Just Another Fast Track Lip Lac?

Written by Adrian Aurrecoechea, MD

Edited by Andrea Greene, MD 

A Case

HPI: A 22-year-old female with no PMH presents to Fast Track, referred from urgent care for lip laceration. Her chief complaint is pain to the face, and the patient reports she was texting on her phone and accidentally walked into a pole with something sharp. There is no head injury or LOC. 

Pertinent exam findings: Vitals unremarkable. Horizontal 3 cm linear buccal laceration 5 mm deep, extending to inside of the mouth from the lower lip vermillion border 

ED Course: The wound is sutured with 3 subcutaneous 4-0 chromic gut deep, simple-interrupted sutures and 4 5-0 chromic gut superficial, simple-interrupted sutures. The patient says you did a good job and is discharged with wound check follow-up in 7-10 days. She asks for a referral to Ob-Gyn Clinic and you say sure, no problem!

The patient is discharged and you sit back down at the computer to submit the Ob-Gyn referral. You scroll through her chart and discover a note from the outside hospital EMR. As you start to read, your heart sinks. “Patient initially described an unlikely mechanism for facial trauma. After asking if someone hit her, the patient admits her husband hit her in the face but states it has never happened before and she is not interested in pressing charges. SW consult placed, and the patient was given information for a women’s shelter.” What more you could have done for your patient on this ED visit?

What is intimate partner violence and who is affected?

According to the CDC, “IPV” or “IPV” refers to “physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy” [1]. Approximately 36% of women in the US experience IPV during their lifetime compared to and 33% of men, with 21% of women experiencing severe violence compared to 15% of men. Prevalence is influenced by social determinants of health such as age, ethnicity, and income [2]. IPV affects women, men, LGBT individuals, and other vulnerable groups such as the elderly and disabled. While these other groups are no less immune to IPV, studies on screening and interventional therapies for these groups are less well studied, highlighting a huge gap in the research literature. This blog post will focus on women of reproductive age in order to simplify the amount of material covered in one post but research on IPV against other vulnerable groups is severely lacking. 

Also of note, IPV is currently on the rise in the midst of great changes in our societal structures during the SARS-CoV-2 pandemic. According to the National Domestic Violence Hotline, their website usership has increased by 9% during the past few months [3]. This issue is especially important right now as the nation grapples with changes in our home environments and increased stress due to economic and health-related insecurities [4].

What are the most common harmful outcomes associated with IPV?

There are a number of physical and mental health harms linked to IPV. In one study, being a victim of physical IPV, especially abuse of power and control versus verbal abuse alone, increased the risk of current poor health, depression, substance use, chronic disease (including chronic mental illness), and general injury [5]. Below is a diagram describing the prevalence of various IPV-related impacts, with fearfulness, safety concern, PTSD symptoms and injury as the most prevalent impacts stemming from IPV. 

Lifetime prevalence of impacts of IPV [5]

What are common physical injury patterns seen in the healthcare setting that should trigger further exploration of IPV?

IPV-related Injury Patterns [5]

Are there evidence-based screening tools for IPV?

According to the USPSTF full recommendation on screening for IPV, five studies tested the accuracy of five different screening tools (HARK, HITS, E-HITS, PVS, and WAST) [2, 6, 7, 8, 9]. The studies found sensitivity that ranged from 64% to 87% and specificity from 80% to 95% for detecting any IPV in the past year [2]. The Ongoing Violence Assessment Tool (OVAT) had a sensitivity of 86% and specificity of 83% [2]. There is good evidence for its use in the ED [9].

Ongoing Violence Assessment Tool Screening Questionnaire [9]

Is screening alone associated with positive outcomes? 

No. According to their recommendation statement, the USPSTF “has found no direct benefit of screening for IPV in adult women…when screening was followed by brief counseling or referral. There were no significant differences between screening and control groups over 3 to 18 months for IPV, quality of life, depression, PTSD, or health care utilization outcomes [2]. The only time screening was associated with positive outcomes is when it was followed up with ongoing support services such as home visits and counseling that address multiple risk factors (beyond just IPV). In other words, identifying IPV in a patient via screening and referring them to a women’s health shelter is likely insufficient. In order to provide meaningful outcomes for victims of IPV, screening should be followed up with ongoing support services such as cognitive behavioral therapy or home visits to address the multifactorial environmental background that belies IPV against women [2].

References

1. 1. Centers for Disease Control and Prevention. IntimateViolence. Website: https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html Last reviewed 2018. Accessed September 17, 2020
2. 2. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: US Preventive Services Task Force Final Recommendation Statement. JAMA. 2018;320(16):1678-1687. doi:10.1001/jama.2018.14741.
3. 3. The National Domestic Violence Hotline. A Snapshot of Domestic Violence During COVID-19.  Website: https://www.thehotline.org/2020/06/05/a-snapshot-of-domestic-violence-during-covid-19/ Published 2020. Accessed September 12, 2020.
4. 4. Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med. 2002;23:260-8.
5. 5. National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention. The National Intimate Partner and Sexual Violence Survey -2010. Website: https://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_ipv_report_2013_v17_single_a.pdf Published 2014. Accessed September 17, 2020Health Resources and Services Administration, Office of Women’s Health. The HRSA Strategy to Address Intimate Partner Violence: 2017–2020. Rockville, MD: Health Resources and Services Administration; 2017.
6. 6. Alvarez C, Fedock G, Grace KT, Campbell J. Provider screening and counseling for intimate partner violence: a systematic review of practices and influencing factors. Trauma Violence Abuse. 2017;18(5):479-95.
7. 7. Futures Without Violence. Prevent, Assess, and Respond: A Domestic Violence Toolkit for Health Centers & Domestic Violence Programs. IPV Health Partners website. http://ipvhealthpartners.org/wp-content/uploads/2018/08/IPV-Health-Partners-Toolkit-8.18.pdf. Published 2017. Accessed September 17, 2020
8. 8. Ernst AA, Weiss SJ, Cham E, Hall L, Nick TG. (2004). Detecting ongoing intimate partner violence in the emergency department using a simple 4-question screen: the OVAT. Violence and Victims, 19, 375-84.

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Latest posts by Andrea Greene (see all)

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