Screening for Interpersonal Violence in the ED: A Review of Evidence-based Screening Tools

Screening for Interpersonal Violence in the ED: A Review of Evidence-based Screening Tools 

Written by Kat Griesmer, MD, MPH

Edited by Lauren Walter, MD

A typical shift in the Emergency Department (ED) consists of a myriad of triaging, diagnosing, treating, and patient counseling. During these ‘typical’ shifts, it may be easy to miss an oft overlooked variable that may, not infrequently, contribute to ED patient presentations: Intimate Partner Violence (IPV), or amongst youths, Teen Dating Violence (TDV). More prevalent than perhaps most realize, IPV is through to contribute to over 100,000 ED visits annually.1 According to the CDC, IPV can occur between dating partners or current or former spouses and encompass physical or sexual violence, stalking, and/or psychological aggression.2 Prevalence is highest among those 18 to 24 years old and among certain minority groups including Black women, Native Americans, and those identifying as sexual and gender minorities. Given the high prevalence and impact of IPV,s the US Preventative Service Task Force (USPSTF) recommends screening all women of reproductive age for IPV, including in acute care settings such as the ED. 

There are multiple IPV screening tools available, each with their own limitations. A common one, HITS (Hurt, Insult, Threaten, Scream) is one of six screening tools recommended by the USPSTF and encompasses all forms of IPV. Sensitivity of this screening tool has been shown to range widely from 38% to 98%, with sensitivities particularly lower for male only study populations; however, inter-rater reliability has been consistently demonstrated to be greater than 88%. Another study, HARK (Humiliation, Afraid, Rape, Kick) was found to have a sensitivity of 81% and specificity of 95%; it is also noted for its ease of use and covering all forms of IPV.  Per a recent scoping review, HARK had the highest sensitivity but was also the least studied with the smallest sample size compared to other screening tools. The Woman Abuse Screening Tool, otherwise known as WAST, has high specificity, greater than 89%, but varied sensitivity from 47% to 88%.  The original WAST is a 10-item questionnaire, but for the busy practitioner, the WAST- Short form is a 2-item screen using consisting of only the first two questions of the original. This ‘Short’ form, however, only focuses on relationship tension. A study that has been predominantly used for screening with perinatal women, the Abuse Assessment Screen or AAS has a sensitivity of 93% and specificity of 55%, though it does cover all types of IPV abuse, including emotional, sexual, and physical. Outside of its typical use in perinatal women, the questionnaire can be used to screen men as well as non-perinatal women via  removal of one question that is only pertinent to pregnant women. A consistent point throughout the evaluation of these screening tools is the lack of or limited studies of screening use with men.3

The Emergency Department setting brings its own challenges to screening for IPV. Larkin et al. found the women screened were more likely to present with less severe injuries, without a psychiatric complaint (OR 2.60 medical vs psychiatric complaint), and during day shift.4 They note these may be secondary to previous documented issues including time constraints and provider knowledge on IPV. Those arriving via ambulance (OR 0.57) were also less likely to be screened, which may correlate to severity or privacy concerns as well. Following the implementation of screening of all women presenting to their ED, they noted an increase of social service referral and documented IPV from 1% to 18%, which is consistent with the prevalence found in other studies. However, the major limitation with their study is the inclusion of only women. Another all-female screening study in community EDs also found that self-administered surveys had higher rates of IPV, with their rates found to be 17% (vs 10%) in the past year and lifetime rate of 39% (vs. 35%). Acute abuse was higher in RN-administered survey (2.4 vs 1.9%). Greater than 80% of abused and non-abused women would support routine screening for IPV, but those reporting acute abuse or IPV in the past year were less likely to agree with mandatory reporting (76% vs 90%).5 Others have researched limitations on the clinician’s part towards IPV screening, with one study on resident’s concerns pointing towards limited knowledge, concern for legal implications, emotional fatigue, and timing constraints. Nearly all surveyed residents advocated for IPV screening with someone other than the physician performing the screen and clearly defined roles of those involved.6

As the ED remains the front line for traumatic injuries and even fulfills the role of primary care for many of our patients, we must recognize the role our patient’s home and personal life plays on their current health or illness state; screening for IPV in this regard become essential. Unfortunately, constraints during a shift are many including time limitations, privacy, and even resources such as social work availability. Focused screening, while incomplete, for those with inconsistent injuries or for populations at high risk may help to uncover some situations where intervention and acute care management may make a difference. Considering implementation of a computer-based or self-survey in the waiting room may be a further feasible option for some EDs with capacity for broader capture. The high prevalence of IPV means that we are likely meeting survivors on a consistent basis, often times not even knowing it, and therefore additionally unaware of IPV’s impact on an individual’s (and the population’s) health; just screen. 




References:

  1. Davidov DM, Larrabee H, Davis SM. United States emergency department visits coded for intimate partner violence. J Emerg Med. 2015;48(1):94-100. 

  2. Intimate partner violence |violence prevention|injury Center|CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html. Published October 9, 2021.  

  3. Arkins B, Begley C, Higgins A. Measures for screening for intimate partner violence: a systematic review. J Psychiatr Ment Health Nurs. 2016;23(3-4):217-235. 

  4. Larkin G, Hyman K, Mathias S, Damico F, Macleod B. Universal screening for intimate partner violence in the emergency department: Importance of patient and provider factors. Annals of Emergency Medicine. 1999;33(6):669-675. 

  5. Glass N, Dearwater S, Campbell J. Intimate partner violence screening and intervention: Data from eleven Pennsylvania and California Community Hospital Emergency Departments. Journal of Emergency Nursing. 2001;27(2):141-149. 

  6. Sormanti, M., & Smith, E. (2010). Intimate partner violence screening in the emergency department: U.S. Medical Residents' Perspectives. International Quarterly of Community Health Education, 30(1), 21–40. 

John Purakal