Description

Patients seeking care in the emergency setting after sexual assault are an at-risk, vulnerable population. It is imperative that they have access to and receive patient-centered and trauma-informed care that addresses their medicolegal and psychosocial needs (Plichta, Clements, & Houseman, 2007). Patient-centered care is respectful of and responsive to individual patient preferences, needs and values, ensuring that patient choices guide all clinical decisions (Committee on Quality of Health Care in America, 2001). Trauma-informed care involves understanding the connection between presenting symptoms and behaviors, on the one hand, and the individual's past trauma history, on the other (Hodas, 2006).

Comprehensive care for these patients requires extensive planning, education and expertise on the part of emergency care providers and their collaborative partners (Sampsel, Szobota, Joyce, Graham, & Pickett, 2009). The emergency nurse is a key member of this team and instrumental in coordinating access to appropriate healthcare providers, collaborating with community-based victim advocates, social workers, and law enforcement personnel (Cybulska, 2013; Linden, 2011). Many nurses have education and certification in the expanded practice role of sexual assault nurse examiner (SANE) in order to provide care in an empowering setting, different from traditional medical care that often left patients feeling re-victimized (Cybulska, 2013; Linden, 2011). The SANE completes a time sensitive examination that includes: assessing, treating and documenting injuries, identifying risks and providing preventative treatment for negative health outcomes associated with sexual assault including exposure to infection, unintended pregnancy, and long term psychological and physical sequelae, collecting evidence, maintaining the chain of custody, safety planning, and providing support with appropriate community referrals (Plichta et al., 2007; Sampsel et al., 2009; Cybulska, 2013). Immediate medical and psychological care directly impacts the patient's well-being and contributes to the beginning stages of the healing process (Plichtaet al., 2007; Cybulska, 2013; Linden, 2011). Successful physical and emotional outcomes, as well as potential prosecution of sexual offenders, require emergency care settings to be prepared to provide competent care and referrals for the sexual assault patient (Plichta et al., 2007).

ENA/IAFN Position

It is the position of the Emergency Nurses Association and the International Association of Forensic Nurses that:

1. Sexual assault patients are provided a safe and private environment upon arrival in an emergency care setting, with access to a community-based advocate at any time during their stay.

2. Emergency nurses use a trauma-informed approach throughout the sexual assault patient's complex plan of care.

3. Sexual assault patients receive consistent, objective, immediate medical care, as well as options for the collection of evidence by emergency nurses and physicians knowledgeable of jurisdictional guidelines and protocols for evidence collection.

4. Whenever possible, forensic nurses with specific training as sexual assault nurse examiners are consulted or assigned to care for this patient population.

5. Sexual assault patients receive medically appropriate sexually transmitted disease prophylaxis and emergency contraception without barriers, according to recommended Centers for Disease Control and American Congress of Obstetricians and Gynecologists guidelines, respectively.

6. Emergency nurses receive continuing education on medical and forensic sexual assault evaluation and maintain access to current legislative guidelines and protocols for proper examination and reporting options.

7. Emergency nurses collaborate with multiple agencies to develop an individualized, multidisciplinary approach to treatment, evaluation and continuity of care to minimize the patient's short and long term physical and psychological trauma.

8. Emergency nurses participate in community education and research to identify and implement best practice standards of care for the sexual assault patient.

9. Healthcare facilities recognize that they have an obligation to provide appropriate medical forensic intervention when a sexual assault patient presents for care, whether or not the facility has a SANE program.

10. Healthcare facilities are cognizant of jurisdictional laws regarding all aspects of the sexual assault medical/forensic exam.

11. Healthcare facilities support SANE practitioners by developing, sustaining or maintaining their own programs, or establishing relationships with other facilities.

12. Lead trauma centers develop and maintain SANE services to address the health needs of this patient population.

Background

Sexual assault patients regularly present to the emergency care setting for treatment following their traumatic event (Plichta et al., 2007). In the past, they have often been treated by emergency department personnel who lacked training in medical forensic evidence collection, and those with training often did not perform exams frequently enough to maintain proficiency and competency (Littel, 2001). The result was poor documentation and improper evidence collection. Historically, emergency physicians have found it difficult to dedicate the amount of time required to provide the necessary level of care for this population while still managing the other patients in the emergency department (Plichta et al., 2007). The understanding that these patients require complex clinical management in a setting that often has significant time constraints, led to the use of specially trained examiners to provide care for sexual assault patients (Sampsel et al., 2009; Linden, 2011; Houmes, Fagan, & Quintana, 2003). One study found proper documentation in 100% of SANE documented evidence kits compared to 79% in non-SANE kits. It also found that proper evidence collection specimens were reported in 96% of SANE collected kits compared to 86% when collected by physicians (Houmes et al., 2003). Case law has repeatedly found SANE-collected kits to be among the strongest courtroom evidence in supporting victim testimony, and SANE nurses themselves have been noted to be very credible witnesses (Plichta et al., 2007; Linden, 2011; Houmes et al., 2003). The role of specially trained sexual assault nurse examiners has been supported by the American College of Emergency Physicians (ACEP) and they are the FBI's preferred examiners for victims and suspected perpetrators of criminal sexual acts (Linden, 2011; Houmes et al., 2003).

Guidelines for the treatment of patients after a sexual assault have been issued by the Department of Justice, ACEP, the American Congress of Obstetricians and Gynecologists and the World Health Organization (Linden, 2011; Houmes et al., 2003). The Centers for Disease Control and Prevention continually update the recommendations for pharmacological treatment after exposure to potential sexually transmitted diseases including HIV. Across these organizations it is recommended that patients presenting to an emergency care setting be assessed for acute traumatic physical injuries and offered forensic evidence collection according to jurisdictional protocols (Linden, 2011). To reduce further re-victimization by providing prompt care and overall better services, patients should be referred to clinicians with education and experience in systematically managing this population (Houmes et al., 2003; Campbell, 2006). Using specialized examiners has alleviated previous issues of emergency department increased wait times, poor clinical outcomes and patient dissatisfaction (Plichta et al., 2007; Girardin, 2005). The new standard of care includes deliberate and timely crisis intervention, proper medical care and evidence collection, and complete coordination and follow up with members of the community sexual assault response team (Plichta et al., 2007; Girardin, 2005). Additionally, the presence of a community-based advocate during the examination as a source of support for the patient improves both medical service and legal system responses for victims (Campbell, 2006).

Resources

American Congress of Obstetrics and Gynecologists: Emergency Contraception: Resource Overview. Retrieved from http://www.acog.org/Womens-Health/Emergency-Contraception

Centers for Disease Control and Prevention: 2015 Sexually Transmitted Diseases Treatment Guidelines: http://www.cdc.gov/std/tg2015/

Sexual Assault Forensic Examiner Technical Assistance: http://www.safeta.org/

Forensic Nursing Education Guidelines: http://www.forensicnurses.org/?page=EducationGuidelines

Position Statement: Collaboration With Victim Advocates: http://www.forensicnurses.org/resource/resmgr/Position_Papers/IAFN_Position_Stat

Position Statement: The Use of Emergency Contraception Post Sexual Assault Statement: http://www.forensicnurses.org/resource/resmgr/Position_Papers/IAFN_Position_Stat

Position Statement: DNA Evidence Collection from the Oral Cavity: http://www.forensicnurses.org/resource/resmgr/Position_Papers/DNA_Evidence_Colle

Management of the Patient with the Complaint of Sexual Assault: http://www.acep.org/content.aspx?id=29562

A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents: https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf

Guidelines for medico-legal care for victims of sexual violence: http://apps.who.int/iris/bitstream/10665/42788/1/924154628X.pdf

Committee on Health Care for Underserved Women Opinion on Sexual Assault: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-H

References