Research
The Impact of a Sexual Assault/Domestic Violence Program on ED Care

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Introduction

Examination and management of the sexually assaulted patient comprise a complex task. On-call nurses with advanced training are used in some hospitals, but their impact on patient care and appropriate forensic examination is largely unknown. We evaluated the impact of the introduction of a sexual assault/domestic violence program (SADVP) on ED flow, comprehensive patient care, and collection of forensic evidence.

Methods

Patients presenting to the 2 emergency departments in the Kingston area (Ontario, Canada) (population, 250,000) after sexual assault were compared during 2 time periods: (1) before SADVP implementation (January 2001 through August 2004) and (2) after SADVP implementation (September 2004 to August 2006). ED, hospital discharge, SADVP, and police records were reviewed. Data abstraction included patient demographics, assault characteristics, forensic examination results, and treatment protocols.

Results

The incidence of patients presenting with a complaint of sexual assault doubled (61 cases before SADVP implementation and 92 cases after SADVP implementation). Median times to initial clinical evaluation were lower in the post-SADVP group (20 minutes vs 33 minutes, P = .04). Patients in the post-SADVP group reported less vaginal/anal penetration (77% vs 98%, P < .001) and had fewer genital injuries (13% vs 39%, P = .007); other sexual assault characteristics were similar between the 2 study periods. Forensic kits were completed more often in the post-SADVP group (77% vs 66%, P = .18). Pregnancy and sexually transmitted disease prophylaxis was offered more consistently after SADVP implementation (98% vs 85%, P = .007), as was counseling (100% vs 95%, P = .06).

Discussion

The profile of patients observed after SADVP implementation changed to include less stereotypical sexual assaults. Introduction of the SADVP decreased wait times for sexually assaulted patients, despite the need for the on-call nurses to attend the emergency department. This program also showed higher completion on a number of important indicators of quality of care: forensic kits, counseling, and pregnancy and sexually transmitted disease prophylaxis.

Section snippets

Overview

We retrospectively examined charted characteristics of sexual assault patients presenting to academic emergency departments in Kingston before (January 2001 to August 2004) and after (August 2004 to August 2006) implementation of the SADVP. The cohort of patients in the pre-SADVP time frame was chosen to maximize the number of patients seen for comparison purposes by use of the most current version of the ED chart, introduced in January 2001.

Setting

Kingston is a city in Eastern Ontario, Canada, with a

Patient and Assault Characteristics

We identified 61 patients reporting sexual assault in the pre-SADVP phase (approximately 1 per month) compared with 92 patients in the post-SADVP phase (approximately 2 per month). All 92 patients in the post-SADVP phase were women, whereas 3 of 61 patients (5%) in the pre-SADVP phase were men. Patient characteristics are further described in Table 1. No significant differences were observed between the patient groups in terms of age, relationship with assailants, number of assailants, weapon

Discussion

The introduction of the SADVP in Kingston resulted in improvements in key areas of clinical care. Pregnancy and STD prophylaxis was given almost universally in the post-SADVP group, which improved upon the high standard of care seen in the pre-SADVP group. The US national averages for provision of STD prophylaxis and pregnancy prophylaxis range from 29.6% to 60% and 7.4% to 20%, respectively.12, 13 The baseline provision of both STD and pregnancy prophylaxes before the introduction of the SADVP

Limitations

One limitation in the pre-SADVP arm of our study is the reliance on presenting complaint and discharge diagnosis for the identification of sexually assaulted patients, which may not be documented and coded, respectively, for their ED stay. In an attempt to reduce the impact of this potential area of error, additional charts were identified by use of the broader search term of “assault.” Abstraction of time to patient contact from the medical record has its limitations, including human error

Implications for Emergency Nurses

This study shows that a primarily nursing-based adjunct ED program improves the quality of care provided to victims of sexual assault. It initially appears counterintuitive that wait times would be decreased in a call-in based service, but rather, the decrease seen in the SADVP on-call group reflects the reality that ED overcrowding and bed blocking are the rate-limiting steps in the initiation of assessment and treatment of patients. Forensic sexual assault examinations are lengthy in nature,

Conclusions

After the introduction of the SADVP, more patients were seen with a shift to include less stereotypical sexual assaults. Decreased wait times were observed for sexually assaulted patients, despite the need for the on-call nurses to attend the emergency department. ED flow is improved through the use of dedicated nursing staff and examination facilities. This program also showed higher completion for a number of important indicators of quality of care, including provision of pregnancy and STD

Kari Sampsel, Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada.

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Kari Sampsel, Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada.

Luke Szobota, School of Medicine, Queen’s University, Kingston, Ontario, Canada.

Donna Joyce, Manager, Sexual Assault Domestic Violence Program, Queen’s University, Kingston, Ontario, Canada.

Karen Graham, Assistant Professor, Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada.

William Pickett, Associate Professor, Departments of Emergency Medicine and Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada.

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