Download Policy - Sexual Assault Forensic Examiners

Subject
Sexually Assaulted Patient
Key words SANE, sexual assault, rape
Category
Attachments
Yes
No
Number
Manual
Effective Date
Issued By SANE Program Director
Last Review/Revised Date
Applicable ED staff, SANEs
Next Review/Revision Date
Retired Date
Review Responsibility SANE Program
Contact SANE Program
Director
I.
PURPOSE
To delineate the procedure for assessing, examining, and supporting the patient who has been sexually assaulted.
II.
POLICY
Females and males 13 years and older will be offered the option of an exam by a SANE. An advocate from Rape
Crisis will be called for support.
III.
PROCEDURE(S)
Triage
1. Patients with complaints of a sexual assault will be triaged immediately to the family room, or another ER
room as appropriate. If significant injuries exist or if the patient requires stabilization for any reason, the
patient will be seen in the ED first and later evaluated for sexual assault.
2. The primary nurse will obtain a full set of vital signs including pain score, PMH, medications, allergies and
LMP. The primary nurse will obtain a very brief statement from the patient regarding the sexual assault so
it can be determined if the following criteria are met.
3. The Sexual Assault Nurse Examiner (SANE) will be paged if:
 The patient is age 13 years or older
 The patient agrees to a forensic exam
 The patient does not have serious injuries requiring immediate care
 The patient is able and willing to give a history and cooperate with an examination
 The assault occurred within the past 5 days.
Arrival
1. The SANE will arrive within ____ minutes of being paged.
2. The SANE will check in with the primary nurse to see if there is any additional patient information available.
3. The paper portion of the patient’s medical record will be located _________. This includes the billing
sheet, multiple labels, consent forms, demographics form, discharge instructions and body diagram. A
computer will be available to the SANE for electronic charting.
Beginning
1. The SANE assumes control of the patient when she arrives, unless the patient has suffered significant
trauma and is in need of emergency medical care.
2. If the patient has not reported the incident to the police, they should be encouraged, but not forced, to do
so.
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3. Police should be called if the patient wishes to report the sexual assault. Emergency Department staff may
be asked to assist with police notification.
4. The rape crisis center on call advocate should be notified that a sexual assault patient is in the Emergency
Department. (without identifying information given out).
History
1. The SANE will take a history of the assault with a focus on events preceding, during, and after the assault.
The history will include force used, threats, coercion or other aspects that indicate the patient’s lack of
consent to sexual activity. The history will also include the type of sexual contact that occurred and if any
objects were used. The history will include whether the patient has any areas of pain. Information for the
State Crime Laboratory will be obtained during the history. The history is not meant to evaluate for preexisting medical conditions.
2. During the history, the SANE will determine if the patient is in emotional crisis and in need of social service
evaluation. If so, the SANE will refer the patient to social service after the forensic exam is complete, or
sooner as needed.
3. Any areas of injury that may have occurred during the sexual assault should be documented with digital
photographs.
4. The digital photographs are downloaded onto a CD and taken to lab along with other evidence, after being
labeled with the patient’s name, birth date, medical record number, current date and time and the SANE’s
initials. The digital photographs will be treated in a chain of custody manner.
5. Colposcope photos are taken of genital injuries and are stored in the office of the Medical Director of the
SANE program.
SEXUAL ASSAULT PROCEDURE
1. The SANE will collect legal specimens in sexual assaults or suspected sexual assaults. Special
precautions must be followed to properly identify specimens and to maintain the chain of evidence to
insure the integrity of the collection and handling of the specimens.
2. A sexual assault evidence collection kit will be performed up to 5 days post assault.
Reagents And Materials
The following is a list of supplies needed to complete a sexual assault exam:
1. Sealed Sexual Assault Kit
 Envelope with comb and paper for collecting possible foreign hairs.
 Envelope for DNA studies for each site--ex. vaginal, oral, rectal, penile, other(miscellaneous)
 Envelope containing blood stain preparation--purple top tube and absorbent paper
 Envelope for foreign material
 Envelope for miscellaneous evidence
2. Brown manila envelope for presumptive labs that will be performed including:
 2 heat sealed packets with:
1. Slide carrier and two slides
2. 3 Plastic Snap-Cap tubes with 3 ml sterile saline
3. Large saline tube for acid phosphatase
4. Note: Heat-sealed packet ensures that supplies are new and unused
 Hospital Sexual Assault Chain of Evidence Form
 2 unsealed plastic envelopes
 2 evidence tapes
3. Additional supplies including:
 Evidence tape
 Cytology spray fixative
 Swabs
 Phlebotomy supplies
 Marker or pencil
 Extra heat sealed packets
 Extra heat sealed packets of 3 - 3ml sterile saline tubes
 Extra unsealed plastic envelopes
 Tape measures
 Paper bags
 Gloves
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
Wood’s lamp
Types Of Specimens
1. A number of specimens will be collected from each site involved. Some may be processed in the
laboratory at the Hospital. Others will be sent to the State Crime Laboratory.
2. Specimens for the State Crime Laboratory:
 Swabs for semen/sperm
 Swabs for saliva
 Fingernail scrapings if indicated
 Pubic combings
 Blood sample for DNA testing
 Blood and urine for DFSA (drug facilitated sexual assault) as indicated
Labeling
1. All specimens are labeled with computer generated labels which include the patient name, medical record
number, birth date, and date. The SANE will circle the date (or write the correct date of exam if the patient
arrived on a date different from the exam date), write the time of exam and place her initials on the label.
2. The cytology slides are handwritten with the patient’s name, medical record number, date and time of
exam, SANE initials and site of collection (oral, vaginal, rectal, skin). A pencil or marker is used for
labeling the slides.
3. An initialed label is affixed to the Sexual Assault Chain of Evidence Form.
Collection - The Exam
1. If drug facilitated rape screen is ordered, see separate procedure.
2. Prepare supplies on the counter before collecting specimens. Start with the oral site, then perineal, vaginal
and rectal. There may also be skin swabs obtained depending on the history and exam with the ultraviolet
light source.
3. Draw blood for the state crime laboratory with the patient’s permission. This can be done at the end of the
exam if blood will be drawn for DNA testing only.
4. The exam will begin by examination of the clothed patient with an ultraviolet light, looking for the greenwhite fluorescence of semen. If the SANE determines there is fluorescence on any of clothing it will be
collected and placed in a paper bag for the state crime laboratory.
5. Clothing that may have assailant DNA is collected in paper bags sealed with evidence tape. Typically this
may just include the underwear. If the victim’s clothing is torn or shows signs of a struggle it will also be
collected for the state crime laboratory. If the clothing is soiled with dirt or debris from the location of the
sexual assault it will also be collected.
6. If the patient has debris on his/her clothing he/she is asked to undress over a double layer of white exam
table paper. The top paper layer with debris is placed into a clean envelope and collected for the state
crime laboratory. The envelope is sealed with a label and evidence tape including the SANE’s initials, date
and time.
7. The SANE will look for fluorescence on the patient’s skin. If there is fluorescence on the skin the SANE
will need the state crime laboratory packet labeled "other site" for collecting skin swabs. 2 swabs are
moistened with saline and gently rolled over the site of fluorescence and placed in the envelope. This is
repeated for a total of 4 swabs for the state crime laboratory.
8. The SANE will visually inspect the patient looking for any signs of trauma. The SANE will examine the
patient for areas of tenderness and pain and document these on the Sexual Assault Report and on the
body diagram.
9. The SANE will photograph any injuries from the assault using a digital camera. A backup 35 mm camera
is available if the digital is not available for any reason.
10. Oral swabs are obtained if there was oral penetration. A total of 4 swabs are obtained by running the
swabs gently along the recesses of the mouth and in the pockets formed by teeth.
11. Perineal swabs are obtained if there was rectal or vaginal penile penetration. Swabs are moistened with
saline and gently rolled on the skin between the vagina and anus to obtain semen or sperm. Swabs may
also be obtained from the perineal area if there was oral contact by the assailant.
12. The SANE examines the external genitalia with the colposcope and photographs any areas of injury.
Colposcope photos will have a patient label attached with the SANE’s initials and date and time of
collection. Colposcope photos are placed in an envelope, sealed with a label, and placed in the locked
colposcope cupboard to await pickup by the SANE supervisor. The photos are stored in the SANE office.
13. A speculum is inserted into the vagina and 4 swabs are collected for the state crime laboratory kit. The
SANE looks at the cervix and vaginal wall with the aid of the colposcope and photographs any injured
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areas. The SANE will view the vaginal walls as the speculum is removed from the vagina, assessing for
injury.
If there was penile rectal penetration 4 swabs are moistened with saline (2 at a time) and inserted just into
the anus and then placed into the state crime laboratory envelope labeled “rectal”. An exam with an
anoscope is performed to assess for injury. Colposcope photos are taken if injury is noted.
Pubic combings are obtained if the patient has pubic hair. The white paper from the pubic combing
envelope is placed under the patient’s buttocks and the pubic hair is lightly combed in search of pubic hairs
that may have been left by the assailant. The comb and white paper are wrapped in the pubic combing
state crime laboratory envelope. If the patient is shaved a visual inspection is made for any loose pubic
hairs which would be placed in the white paper and put in the pubic combing envelope if found.
If indicated, fingernail scrapings may be obtained if there is a possibility the victim scratched the assailant.
These swabs are placed in the miscellaneous state crime laboratory envelope.
A copy of the Sexual Offense Medical Report is printed from the computer and enclosed in the crime
laboratory box.
The SANE will fill out the Sexual Assault Chain of Evidence Form that accompanies the evidence to lab.
Toxicology Drug Testing for Suspected Drug Facilitated Sexual Assault (DFSA)
1. If the possibility exists of a drug being given to a victim to aid in a sexual assault, a drug facilitated rape
panel should be obtained for the state crime laboratory. Feeling intoxicated when no or minimal alcohol
was ingested, or an episode of amnesia and uncertainness regarding the assault are indications of
possible drug ingestion.
2. Both urine and blood should be obtained in cases of suspected DFSA up to 72 hours after assault.
3. The SANE will obtain a urine sample from the patient as soon as possible since the drugs are metabolized
very quickly. A DUI urine kit is used for this. The paperwork in the kit is filled out by the SANE and the
state crime laboratory is instructed that the urine is to be tested for a date rape panel. The urine container
is labeled and sealed with evidence tape or the label provided in the kit. The box is sealed with evidence
tape with the SANE’s initials, date and time.
4. The SANE will obtain a blood sample from the patient using the DUI blood kit. The skin is cleansed with a
non-alcohol solution prior to the blood draw. 2 gray top tubes are included in the blood DUI kit. The
paperwork in the kit is filled out with an indication to the state crime laboratory that a date rape panel is to
be ordered. The tubes are labeled with the patient’s name, SANE initials, date and time. The kit is sealed
with evidence tape with the SANE’s initials, date and time. If the SANE is unable to draw the blood an ER
nurse or phlebotomist from lab can be asked for assistance. The person who draws the blood must initial
the blood tubes.
5. The DUI blood and urine kits are listed on the Sexual Assault Chain of Evidence Form and taken to lab
with the other evidence.
Sample Handling And Storage
1. Individual state crime laboratory envelopes may be sealed with water, sterile saline, or a patient label. The
state crime laboratory envelopes are placed in the state crime laboratory box along with a copy of the
Sexual Assault Report printed from the computer. The box is then sealed with evidence tape which
includes the SANE’s initials, date and time. The patient’s name, SANE ‘s name, and police case number
are printed on the outside of the box.
2. Clothing collected as evidence is placed in a paper bag with a patient label and sealed with evidence tape.
Only 1 piece of clothing is placed in each bag. Contents of the bag are written on the bag. (i.e. pink
panties).The evidence tape is labeled with the SANE’s initials and the date and time of collection. The
SANE may place her initials on the clothing label to help identify it, although this is not mandatory. The bag
may be stapled for extra security. This is especially helpful if a large item is placed in a bag.
3. Digital photographs are downloaded onto a CD which is labeled with the patient’s name, SANE initials,
date and time. The CD is placed in a manila envelope with a patient label with SANE initials, date and
time.
4. Clothing, state crime laboratory kit, hospital labs, DUI blood and urine kits, and digital CD or 35 mm film
are taken to the lab to be logged in as evidence. All of these items are listed on the Sexual Assault Chain
of Evidence Form which is also taken to the lab. The lab tech will check to make sure that everything is
properly labeled and will take custody of the evidence and sign the form.
5. Police agencies may accompany the SANE to lab to take custody of the evidence after it has been logged
in by lab personnel and then signed out by police. Police may not take the evidence directly from the
SANE.
6. Typically, the lab calls the appropriate police agency listed on the Chain of Evidence form the next day
and requests that the police pick up the evidence. If the patient has not reported the assault and there is
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no case number the lab will hang onto the evidence for 3 months. After that time it may be destroyed by
lab.
SO Pregnancy Prevention
1. Pregnancy prevention should be offered to all patients 13-50 years old, unless they have had a
hysterectomy, tubal ligation, are currently getting the depo provera shot, or have virtually no risk of
pregnancy.
 Plan B (levonorgestrel)) is offered: Two tablets (0.75 mg) po within 120 hours of vaginal intercourse.
 Patients are informed of the risks and benefits of Plan B.
 If the patient refuses Plan B the reason should be documented in the chart.
SO STD Prophylaxis
1. Prophylactic treatment of G.C. and Chlamydia should be offered to all sexual assault patients.
2. Patients are advised that they are not being treated for all STD’s and need to follow up with a medical
appointment in the next week.
 Treatment
1. Vantin 200 mg po x 1 and Azithromycin 1 g po x 1 are the most commonly used.
2. Alternative medications may be given if the patient is allergic to these medications.
HIV Risks
1. Every patient will have their risks for HIV discussed with them.
2. The risks of HIV infection are typically very low. The incidence of HIV in the metro area is 0.2%.
3. Risks of HIV infection increase with:
 Multiple assailants
 Known HIV positive assailant
 Anal penetration
 Vaginal or anal tears from the sexual assault
 Significant exchange of body fluids from an assailant of unknown HIV status
 Presence of genital lesions on either the victim or assailant
 Assailants from high risk groups such as homosexual or bisexual men, IV drug abusers, or assailants
from an area or country with a high incidence of HIV
4. Patients may receive prescriptions for HIV prophylaxis if they wish, even if the risk is deemed low.
5. HIV prophylaxis is most effective when initiated as soon as possible and definitely within 72 hours of
assault.
6. A prescription for a 3-5 day supply of Combivir is given to the patient for low risk exposures. If the risk is
higher a 3-5 day prescription for both Combivir and Kaletra may be given. The patient must be made
aware that the meds must be taken for 28 days and that close follow up is done by the ID clinic.
7. The cost of these medications is not covered by the counties like the sexual assault exam. The patient
may use their insurance. If the patient has no insurance the financial counselors may be able help the
patient apply for medical assistance if they qualify. There is currently no charity fund to assist in paying for
these medications so the patient will have to pay cash if they have no insurance or do not qualify for
medical assistance.
8. The patient is referred to infectious disease clinic for follow up and any further prescriptions for the rest of
the month.
9. All sexual assault victims are given a schedule for recommended HIV testing with their discharge
instructions.
ED Evaluation
1. If injuries or mental health concerns need to be addressed after the SANE exam is complete the SANE will
return care back to the ED.
2. Report will be given to the primary nurse, ER physician and Crisis social worker if needed.
3. If the patient is intoxicated and it is unclear if they are safe to be discharged care is returned to the ED.
Social Work involvement with Sexual Assault survivors
1. When a survivor of sexual abuse is treated in the ED, the SANE will contact the ED social worker when
certain concerns arise.
2. The SANE or rape crisis center advocate may consult with the social worker about the patient and may
refer the patient to the social worker at any time.
 Examples of patient situations that might require social work intervention:
1. Patients with suicidal thoughts
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2. Extremely violent or traumatic rapes
3. Evidence of poor coping by patient or family
Discharge
1. The rape crisis center advocate will refer the patient for counseling regarding the sexual assault if the
patient consents.
2. Safety issues are discussed with the patient. If the patient feels unsafe to return home the rape crisis
center will help obtain a temporary shelter or a hotel room for a night.
3. Discharge instructions are discussed with the patient including advice for follow up within a week, HIV
testing and symptoms to watch for in the next few days.
4. Each patient will receive a record of medications received in the ED and will be encouraged to follow up
for medical care within a week. Rape Crisis will refer the patient to a clinic with experience in dealing with
sexual assault victims if the patients prefers.
Mandated Reporting of Vulnerable adults
1. Social work MUST be consulted in cases of vulnerable adults. This is a mandatory report to the county.
Social Work is the discipline that coordinates this process.
2. Patients who fit the legal definition of "vulnerable adult" are:
 Patients living in group homes, nursing homes, board and care, etc. or who were raped while in a
hospital. NOTE exception: When victim/perpetrator is an in-patient on a mental health floor, the mental
health staff will provide follow-up counseling and will do the mandatory reporting.
 Patients who receive services at or from a facility that is required to be licensed (e.g. home health
care, PT, etc)
 Patients who possess a physical or mental infirmity or other physical, mental, or emotional dysfunction
which:
 impairs the ability to provide adequately for her own basic needs and,
 because of the dysfunction or infirmity and the need for assistance, have an impaired ability to
protect self from harm
ENDORSEMENT : ED Administration, SANE Program
APPROVAL(S) :
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