CASE: ACUTE SEXUAL ASSAULT
Note: Evaluation of the acute sexually assaulted patient may be challenging for health care professionals. For many, acute sexual assault is an emotionally difficult topic. Be mindful of your own feelings as they arise and make note of them; this could be an indication of how you may feel when actually responding and caring for a patient in a similar situation.
It is Saturday morning at 6am. You are the triage nurse in a busy ED. As you are walking across the waiting room, a young woman, Lorraine, comes up to you and states in a hushed voice, “Can I talk to you in private?” Together you walk to triage room where others cannot hear. She starts to cry and says, “I need the morning after pill…I was just raped.”
You are in a large ED with mental health providers and GYN (via the academic affiliate) available on-call 24/7. Social work is available on-site from 8am to 12am and on-call otherwise. Your VA has an agreement with a local SANE/SAFE organization to provide 24/7 on-call on-site services. Radiology, lab and pharmacy services are available on-site 24/7. Your VA in is a non-mandatory reporting state.
TRIAGE QUESTIONS
What are the first steps in triaging Lorraine? What is necessary to assign an ESI? (N)
· Main goal: ensure safety; assess high acuity presentations (ABCs); identify signs/symptoms of hemodynamic instability
· Establish private area free from interruptions
· Offer reassurance that she is safe now and that you are here to help
o Example: “Yes, we can definitely help you. We have emergency contraception here; first can I ask you some questions and take your vital signs to check on your safety today?”
· Obtain HPI and brief ROS:
o Ask direct questions about traumatic injuries and/or pain
o Ask about high acuity presentations – pain, CP, SOB?
o LMP
· Vital signs
· Pain assessment
· Inquire about a desire to report the assault now or possibly in the future
o Ask whether law enforcement has been notified
o Ask about a desire to report the assault and/or have forensic evidence collected
o Example: “Have you notified or do you want to notify the police? If so, we can help you. Our emergency department is fortunate to have expert sexual assault examiners available who can help exam you and collect any evidence during your visit today. Is this something you are interested in?”
*Note to facilitator: Some triage nurses may prefer to not bring this topic up in the triage area to avoid undue anxiety in the patient at presentation and defer this to the primary nurse or provider, but acknowledge the longer it takes to determine if the forensic exam is desired, the greater the chance of compromising evidence.
What initial questions would you want to ask Lorraine to help determine an accurate acuity (N)?
· When did this happen?
· Were you injured physically?
· Safety screen – Any thoughts of hurting yourself? Or hurting others?
o Don’t assume that those accompanying the patient weren’t involved in the assault (majority of women sexually assaulted are acquainted or in a past/current relationship with the perpetrator)
What else can you do to provide compassionate care in this situation (N)?
· Ask about desired supports
o Example: “Did someone accompany you or is there someone you would like me to call to be with you?”
· Don’t leave the patient alone
· Offer empathy, do not judge the patient in any way
What ESI (Emergency Severity Index) level would you assign Lorraine and why? (N)
· ESI = 2, based on high risk situation (acute sexual assault is ESI level 2 based on AHRQ standards)
How would you orient Lorraine to the next steps in care?
· Provide continuous support and encourage informed care
o Example: “I’m going to bring you back within the emergency department to meet the nurse and provider dedicated to caring for you. Is that OK?”
· Reinforce that ED staff are here to help and make her as comfortable as possible.
o Inquire about gender preferences – is a male nurse/provider OK or do you prefer a female nurse/provider?
ABCs are intact. Lorraine, who is 27 yo, appears anxious and tearful when discussing the assault which occurred 3 hours ago at a friend’s house. She denies any acute injuries, pain, or any other symptoms of concern. Her LMP was 1 week ago. She denies thoughts of hurting herself or others, and no one has accompanied her here today.
VS: T 98.8, HR 98, BP 134/76, RR 24, 98% on room air
Pain: 0/10
Lorraine expresses interest in a sexual assault (forensic) exam, but does not want to notify law enforcement. You notify her that you are going to call the charge nurse to ensure a private room is available. You tell Lorraine she will be offered a chance to talk to a mental health provider. Lorraine asks that her roommate be called. She requests you don’t share any details, except she is safe and would like her to come to the ED. She also requests female nurses and providers, if possible.
You escort Lorraine to her room and provide handoff to the primary nurse including letting her know she is going to call the roommate and will let them know when she arrives. The charge nurse informs there is a female provider available.
PRIMARY NURSE ASSESSMENT
Once triaged, what are the primary nurse’s initial steps (i.e. care, assessment)? (N)
· Nursing care
o Introduce yourself; communicate your role and what you will be doing
o Meet any immediate medical needs
o Continue to provide continuous support , informed care, and offer comfort and choice
§ Explain in lay terms the course of evaluation and treatment
§ Respect the patient’s right to refuse any undesired care
§ Example: “Please let me know if there is anything I can do to make you more comfortable: room layout, curtain placement, another blanket, tissues, etc.”
· Nursing assessment (through clothing unless medically necessary to remove, gloves to avoid contamination of evidence)
o Reassessment from triage findings; confirm information gathered in triage
o Confirm that she wants a forensic examination
o Medication reconciliation, allergy assessment
· Limit questions to information necessary to provide care, do not probe into unnecessary details
· Avoid revictimization of having the patient retell traumatic details of the event multiple times if not necessary to care
· If possible do not leave Lorraine alone for extended periods of time. If you need to leave the room let her know and inform her of when you anticipate returning. Knock and identify self before re-entering room.
How do you inform Lorraine about what the forensic exam is and entails? (N&P)
· Purpose of the exam is to collect statements, observations and physical evidence
· Comprehensive head to toe exam, including pelvic exam
· An expedited exam is key to help preserve evidence
o Patients are asked to try to refrain from any activities that could compromise evidence such as disrobing, showering, eating/drinking, urinating/defecating, brushing teeth, chewing gum, brushing hair
· Even though evidence is collected, it is the patient’s choice to report or not
o Evidence may be collected and stored anonymously for a potential future prosecution
· Patient may refuse any element of evidence collection, and yet still have any or all other elements collected if desired
What if Lorraine says she needs to use the bathroom? What are your concerns about evidence? (N&P)
· Compromising evidence
o Urinating and/or defecating may potentially compromise the collection of important evidence that could influence a prosecution therefore best to wait until the forensic exam is performed to void
o Inform patients of the potential impact of post-assault activities on the integrity of evidence but then respect the patient’s wishes and document them as such
o Appreciate it is the patient’s choice whether she waits to void or not
§ If voids, document the number of times patient urinated prior to collection of the sample
· Drug facilitated sexual assault (DFSA)
o Inquire about the possibility of a DFSA – using drugs or alcohol to incapacitate a victim in order to commit nonconsensual sexual acts
§ Half of all sexual assaults involve drug or alcohol ingestion, with alcohol being the most common
o If a DFSA is suspected, informed consent must be obtained to collect a urine toxicology sample ASAP even if patients are undecided about reporting to law enforcement
§ The sooner urine is obtained post assault, the greater the changes of detection of substances that are quickly eliminated from the body
§ If patients may have ingested a drug used for DFSA within 96 hours prior to the exam, urine should be collected in a clean plastic container
§ Urine specimen does not have to be a clean catch – bacteria in the urine will not compromise test results and the process of cleaning the genital area for a clean catch will likely destroy evidence)
§ Be aware that the specimen collected is evidence and the provider must document and maintain the chain of custody
How would you orient Lorraine to the next steps of care? (N)
· Provide continuous support and keep her informed of next steps in care
o Example: “A female provider is going to come in and ask a few questions; she may want to perform an exam to make sure there are no injuries that need immediate treatment because we want to make sure you get all the treatment you need. Also, we offer all survivors of sexual assault an opportunity to meet and talk with our mental health providers. How do you feel about that?”
Lorraine is oriented to her private ED room and introduced to you as her primary nurse. When asked what would make her more comfortable, she says she’d like to use the restroom. You confirm with Lorraine her desire to have a forensic exam, but not notify law enforcement. You answer questions she has about the forensic exam including explaining urinating may compromise the collection of important evidence and it would be best to wait until the forensic exam is performed. Lorraine acknowledges this and feels as though she can wait to use the bathroom until the forensic exam.
Lorraine discloses to you the sexual assault occurred 3 hours ago. The perpetrator, an acquaintance, held her down forcibly by her wrists and had nonconsensual, unprotected vaginal intercourse. Lorraine also shared that she went to a friend’s house after but her friend was not home, so then she came to the ED. She has not showered or changed her clothes since the assault. She asks if she can talk to the ED provider about being treated for sexually transmitted infections and “the morning after pill”. Lorraine expresses interest in talking with mental health.
She says her wrists are feeling sore, but denies other physical injuries. She takes no medications and has no known allergies.
Lorraine continues to be tearful at times, but appears to appreciate the direct communication about the next steps in her care.
Reassessment reveals stable vital signs.
The charge nurse knocks on the door and announces Lorraine’s roommate has arrived and asks her whether it is okay if she comes back to the room. Lorraine is relieved to have her friend with her and asks if her friend can remain in the room for her entire evaluation. The charge nurse and friend remain with Lorraine as you step away to communicate with the ED provider.
What would you communicate with the provider? With the ED team? (N)
· 27 yo woman sustained an acute sexual assault 3 hrs ago; nonconsensual, unprotected vaginal intercourse by male acquaintance
· Vital signs are stable and she denies physical injury other than wrist soreness
· Interested in a forensic examination, but does not want to report to law enforcement
· She is waiting to use the restroom until evidence is collected
· She requested her female roommate be with her for support, is concerned about STI and pregnancy, and interested in talking with mental health, so you will contact them now
*Note to facilitator: there may be overlap in the history gathered by the nurse and provider; try to limit duplication of history taking; therefore, any details of the event the patient discloses to the nurse should be communicated to the provider
The primary nurse contacts mental health on-call per provider orders. The ED provider enters the room.
PROVIDER ASSESSMENT
What are the critical actions for the provider as part of initial contact with Lorraine? (P)
· Consider sexual assault patients a priority
· Be aware of your state’s mandatory reporting requirements before seeing the patient
o It is the provider’s obligation to report, not the patient’s
· Introduction of name and role
· Confirm information already provided
o Example: “Lorraine, your nurse told me why you are here. Firstly, I know you have had a recent sexual assault and that you are interested in emergency contraception and possibly treatment for STIs. Secondly, she said although you do not want to report the assault to law enforcement at this time you’d like to have an exam performed to collect evidence in case you change your mind at a later time – is this correct?”
· Inform and orient patient to all parts of the examination and process while she is fully clothed
o Example: “My primary purpose is to make sure your medical needs are met. Comprehensive care for those sexually assaulted often involves the expertise of several different providers and may require multiple steps: mental health; law enforcement involvement if desired (or as required by your particular state); evidence collection; pregnancy prevention; STI treatment.”