To verify that the chain of custody was maintained, several items must be signed or initialed by both the provider and the law enforcement officer who receives the kit:
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The evidence log sheet. This should be included in the original kit (see Figure 2 for a sample). It should be removed from the kit, completed, and affixed to the outside of the kit before the kit is sealed. A copy of this log should be kept attached to the patient chart.
•
The evidence kit itself. The lid bears a form to be completed by the practitioner.
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The components of evidence other than the kit (ie, clothing bags, sterile specimen cups containing collected specimens). These bear labels, preprinted with the patient’s name, date of birth, and medical record number, which are signed by the practitioner.
TREATMENT AND
PROPHYLAXIS
The likelihood for a sexual assault victim to have contracted an STI is 26.3%.3 Current recommendations from the CDC,4 including postexposure vaccination against hepatitis B, must be followed for prevention of and treatment for STI. Prophylactic treatment for gonorrhea, chlamydia, and trichomonas should be offered to all victims of sexual assault, as cultures are not taken until patient follow-up at the primary care provider’s office or the county health department.4 Prophylactic treatment for hepatitis B or HIV may be discussed with the patient; he or she must be fully informed about the rigorous follow-up treatment regimens required, as well as the associated adverse effects.
According to the CDC,4 baseline test results for HIV, hepatitis B, and syphilis may be negative, but antibodies can develop over time; thus, reexamination with re-testing should be performed at three months, six months, and 12 months postassault.
Progestin-only emergency contraceptive tablets should be offered through 72 hours postassault to all female sexual assault victims with a negative pregnancy test result in the ED.14
Julie was treated with intramuscular ceftriaxone 250 mg for prevention of gonorrhea, azithromycin 1 g by mouth for prevention of chlamydia, and progestin for pregnancy prevention. She had undergone the hepatitis B vaccination series as a child and had a positive titer drawn before the current school year. Julie declined prophylaxis for HIV because she felt the suspect was at low risk for HIV; however, she was encouraged to undergo HIV testing at her follow-up visit at the local health department.
FOLLOW-UP
Follow-up counseling is a vital component of care for the victim of sexual assault. The police will arrange to ensure the patient’s safety at home before he or she is discharged. A victim of sexual assault should never be discharged if suicidal ideation is evident; in this case, a psychiatry consult must be arranged. For survivors of sexual assault who reside in remote or rural areas, treatment via videoconferencing-based technology has been shown to reduce measures of depression and posttraumatic stress.15
Information regarding rape crisis services should be provided before patients are discharged; the advocate present during the exam should be familiar with services offered in the area. These centers offer emotional support, helpful medical and legal information, and post-rape counseling.7
CONCLUSION
Although the ED is ordinarily the first medical entry point for a sexual assault victim, clinicians in other settings, too, must be prepared to offer medical care to these patients and collect forensic evidence appropriately. Comprehensive care of a sexual assault victim must be completed in a timely and sensitive manner, with documentation that can withstand the exacting requirements of the court system.
REFERENCES
1. Sampsel K, Szobota L, Joyce D, et al. The impact of a sexual assault/domestic violence program on ED care. J Emerg Nurs. 2009;35(4): 282-289.
2. Patel A, Panchal H, Piotrowski ZH, Patel D. Comprehensive medical care for victims of sexual assault: a survey of Illinois hospital emergency departments. Contraception. 2008;77(6):426-430.
3. Straight JD, Heaton PC. Emergency department care for victims of sexual offense. Am J Health Syst Pharm. 2007;64(17):1845-1850.
4. CDC. Sexually transmitted disease treatment guidelines, 2010: sexual assault and STDs (2010). www.cdc.gov/std/treat ment/2010/sexual-assault.htm. Accessed November 26, 2012.
5. Stermac L, Dunlap H, Bainbridge D. Sexual assault services delivered by SANEs. J Forensic Nurs. 2005;1(3):124-128.
6. Plichta SB, Clements PT, Houseman C. Why SANEs matter: models of care for sexual violence victims in the emergency department.
J Forensic Nurs. 2007;3(1):15-23.
7. National Criminal Justice Reference Services. A national protocol for sexual assault medical forensic examinations: adults/adolescents (2004). www.ncjrs.gov/pdffiles1/ovw/206554.pdf. Accessed November 26, 2012.
8. Burgess AW, Hazelwood RR. Victim care services and the Comprehensive Sexual Assault Assessment Tool (CSAAT). In: Hazelwood RR, Burgess AW, eds. Practical Aspects of Rape Investigation: A Multidisciplinary Approach. 4th ed. Boca Raton, FL: CRC Press; 2009:47-68.