EM · Adult safeguarding and domestic abuse
Adult safeguarding and domestic abuse in the ED
Also known as Elder abuse · Intimate partner violence · Human trafficking · Domestic violence screening
Adult safeguarding in the ED — recognising abuse, using validated screening tools (HITS, ERASE, RAFT), documenting verbatim, multi-agency reporting, and Care Act 2014 / reporting frameworks.
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Target exams
Red flags
- If the story and the injury do not fit, isolate the patient and ask direct, non-judgemental questions alone.
- Never use the partner or family member as an interpreter.
- Document verbatim — 'patient said...' not 'alleged'.
- Discharge to an unsafe environment without a safeguarding referral is an ED failure.
Recognising abuse
Abuse may be physical, sexual, psychological, financial, or neglect[1]. The classic patterns are injury inconsistent with history, delayed presentation, injury at protected sites (head, face, neck, defensive upper-limb)[3], perpetrator answering all questions, multiple attendances, and non-specific deterioration in the dependent older adult[1]. Sexual elder abuse shows injury at the genital and perianal area, often with significant injury elsewhere — head, arms and medial thigh.[3].
Screening tools
- HITS — Hurts, Insults, Threatens, Screams (IPV)
- ERASE — elder-abuse early warning (gut + 6 signs)
- RAFT — 4-item trafficking screen validated in ED
Sentinel injury patterns
- Head/face/neck
- Defensive upper-limb bruising
- Multiple stages of healing
- Patterned bruise (bite, ligature, burn)
References5ShowHide
- [1]Gottesman E, Elman A, Rosen T. Elder mistreatment: emergency department recognition and management Clin Geriatr Med, 2023.PMID 37798065
- [2]van Houten ME, Vloet LCM, Rikkert MGMO, et al. ERASE: a feasible early warning tool for elder abuse in the Dutch ED BMC Emerg Med, 2024.PMID 38570746
- [3]van Houten ME, et al. Types, characteristics and anatomic location of physical signs in elder abuse: systematic review Eur Geriatr Med, 2022.PMID 34514555
- [4]Shakil A, Bardwell J, et al. Development of verbal HITS for intimate partner violence screening Fam Med, 2014.PMID 24652635
- [5]Chisolm-Straker M, Singer E, et al. Validation of RAFT screening tool for labor and sex trafficking in ED J Am Coll Emerg Physicians Open, 2021.PMID 34667976