National Protocol – Operational Issues – Facilities

Recommendations at a glance to build the capacity of health care facilities to respond to sexual assault cases:

• Recognize the obligation of health care facilities to serve sexual assault patients in a culturally and linguistically appropriate manner.
• Ensure that exams are conducted at sites served by examiners with advanced education and clinical experience, if possible.
• Explore possibilities for optimal site locations.
• Communities may wish to consider developing basic requirements for designated exam sites.
• If a transfer from one health care facility to a designated exam site is necessary, use a protocol that minimizes time delays and loss of evidence and addresses patients’ needs.

Recognize the obligation of health care facilities to serve sexual assault patients in a culturally and linguistically appropriate manner.¹

It is essential that all sexual assault patients who present to health care facilities be thoroughly evaluated. Treating injuries alone is not sufficient in these cases. Staff who examine these patients must be educated and clinically prepared to collect evidence and document findings while maintaining the chain of custody. They should be able to coordinate crisis intervention and support for patients, as well as provide STI evaluation and care, pregnancy assessment, and discuss treatment options. They must be aware of and follow jurisdictional reporting policies, and be able to provide court testimony if necessary.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)² requires emergency and ambulatory care facilities to have established policies for identifying and assessing possible victims of sexual assault. It also requires staff to be trained on these policies. As part of the assessment process, JCAHO requires these facilities to define their responsibilities related to the collection and preservation of evidentiary materials.³ Sexual assault examiner programs are helping many health care facilities to carry out these requirements. Facilities should also familiarize themselves with the federal Emergency Medical Treatment and Active Labor Act (EMTALA), which has provisions pertaining to the ability of hospitals to turn away patients with emergency medical conditions.⁴

Ensure that exams are conducted at sites served by examiners with advanced education and clinical experience, if possible.

Some jurisdictions designate specific facilities as exam locations because they employ or have ready access to specially educated and clinically prepared examiners, as well as the necessary space, equipment, supplies, and policies to facilitate the exam process. Jurisdictions may rely on examiner programs to serve multiple exam sites within a specific area. ⁵ Communities can benefit from designated exam facilities and examiner programs that use specially educated and clinically prepared examiners to conduct the exam because they:

• Increase the quality of care for patients and attention to their needs.
• Increase the likelihood of a state-of-the-art examination.
• Enhance a coordinated team approach.
• Encourage quality control (e.g., through use of competent and dedicated examiners, established
  procedures for evidence collection, and standards for medical care).

Explore possibilities for optimal site locations.

SART/SARRTs (or involved agencies) should determine where exams should be conducted. Some factors to consider when identifying sites include safety and security for patients and staff, physical and psychological comfort for patients, capacity to accommodate victims with disabilities,⁶ availability of examiners with advanced education and clinical experience, access to a pharmacy for medication, access to medical support services for care of injuries, access to lab services, and access to the supplies and equipment needed to complete an exam.⁷ Decisions about site location should reflect the needs of victims (e.g., for accessible care close to their home and local referrals), what is most efficient for the multidisciplinary response team, and the need to maintain the neutrality and objectivity of examiners (e.g. if the site location is at a rape crisis center, it may be seen as biased against the offender). Designated facilities may be in hospitals, health clinics, mobile health units, or other alternative sites, including family justice centers⁸ or nonprofit sexual assault victim services programs.⁹ The majority of medical forensic exams are conducted in hospital emergency departments. This location typically offers some level of security, is open 24 hours a day, and provides access to a wide array of medical and support services. Clinical staff often have the experience and expertise to perform the exam and collaborate with appropriate disciplines. Some jurisdictions have or are developing specialized hospital or community-based examiner programs.¹⁰

SART/SARRTs may need to decide whether a tribal, local, regional, or state/territorial system of designated facilities best serves community needs. Some issues that might impact this decision include community demographics and geography; the need for and availability of specialized services; availability of local health care facilities; local capacity to secure competent examiners and necessary space, equipment, and supplies; willingness of involved disciplines to coordinate with a local facility or examiner program; distance to/from tribal, regional, or state/territorial facilities; and service capacity of tribal, regional or state/territorial facilities.
Communities are encouraged to first consider using local designated exam sites. However, some may ultimately opt for tribal-, regional- or state/territorial-level facilities. For example, a small state, tribe, or sparsely populated region may establish one or more designated facilities to serve all of its localities. Exam facilities and examiners that serve at the local level may benefit from networking with examiners in other facilities or areas for support for peer review of medical forensic reports, quality assurance, and
information sharing (e.g., on training opportunities, practices, and referrals for patients).

Table of Contents

Exam site basic requirements

 

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¹ This and the next paragraph were drawn from L. Ledray, Evidence Collection and Care of the Sexual Assault Survivor: The SANESART Response, 2001, p. 1. ² JCAHO standards for accreditation address a health care organization’s level of performance in specific areas—not just what the organization is capable of doing, but what it actually does. The standards set forth maximum achievable performance expectations for activities that affect the quality of care. These standards are developed in consultation with health care experts, providers, measurement experts, purchasers, and consumers, and usually are updated every 2 years. (Drawn from http://www.jointcommission.org/standards_information/standards.aspx). ³ The JCAHO requirements are discussed at http://www.mincava.umn.edu/documents/commissioned/2forensicevidence/2forensicevidence.html.
⁴ 42 U.S.C. § 1395dd. See http://www.emtala.com for more information about EMTALA. ⁵ A mobile examiner program may be based in a health care facility—in addition to providing services at that facility, it also may contract with other exam sites to provide services as requested. Such a program may also be independent, with administrative offices only, and solely contract with exam sites to provide examiner services.
⁶ Title II and Title III of the Americans with Disabilities Act explains requirements for facilities in accommodating persons with disabilities (which may vary depending on the type of facility). Title II prohibits discrimination against persons with disabilities in all programs, activities, and services of public entities. Title III requires places of public accommodation to make reasonable modification in their policies, practices, and procedures in order to accommodate individuals with disabilities. See http://www.ada.gov/ for related information and resources.
⁷ Drawn from L. Ledray, SANE Development and Operation Guide, 2000, pp.35–36.
⁸ Particularly on tribal land that is devoid of or a significant distance from a hospital, and the tribe is serviced by an Indian Health Service (IHS) facility; consideration should be given to securing and maintaining examiners and necessary space, equipment, and supplies to conduct these exams. Ideally, all IHS facilities should have examiners and a minimum standard for examiner training. 9 For more information on the President’s Family Justice Center Initiative, see https://www.justice.gov/ovw. ¹⁰ The pros and cons of developing hospital versus community-based examiner programs are discussed in more detail in L. Ledray’s SANE Development and Operation Guide, 2000, pp.35–9; L. Ledray’s Sexual Assault: Clinical Issues, SANE Program Pros and Cons, Journal of Emergency Nursing, 23(2), p.183; and in K. Littel’s SANE Programs: Improving the Community Response to Sexual Assault Victims, pp.10–11.