Do sexual assault victims receive adequate care? If not, you risk fines, violations
Do sexual assault victims receive adequate care? If not, you risk fines, violations
In many EDs, rape victims fall to the bottom of the list’
A rape victim is brought to a New York City emergency department (ED), where she waits more than three hours before being examined. Poorly trained staff lose key evidence, including underwear and vaginal swabs. Tests for sexual transmitted diseases (STDs) aren’t processed by the lab. A second dose of emergency contraception is never given. No plan is given for follow-up care. No one obtains contact information for this patient. The assailant is a serial sex offender who attacked the woman the day after his release from prison, but no usable evidence is found in the hospital’s rape kit. As a result, prosecutors cannot convict.
If this sounds like a fictitious worst-case scenario, think again. It occurred at a New York City hospital, which was cited for 23 violations and fined $46,000 by the state health department.
"I was actually glad to see that fine imposed," says Linda E. Ledray, RN, PhD, FAAN, director of the Sexual Assault Resource Service in Minneapolis. "I believe this is a clear statement that hospitals can no longer get by with providing substandard care." The shocking incident puts a spotlight on inadequate care of rape victims in the ED, according to Ledray. "Too often, victims are not being tested for STDs and are not being treated prophylactically," she says. "Crisis intervention needs are also being overlooked."
Here are common problems that occur in EDs as identified by sexual assault nurse examiners (SANEs), along with strategies to improve care:
• Rape victims are asked the same questions repeatedly. Avoid having the patient repeat the story over and over, advises Lianne Ritch, RN, nurse clinician and SANE coordinator for the Sexual Assault Service at British Columbia Women’s Hospital in Vancouver, Canada. For example, the triage nurse’s role is to assess whether urgent care is needed, and he or she doesn’t need to know all the details about the assault, she says. "People tend to ask a lot of things that are irrelevant and don’t impact the patient’s care," adds Ritch. She gives the following examples of questions that aren’t appropriate to ask at triage: What were you doing before the assault? Did he use a condom? How many drinks did you have? Did you know him? Did you fight back or scream?
• Patients’ concerns are not addressed. Ritch points to research indicating that rape victims appreciate having control over their care.1 She recommends asking the patient, "How can we help you? What are you most concerned about?" "Then we can address that concern right away, which relieves a lot of anxiety and fear," Ritch says. For example, if a patient is worried about pregnancy, you can explain that emergency contraception is available, says Ritch. "Often, our agenda is focused on forensic and legal issues. But the patient’s health is their primary concern," she says. "That’s why they have come to us."
Your protocols must address patient concerns about injuries, STDs, and pregnancy, emphasizes Eileen M. Allen, RN, BSN, DABFN, SANE program coordinator for Monmouth County, NJ.
• The patient is examined in an inappropriate space. You’ll need a room large enough for a comfortable interview, and adequate space for law enforcement, medical staff, and advocates for the victim, says Kathy Hendershot, RN, director of clinical operations for the ED at Methodist Hospital in Indianapolis. The ED uses a room large enough to seat at least four people simultaneously, she says. "We hold this room for sexual assault exams and interviews only. It is never used for anything else," adds Hendershot. The room doesn’t need to be in the ED and may even have a separate entrance from the ED triage area, but close proximity is preferable, says Hendershot. "Currently we are entertaining the thought of relocating our sexual assault treatment area from our ED to a place of less traffic," she notes.
• Emergency contraception is not offered. According to several studies, EDs often fail to offer rape victims emergency contraception.2-4 "This is likely not unusual," says Ledray. "We just don’t realize how bad it is," she says. To address this, Ledray added a sheet explaining this option to the clothing kits provided to all rape victims in her state. (See Emergency Contraception: Important Information for Survivors of Sexual Assault: Click here.)
Ensure that every rape victim is told about emergency contraception, says Ledray. "If they want emergency contraception, you should have the medication available to give to the rape victim," she adds.
• There is a lack of privacy. A rape victim actually might leave the ED if she has have to disclose information in front of other patients, warns Ritch.
Allen acknowledges you’ll need to find creative ways to provide privacy in a crowded ED. For example, patients can be escorted to a small conference room near the ED to await the nurse examiner, advocate, and police officer after triage. "A sign can be added to the door indicating that the room is occupied, to limit unnecessary intrusions," adds Allen.
At Methodist Hospital, the ED’s triage policy requires a victim of sexual assault to be taken immediately to a private room, says Hendershot. If a general exam room is not available, the staff makes it a high priority to find another private space, such as a consultant room, office space, or assessment room, says Hendershot.
Forensic sexual assault interviews and examinations never should take place in a curtained cubicle, Allen adds. If a separate dedicated room is not available, she suggests using a walled exam room equipped with a gynecological examination table, evidence collection kits, and other necessary materials.
• Evidence is not collected properly. When untrained staff with little experience and lack of proper equipment attempt to collect evidence, errors occur, says Diana Faugno, BSN, RN, CPN, FAAFS, district director of forensic health services for the sexual assault response team in Escondido, CA. "Both the ED nurse and physician wind up reading the long instructions on how to collect evidence, in front of the victim," says Faugno. "This is a disaster waiting to happen."
She suggests the following to avoid this:
- have staff review evidence collection instructions on a quarterly basis;
- ask the crime lab to give an annual presentation about evidence collection kits;
- hang up posters about the top problem areas for improper evidence collection;
- ask the hospital’s risk management department to give an inservice on exposure to lawsuits for failure to collect evidence.
• Rape victims are not considered a priority. More than 90% of all rape victims do not sustain serious physical injuries, but most present with significant emotional trauma, says Allen. "Every survivor who seeks assistance at a hospital deserves to receive prompt attention from health care providers with specialized training to meet their physical and psychological needs," she underscores.
Unfortunately, sexual assault victims often wait hours to be seen since the typical patient is hemodynamically stable, says Hendershot. "The priority for ED staff would be trauma cases, heart attacks, and other life-and-death issues," she says. "Sexual assault cases are often put at the bottom of the list." You should have a protocol for these patients to facilitate the examination, documentation, and collection of evidence, says Hendershot. "The body is the crime scene, so evidence should be collected as soon as possible," she adds.
• Basic essentials are not provided. During the evidence collection process, clothing and other items may be taken from patients, says Allen. She adds that victims at the county’s exam sites are supplied with new sweat suits, socks, and underwear, along with patient comfort’ kits containing a toothbrush, toothpaste, soap, lotion, and a hairbrush, all donated by local rape care advocacy programs. "These items help to ensure that each survivor has an opportunity to clean up and is fully clothed when leaving the exam site," says Allen.
References
1. Ericksen J, Dudley C, McIntosh G, et al. Client’s experiences with a specialized sexual assault service. J Emerg Nurs 2002; 28:86-90.
2. Doughton S. Contraception after the act. Tacoma News Tribune, Aug. 20, 2001: accessed at search.tribnet.com/ archive/archive30/0820s11.html.
3. Catholics for a Free Choice. Catholic Health Restrictions Updated. Washington, DC: Catholics for a Free Choice; 1999.
4. Clara Bell Duvall Reproductive Freedom Project. Emergency Contraception Services for Rape Victims in Pennsylvania Hospitals. Philadelphia, PA: Clara Bell Duvall Reproductive Freedom Project: accessed at www.aclupa.org/duvall/ecinPA.html.
Resources
A free Sexual Assault Nurse Examiner (SANE) guide is available for download at no charge at the Sexual Assault Resource Service web site (www.sane-sart.com). The guide is designed for nurses who evaluate sexual assault victims. Or if you are interested in learning more about SANE/Sexual Assault Response Team (SART) programs in your state, you can go to the map on the site. Click on "If you are interested in learning more about SANE-SART Programs in your state, you can go to the map and find a contact from a program in your area."
Sources
For more information about caring for sexual assault patients in the ED, contact:
• Eileen Allen, RN, BSN, DABFN, SANE Program, 132 Jerseyville Ave., Freehold, NJ 07728. Telephone: (732) 866-3570. E-mail: [email protected].
• Diana Faugno, BSN, RN, CPN, FAAFS, District Director of Forensic Health Services, Sexual Assault Response Team, Palomar Pomerado Health, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3444. Fax: (760) 739-2611. E-mail: [email protected].
• Kathy Hendershot, RN, MSN, CS, Director of Clinical Operations, Emergency Medicine and Trauma Center, Methodist Hospital, I-65 at 21st St., P.O. Box 1367, Indianapolis, IN 46206-1367. Telephone: (317) 962-8939. Fax: (317) 962-2306. E-mail: [email protected].
• Linda E. Ledray, RN, PhD, FAAN, Director, Sexual Assault Resource Service, 525 Portland Ave. S., Minneapolis, MN 55415. Telephone: (612) 347-5832. Fax: (612) 347- 8751. E-mail: [email protected].
• Lianne Ritch, RN, Nurse Clinician/SANE Coordinator, Sexual Assault Service, British Columbia Women’s Hospital, 4500 Oak St., Vancouver, British Columbia, Canada V6H-3N1. Telephone: (604) 875-3284. Fax: (604) 875-2041. E-mail: [email protected].
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