For sexual abuse, take steps to protect children
Do’s and don’ts can make or break case
It’s heartbreaking when a child comes to the ED as a result of sexual abuse — but how would you feel if something you did helped the perpetrator to go unpunished? Offering the child juice or asking what happened to them may seem helpful, but these seemingly innocent actions can make it impossible for an offender to be prosecuted, says Sheila Prynkiewicz, RN, ADN, SANE, clinical nurse coordinator for the pediatric ED at Medical University of South Carolina in Charleston.
Most EDs don’t have access to pediatric sexual assault nurse examiners (SANEs), so this means that you’ll need to know how to protect evidence before law enforcement arrives, says Prynkiewicz. "There are not many adult SANEs, and pediatric SANEs are even fewer," she says. "There are very few programs of this nature."
To improve care of pediatric sexual assault victims, use these tips from two SANE nurses:
• Don’t question the child about the assault.
"The worst thing a nurse could do is question the child or caregiver inappropriately," says Debbie Kleypas, RN, SANE CA/CP, SANE-A, coordinator for the sexual assault program at Scott & White Hospital & Clinic in Temple, TX. "It is very important that children do not have to repeat their story over and over" so that emotional trauma to the child is minimized, she says.
The physical evaluation and genital assessment should be performed by specially trained physicians or nurses, says Kleypas. At Scott & White, these steps occur when there is a concern about abuse:
— The ED triage nurse assesses the patient for life-threatening injuries and reports concerns about abuse to the charge nurse.
— The charge nurse reports concerns to a physician and social worker for further assessment.
— If the assessment substantiates abuse or safety risks for the child, the SANE nurse on call is notified, and he or she coordinates with child protective services and law enforcement.
Triage nurses should get the basics from the parents or caregivers, but not in front of the child, says Prynkiewicz. If sexual abuse is suspected, determine what occurred, when and where it happened, the identity of the alleged offender, and whether the police were notified, she adds.
Don’t ask leading questions such as, "Did someone take your clothes off and make you touch his privates?" she says. Instead, simply ask, "Do you know why are you coming to the ED today?" advises Prynkiewicz.
"I ask this question at triage for several reasons," she says. "Most kids answer, To see the doctor,’ and that allows me to prepare them for a basic medical screening exam. Sometimes that same question elicits children to tell you what happened without ever asking a direct question about the alleged incident. Children can be very forthcoming with information."
• Notify the appropriate police department if no report has been filed.
If the ED is notifying the police, be sure to determine the address of the location of the alleged incident, Prynkiewicz advises. "The report is filed with the police in the district of where the alleged incident took place," she explains. "Knowledge of the address makes everything easier in the long run."
If the incident happened far away, such as another county or state, the appropriate officer in the correct district can give the nurse a case number over the phone while en route to the ED, Prynkiewicz says. "In our hospital program, the ED nurse makes certain there is a case number prior to notifying the pediatric sexual assault team."
Pamela Smith, BSN, RN, clinical operations coordinator of the pediatric SANE program, says they want to ensure that the legal system has been accessed when a forensic exam is indicated. "It can become sticky when the parent doesn’t want to press charges unless there is proof of assault, and we can’t do the exam to prove the assault unless we have a case number."
• Know what to document.
Document what police department was notified, the name of the detective, the time the assault team was notified, and documentation of the patient’s transfer if needed, says Prynkiewicz. "These simple things will demonstrate the ED nurse being the advocate for the patient," she says.
Don’t identify the perpetrator in the patient’s chart unless you are certain of the correct individual’s identify, warns Prynkiewicz. She points to a case where there was a discrepancy between the police report, advocacy group report, and SANE report. "One half had the uncle’s friend’ identified, and the other half had uncle’ labeled as the alleged offender," she says. "The discrepancy was discovered in court, and that fumbled detail eventually lost the case for the prosecution."
• Don’t give fluids.
When a child recently came to Scott & White’s ED after an acute sexual assault, nurses gave her apple juice while the examiner was on their way.
"When the examiner arrived to do the exam, the child revealed the alleged offender forced her to perform oral sex and that he ejaculated in her mouth," says Prynkiewicz. "Unfortunately, the juice washed out the DNA and potential sperm."
Sources
For more information on pediatric sexual abuse, contact:
- Debbie Kleypas, RN, SANE CA/CP, SANE-A, Coordinator, Sexual Assault Program, Scott & White Hospital & Clinic, 2401 S. 31st St., Temple, TX 76508. Telephone: (254) 724-8296. E-mail: [email protected].
- Sheila M. Prynkiewicz, RN, SANE, Clinical Nurse Coordinator, Pediatric Emergency Department, Medical University of South Carolina, 169 Ashley Ave., Charleston, SC 29425. Telephone: (843) 792-1269. Fax: (843) 792-1307. E-mail: [email protected].
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