Impact of sexual assault nurse examiners on the evaluation of sexual assault in a pediatric emergency department.
BACKGROUND
Nearly 44% of sexual assault victims in the United States are younger than 18 years. These victims often present to emergency departments for care after the assault. To date, the effectiveness of sexual assault nurse examiners (SANEs) on the evaluation and management of pediatric and adolescent sexual assault victims in a pediatric emergency department (PED) has not been evaluated.


OBJECTIVE
To evaluate whether the use of SANEs in a PED improves the medical care of pediatric and adolescent sexual assault victims.


METHODS
Medical records of patients who presented to an urban PED with a history of sexual assault and required forensic evaluation (rape kit) from December 2004 to December 2006 were reviewed in a retrospective, blinded fashion for the following documentation: (1) the genitourinary (GU) examination and if a GU injury was present; (2) evaluation for sexually transmitted infections (STIs) (Neisseria gonorrhoeae and Chlamydia trachomatis), and serologies for hepatitis B and C, HIV, and VDRL; (3) prescription of prophylaxis for STIs, HIV, and pregnancy; (4) evaluation by a PED social worker; and (5) referral to sexual assault crisis services. Patients were grouped as to whether a SANE had been involved in their care. The assignment of a patient to a SANE was random, as SANEs in the PED of this institution do not take call from home and are present in the PED as part of their routine nursing shift. To examine the differences between groups, chi analysis or Fisher exact test was used.


RESULTS
Of the 114 patients whose medical records were reviewed, 60 had been evaluated by a SANE (SANE), and 54 patients had not (SANE); 98% of patients were girls. There were no differences between the 2 patient groups with respect to time of day when they presented to the PED, time after assault to presentation to the PED, sex, age, or race. All medical records had the history of the sexual assault documented in the medical record. Patients evaluated by a SANE were more likely to have the GU examination documented (71% vs 41%; P < 0.001) and to have GU injury documented (21% vs 0%; P = 0.024). Eligible patients were more likely to have testing for N. gonorrhoeae and C. trachomatis (98% vs 76%; P < or = 0. 001), and serologies for hepatitis B and C (95% vs 80%%; P = 0.03) and HIV (93% vs 72%; P = 0.03) when a SANE had been involved in their care. There were no significant differences between groups with respect to obtaining serology for VDRL. There were no significant differences between groups with respect to provision of prophylaxis for N. gonorrhoeae, C. trachomatis, or HIV. Significantly more patients were prescribed prophylaxis for pregnancy by a SANE (85% vs 64%; P = 0.025). Although there were no significant differences between groups with respect to an evaluation by a PED social worker, significantly more patients in the SANE group were referred to the Rape Crisis Center for support and counseling (98% vs 30%; P < 0.001).


CONCLUSIONS
Many more patients who had been sexually assaulted received STI testing, pregnancy prophylaxis, and referrals to the Rape Crisis Center when a SANE was present for the evaluation in the PED. Even with a SANE providing medical care, not all eligible patients had medical record documentation of the GU examination or that they received appropriate STI testing or STI and HIV prophylaxis. Ongoing quality assurance in programs that use SANEs is needed to ensure optimal medical evaluation of children and adolescents with sexual assault.
Bechtel
Kirsten
K
Department of Pediatrics, Yale University School of Medicine, and Section of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT 06504, USA. Kirsten.bechtel@yale.edu
Ryan
Elizabeth
E
Gallagher
Deborah
D
D000293:Adolescent; D000328:Adult; D002648:Child; D002650:Child Abuse, Sexual / Q000175:diagnosis*; D002675:Child, Preschool; D003376:Counseling; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D053604:Forensic Nursing / Q000379:methods*; D006801:Humans; D008297:Male; D009730:Nursing Assessment / Q000379:methods*; D010372:Pediatrics; D011785:Quality Assurance, Health Care / Q000379:methods*; D012189:Retrospective Studies; D012749:Sexually Transmitted Diseases / Q000175:diagnosis