the act of leaving or immediately after they have left their abuser. Enlisting the services of a social worker can help bring victims into contact with resources such as shelters, social services, legal assistance, support groups, and other referrals that may benefit the patient.
Providers should also document the ED visit thoroughly. A review of IPV patient ED charts found that site of assault was not documented in 88% of charts, force/object use was not documented in 13% of charts, and police involvement was documented in only 54% of cases in a state that mandates reporting of IPV (12). It is also important to document the patient’s exact words, affect, and emotions, as factors can determine whether the patient’s statement will be admissible as evidence in court. Additionally, photographs or body maps should be used to document injuries. An accurate and thoroughly documented medical record can be an asset to an IPV victim’s case.
Violence in the ED
Many violent encounters in the ED can be prevented if a situation is recognized and controlled before an incident occurs. It is important to take steps to avoid confrontation, as patients often act out of a sense of fear or danger. Healthcare providers should never respond to patients’ threats with threats of their own. All assaults against medical personnel should be reported to law enforcement agencies.
The patient should be approached from the side and should be watched for possible missiles or weapons. A nonoffensive posture, with hands out front but not raised, should be employed. The care provider should be cognizant of the patient’s personal space and stay approximately two arm lengths away. It is important to acknowledge the patient’s needs and ask him or her to discuss the problem. The patient should be informed in a low voice that help is available and that support will be provided but that the patient must take control of his or her own behavior. Expectations should be defined, and the consequences of aggressive behavior need to be clear. Frequently, talking to the patient and making offers of food and drinks may be calm and defuse the situation.
When possible, the patient should be interviewed alone and in private, but the provider should keep the door ajar and maintain space between the patient and the door should an escape be necessary. Some patients may not respond to these measures, and here a “show of force” may be needed. Before interviewing the patient, assemble a group of security personnel who will remain within calling distance. Frequently, this show of force may be sufficient to help disorganized patients gain control of their thoughts and behavior and back down.
The history may be difficult to obtain, and other sources, such as family members, friends, and medical records, should be used. A physical examination should be performed to exclude an organic cause of the patient’s behavior (see Table 383.2). Blood tests, including toxicology screen and a blood sugar, should be obtained.
ED MANAGEMENT
Interpersonal Violence
If the police are not already involved, the physician can offer to call them or help the victim to do so. The patient should be told that battering is a crime and that he or she does not deserve to be treated in this manner. If a sexual assault occurred, state law often requires providers to report all rapes and sexual assaults. Cases involving the abuse or neglect of elders, minors, and certain persons with disabilities must also be reported to the appropriate government agencies.
Some states may also require reporting of injuries from IPV. It is important to be familiar with the state laws that apply to reporting IPV, because these laws vary considerably.
If the patient chooses not to talk with police or social workers, it is important for the provider to be empathic and not to criticize the patient. Offer the patient information and contact numbers, which she may use later. Ensure that the patient is safe to go home and that he or she has a safety plan such as preparing an escape route should the situation at home escalate.
Violence in the ED
If a patient is or becomes combative or poses a danger to themselves or others, physical restraints may be needed. Explain clearly to the patient what is about to happen and why. Assemble a team, preferably with five members, four to restrain the limbs and one to act as team leader. Soft restraints should be used to secure each limb to the stretcher. After the patient is restrained, he or she should be searched for weapons or objects that could inflict harm and then moved to a quiet area. Zun (19) reported that the most common complications of physical restraints were vomiting, injuring self, and increasing the patient’s agitation.
Pharmacologic intervention may be required if the patient remains agitated and uncooperative. Twenty-eight percent of patients in one study who were already physically restrained required chemical restraints (19). Frequently used agents include haloperidol (2 to 10 mg intramuscularly or intravenously in the young and 0.5 to 2.0 mg in the elderly) or benzodiazepines (e.g., diazepam 5 to 10 mg, or lorazepam 2 to 4 mg, intravenously or orally). Geodon (10 mg intramuscularly every 2 hours or 20 mg intramuscularly every 4 hours) has also been approved by the US Food and Drug Administration (FDA) for active psychosis. One randomized trial reported that haloperidol produced a faster onset of sedation and more clinical improvement over the first 2 hours than did lorazepam, although there were no differences in the need for additional intervention or physical restraints between these medications (20). The reason for physical or chemical restraint use, as well as specific alternative measures implemented to avoid restraints and to ensure the patient’s comfort and safety in restraints should be clearly documented in the medical record (19).
CRITICAL INTERVENTIONS
• Identify victims of violence.
• Develop a safety plan and involve authorities and local agencies with victims.
• Intervene early with potentially violent patients prior to escalation.
DISPOSITION
Victims of IPV should be asked where they will go if they leave the ED and who is waiting for them outside. If necessary, they can leave through a less-visible exit. All patients at risk for IPV should be given a list of emergency numbers and community resources. The option of overnight hospitalization should be discussed with the victim if he or she does not have a safe place to go upon discharge.
The discharge plan should include specific considerations for the patient’s need including a safe place to stay and resources for daily living, including as money, personal documents, car keys, and clothing for herself and her children. IPV victims should be informed of local programs for battered women that provide free, confidential social and legal services as well as housing, child care, and practical support.
Physicians should discuss protection against sexually transmitted diseases and pregnancy, especially for those patients who have been raped or who have experienced coercive sexual activity as part of the violence.
For patients with violent behavior in the ED, some may be discharged after a period of observation in the ED (e.g., those with alcohol- or drug-induced violent behavior). Some may require admission because of an underlying medical condition. Other patients may require further evaluation by mental health services and admission to psychiatric facilities. Patients without medical or psychiatric conditions requiring admission and who are under arrest may be discharged to the custody of law enforcement authorities after a medical evaluation.
Common Pitfalls
• Failure to make the diagnosis of IPV (especially in patients who may not disclose abuse, including elderly patients, patients with a language barrier, or patients who present to the ED with the perpetrator).
• Asking about IPV in the presence of a partner or family members.
• Failure to provide appropriate referrals and follow-up for victims of IPV.
• Failure to recognize the patient who is starting to escalate and who could have been calmed before the situation gets out of control.
• Attributing violent behavior to drug or alcohol intoxication without looking for an organic cause.
REFERENCES
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