Suggested clinical pathway - Offering medical and forensic responses to sexual assault in the context of COVID-19

During the COVID-19 pandemic, it is important that NSW Health services continue to identify and respond to violence, abuse and neglect, and avoid any disruption to the provision of specialist medical and forensic services. However, some modifications to practice may be helpful to minimise time spent in emergency departments, and to ensure compliance with COVID-19 infection prevention and control protocols.

This clinical pathway is provided as optional guidance to districts/networks to assist in service planning in the context of COVID-19. The pathway will require variation based on local circumstances and the changing risk profile of COVID-19. Sexual Assault Services should:

  • refer to their district/network’s approved checklist for identifying risk factors for COVID-19
  • check regularly for local processes and procedures for management of COVID-19 cases and risks
  • check regularly for possible PPE supply issues in their district/network.

All Sexual Assault Services (SAS) staff (psychosocial and medical and forensic) who respond to COVID-19 positive patients must have had practical personal protective equipment (PPE) training. Where possible SASs may consider having designated medical and forensic examiners* and counsellors in the SAS who are competent with PPE to respond to COVID-19 positive patients.

In addition to this clinical pathway, SASs may wish to develop telehealth pathways for psychosocial support.

This clinical pathway sits within a broader set of advice and guidance regarding responses to violence, abuse and neglect during COVID-19.

*Note: throughout this document, the term “medical and forensic examiner” or “examiner” includes both examiners who are doctors and Sexual Assault Nurse Examiners (SANEs).

On this page

Definitions

Low risk patient (Green)

No risk factors for COVID-19, plus no fever and no acute respiratory infection symptoms.

High risk patient (Red)

Confirmed, probable or suspect COVID-19 case as per Local Health District definitions (Note: see also Commonwealth definitions and current NSW testing criteria for COVID-19)

Vulnerable patient or health worker

(ie: a patient or health worker who may be at higher risk of serious illness if they contract COVID-19)

A patient or health worker who meets one or more of the following criteria: 1

  • Aboriginal and Torres Strait Islander person 50 years and older with one or more chronic medical conditions
  • people 65 years and older with chronic medical conditions
  • people 70 years and older
  • people with compromised immune systems (see Department of Health​)
  • people who are pregnant 2

List of chronic medical conditions for consideration: 3

  • chronic renal failure
  • coronary heart disease or congestive cardiac failure
  • chronic lung disease (severe asthma (for which frequent medical consultations or the use of multiple medications is required), cystic fibrosis, bronchiectasis, suppurative lung disease, chronic obstructive pulmonary disease, chronic emphysema)
  • poorly controlled diabetes
  • poorly controlled hypertension

List of significant causes of immunosuppression: 4

  • Haematologic neoplasms: leukemias, lymphomas, myelodysplastic syndromes
  • post-transplant: solid organ (on immunosuppressive therapy), haematopoietic stem cell transplant (within 24 months or on treatment for GVHD)
  • Imunocompromised due to primary or acquired immunodeficiency (including HIV infection)
  • current chemotherapy or radiotherapy
  • high-dose corticosteroids (≥20 mg of prednisone per day, or equivalent) for ≥14 days
  • all biologics and most disease-modifying anti-rheumatic drugs (DMARDs):
    • Azathioprine >3.0 mg/kg/day
    • 6-Mercaptopurine >1.5 mg/kg/day
    • Methotrexate >0.4 mg/kg/week
    • Tacrolimus (any dose)
    • Cyclosporine (any dose)
    • Cyclophosphamide (any dose)
    • Mycophenolate (any dose)
    • combination (multiple) DMARDs irrespective of dose.

Notes

  1. Taken from Australian Health Protection Principal Committee recommendations:
  2. There is limited evidence at this time regarding the risk in pregnant women.
  3. Source: Factors that increase the risk of serious illness from COVID-19
  4. Source: Factors that increase the risk of serious illness from COVID-19

Pathways at glance

Follow Pathway A for a patient yet to present to an emergency department. Follow Pathway B for a patient in an emergency department that does not have a SAS or COVID-19 treatment zone. Follow Pathway C1 for a patient in an emergendy department that has an SAS, where the patient is at low risk of COVID-19 and no community transmission is present in the LGA. If community transmission is occuring in LGA, follow Pathway C2. For patients with suspected or confirmed COVID-19, use Pathway C3.

Patient in ED in a Health facility

Patient in ED in a Health facility
Follow Pathway A. Patients not yet in the Emergency Department
Follow Pathway A. Patients not yet in the emergency department

Patient not in ED

Patient not in ED
Patient at an ED with a SAS
Patient at an ED with a SAS
Patient at an ED without a SAS or a hospital without a COVID-19 treatment zone
Patient at an ED without a SAS or a hospital...
Low risk (Green) patient: No risk factors for COVID-19 + no respiratory symptoms + no unexplained fever
Low risk (Green) patient: No risk...
High risk (Red) patient: Suspected or confirmed COVID-19 case
High risk (Red) patient: Sus...
Follow Pathway B. Patients who present to
an ED without a SAS or without a COVID-19 treatment zone

Develop local pathways to safely transfer high
risk (red) patients to an appropriate SAS or to establish a temporary COVID-19 treatment
zone.
Follow Pathway B. Patients who present to...
No community transmission in LGA
No community transmissi...
Community transmission in LGA
Community transmissi...
Follow Red Pathway C3
Contact and droplet precautions, social distancing
Follow Red Pathway C3...
Follow Green Pathway C1Follow Green Pathway...
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Pathway A: Patients not yet in the emergency department

Where a patient contacts the SAS by phone regarding a medical and forensic consultation, but has not yet presented to an emergency department, in addition to usual intake and screening processes consider:

  • screen the patient for COVID-19 risks and vulnerabilities (see definitions of risk and vulnerability in the definitions table above)
  • if neither are present, the patient can present to ED as usual
  • if COVID-19 risks are present, a SAS worker should liaise with the examiner and with ED prior to the patient attending.
  • if vulnerabilities are present:
    • the SAS worker is to involve the medical and forensic examiner in the consultation
    • the SAS worker and examiner are to do a joint risk assessment/triage for urgent mental and physical health needs
    • the examiner is to assess eligibility for a medical and forensic examination.
    • If the patient expresses concerns about attending a Health facility due to COVID-19, the examiner should discuss with the patient the risks and benefits of attending a hospital for a medical and forensic consultation, and any risks of delaying the medical and forensic response, to ensure they are able to make an informed choice. The emphasis should be on identifying ways to ensure safety for patients and health workerswhile still offering an in-person response. If a patient makes an informed choice to delay attending, advice should be provided about how to reduce the risk of evidence loss.
    • If the patient is not able to, or chooses not to, attend a hospital, they cannot have a medical and forensic examination but at a minimum should have a targeted medical consultation via telehealth to ascertain if there are any urgent medical care needs and to formulate a plan to meet these.
    • The SAS worker and examiner should document the consultation in line with documentation standards in the Responding to Sexual Assault (Adult and Child) Policy and Procedures.

Pathway B: Patients who present to an emergency department without a SAS or without a COVID-19 treatment zone

Patients who present to an ED without a SAS

SASs in partnership with local EDs may need to develop local pathways to safely transfer high risk (red) patients to an appropriate SAS if they present to a hospital without a SAS.

Patients who present to an ED without a COVID-19 treatment zone

Where a patient who is COVID-19 suspected, probable or confirmed presents to a hospital with a SAS, but without a COVID-19 treatment zone, SASs, in partnership with local EDs, will need to consider options based on the circumstances of the patient. Options to be considered include establishing a temporary COVID-19 “red’ treatment zone within the hospital to ensure the patient can receive a timely medical and forensic response, or transferring the patient where this would be appropriate (considering the patient’s level of distress, distance to the nearest SAS, the length of time since the assault, and other relevant factors).

Pathway C: Patients who present to an emergency department with a SAS

Where a patient presents to an ED in a hospital with a SAS and an identified zone for treating high-risk (red) patients, the appropriate clinical pathway will depend upon the patient’s condition and level of individual and epidemiological risk.

Clinical pathway for low risk (green) patients

Decision-making about whether to follow Pathway C1 or C2 may require consultation with the ED to establish consensus on local risk.

Pathway C1 – low levels of infection and transmission in the neighbouring Local Government Areas (LGA)

Refer to Information on number of cases and community transmission by LGA.

SASs should follow standard procedures for medical and forensic consultations where the patient is low risk and there is no or limited confirmed community transmission in the neighbouring LGAs. However, SASs are advised to:

  • adhere to social distancing rules (e.g. 1.5 metres between people and 4 square metres per person) whenever possible
  • perform hand hygiene by staff and patients / others (e.g. support people, police)
  • adhere to their district/network’s advice about PPE
  • ensure that shared equipment and frequently touched surface are cleaned following local cleaning processes.

Optionally, and subject to district/network advice, SAS staff may consider wearing scrubs or changing clothes/shoes before leaving the hospital and washing them in hot water at home.

Pathway C2 – Confirmed infection and transmission in the neighbouring LGAs

  • Perform hand hygiene.
  • Adhere to district/network’s advice about PPE.
  • Perform a DNA-clean on all relevant surfaces/objects before and after the consultation following local cleaning processes.
  • Ensure that shared equipment and frequently touched surface are disinfected following local cleaning processes.
  • Maintain 1.5 metres distance where possible, where not possible, all persons other than the patient should wear a surgical mask throughout the consultation, unless it is district/network policy for the patient to wear a mask.
  • Have the examiner wear gown and gloves from the DNA Decontamination Kit, and eye protection, throughout the sampling and physical examination when providing a medical and forensic examination (if providing medical care only, follow local PPE practice).
  • Change gloves after touching a surface, every time.
  • Use clean gloves if DNA-free gloves run out.
  • Perform hand hygiene, including use of hand sanitiser where appropriate if handwashing would risk DNA loss.
  • Change into and out of scrubs at the hospital.

Pathway C3. Clinical pathway for high risk (red) patients

General principles

Note: SASs should ensure that the process described below is approved by local infection prevention and control team

  • Follow Clinical Excellence Commission (CEC) protocols for PPE use: always use the correct equipment; don and doff equipment in the correct order; dispose of used equipment correctly – see COVID-19 Infection Prevention and Control Resources for health and other workers and Personal protective equipment - My Health Learning Videos for up-to-date advice.
  • Use hand hygiene and avoid touching your eyes, nose or mouth at all times.
  • Ensure patient has been medically triaged as stable enough to have a medical and forensic sexual assault examination.
  • Follow local ED guidelines regarding location of the examination (sexual assault medical and forensic examination room or red zone area in ED).
  • The number of accompanying support persons should be limited to one – it is preferable to have none.
  • An in-person response should remain standard practice for medical and forensic consultations. However, telehealth may be offered in limited circumstances such as:
    • where no face-to-face options are available
    • where staff unexpectedly do not have access to the appropriate equipment (including PPE) or training in the use of PPE to meet local district/network infection prevention and control protocols in providing a face-to-face response, or
    • where an examiner is not able to provide a face-to-face consultation under their district/network guidelines (e.g. because they are self-isolating) and no other examiner is available
    • where it will not be possible to maintain appropriate distancing from the patient during a lengthy medical and forensic consultation (e.g. where the examination is taking place in a small space) and there is a need to reduce time in the room with a patient to minimise the risk that PPE may be compromised.
  • Where telehealth is considered, in line with the circumstances above:
    • the examiner and SAS worker should perform an assessment of suitability for telehealth with the patient, which may include a review of information provided by ED and NSW Police, and should discuss privacy and confidentiality with the patient
    • if the patient’s physical or psychological needs require the physical presence of the SAS worker, for any stage of the consultation, the SAS worker must adhere to local PPE processes with supervision during the donning and doffing stages (best practice is for the worker to have a PPE “spotter” during both stages). Social distancing should be maintained throughout.
    • the preferred option is for the patient to use their own device where possible and when the patient is happy to do so, with a backup plan if the connection drops out (e.g. who will call back, what device to use if the call-back fails).
    • The SAS worker should complete as much of the Medical Forensic Examination Record (MFER) as possible from outside the patient’s room but within the hospital. This should ideally be done via a videoconference call on a secure platform but can be done by using a phone either on speaker or using teleconferencing, with the SAS worker in the room with the examiner. This will require confirming the identity of the patient and seeking verbal consent for telehealth.
  • It is preferred that examiners attend in person. However, if an examiner is not able to attend a hospital for a face-to-face consultation under their district/network guidelines (e.g. because they are self-isolating) and no other examiner is available, the examiner may provide telehealth consultation off-site if they are able to meet requirements for a confidential space to conduct the consultation, document the consultation and organise follow-up care.

Suggested procedure for medical and forensic examination where patient is stable and no aerosol generating procedure being performed in the room

Note: Health facilities can adopt other safe ways of performing a medical and forensic examination with contact and droplet precautions according to local guidelines and procedures.

Phone consultation and preparation

As above, an in-person response should remain standard practice for medical and forensic consultations, and telehealth offered only in limited circumstances. Where telehealth is considered, in line with the circumstances above:

  1. Telehealth consultation by the examiner with patient prior to face to face: examiner to introduce her/himself, ensure patient is in a safe, secure location and able to speak freely (e.g. ED single room on their own). SAS worker should be on the call to provide virtual support. Video-calling is preferred, if there is a safe platform; otherwise, use the telephone. Careful attention should be paid to confidentiality and documentation.
  2. Obtain as much information over the phone as possible, including discussion of options for examination, obtaining verbal consent, targeted medical history, history of assault if patient able to provide this, and standard questions. Document this in the MFER. In the client file, document why verbal consent was required.
  3. When seeking consent for a medical and forensic examination, the examiner should explain that PPE will be required and why.
  4. While the SAS worker continues to provide support for the patient, the medical and forensic examiner can collect the equipment that will be needed for the examination (see Appendix 1). Write the kit batch numbers into the MFER.
  5. Obtain a cleanable trolley, ideally with two shelves.
  6. Temporarily end the telehealth connection if the SAS worker is needed to help the examiner set up (see below); otherwise, the SAS worker should continue to provide telehealth support.

Setting up

  1. Take the equipment to the PPE donning/doffing area (if there are separate areas for this in the facility, the examiner should ensure that they have the material for double bagging and a piece of evidence tape at the doffing stage). This may be a clean zone (outside the patient contact zone) that is separate from the designated donning area, if this is appropriate.
  2. Perform hand hygiene.
  3. Don PPE for contact and droplet precautions in the following order: mask, eye protection, hand hygiene, and gloves for cleaning and setup. Use a P2/N95 mask if local LHD policy is to wear a P2/N95 mask for high risk patients. If using gloves for cleaning, remove and perform hand hygiene on completion of cleaning
  4. In the same zone, clean the trolley following standard local SAS processes.
  5. If the trolley has two shelves, put non-DNA-free equipment such as the MFER and paper evidence bags on the lower shelf; if there is only one shelf, put them on the trolley and they will then go underneath the work sheet from the DNA Decontamination Kit. Have the MFER open to the examination pages.
  6. Open the DNA Decontamination kit onto the trolley and unfold the cover.
  7. Open the kits that will be used and tip the contents onto the trolley without touching them.
  8. If no assistant available, open other equipment (e.g. lubricant, anoscope, speculum) and tip onto the trolley in DNA-free field away from the contents of the DNA-free kits. Alternatively, a SAS worker can put on a mask and gloves and drop them onto the trolley without touching the contents.
  9. Remove gloves if don and perform hand hygiene. Don DNA free gown and two pairs of DNA-free gloves (these will also serve as contact precautions PPE). (NB: double-gloving is a standard requirement of the forensic examination process).
  10. Set up kits. Take the gold Sexual Assault Investigation Kit (SAIK) envelope out of its plastic zip lock bag. Complete the front. Put the padded envelope inside it. Put the SAIK envelope back in its plastic bag. (Alternatively, completion of the front of the SAIK envelope can be done during doffing.)
  11. Open the flaps of both the large gold envelope and padded envelope, to make it easier to insert material later with minimal touching of the envelopes.
  12. If an oral rinse is required, the SAS worker, wearing a mask and gloves, should put 5 mL of sterile water into the yellow specimen jar.
  13. Label specimen containers.

Examination

(Note: this pathway does not address photography, given its complexity. SASs that wish to continue photography may need to develop local processes.)

  1. Bring the prepared trolley into the workspace, remaining as far as practical from the patient contact zone (1.5 metres around the patient).
  2. If touching any surfaces or equipment in the room, clean them following local DNA decontamination processes.
  3. Remain > 1.5 metres (at least) from patient unless taking specimens/performing examination requiring closer contact
  4. Confirm verbal consent and if necessary clarify any elements of the history.
  5. Change outer gloves (unless there has been no contact with objects or patient).
  6. Ask the patient to change into a DNA-free gown while the examiner puts the DNA-free sheet on the examination couch. If collecting clothes, ask the patient to put each item into an individual paper evidence bag. Ask the patient to put their underpants in the labelled paper bag and temporarily store this on the bed.
  7. Change outer gloves.
  8. Using the standard precautions, collect the non-oral samples first, changing outer gloves between body sites. If DNA-free gloves run out, use clean gloves.
  9. Collect a peri-oral swab (+/- slide) if appropriate, taking care to stand slightly to the side of the patient to reduce contact.
  10. Change outer gloves. If an oral rinse is being collected, ask the patient to put gloves on, pass them the yellow specimen container, stand back 1.5 metres, ask the patient to swoosh the water around their mouth and then dribble it into the jar. Ask the patient to put the lid on the jar and tighten it. Open a biohazard bag and ask the patient to put the jar in. The patient can then take off their gloves. If it is local SAS policy to store the oral rinse in the SAIK, add it to the padded bag.
  11. Collect a buccal swab. Change outer gloves.
  12. Collect samples from other body areas including genital samples, changing outer gloves between body sites.
  13. Sheath all the swabs and slides; put them into the small A5 gold envelope.
  14. Put the small and large gold envelopes in the padded bag.
  15. Put the bag with the underpants into the padded bag.
  16. Collect toxicological samples if appropriate and store them in a biohazard bag.
  17. Still wearing double gloves, complete a targeted physical examination and injury documentation and provide any necessary face to face care to the patient. Remove the outer gloves.

Documentation and packaging

  1. If returning the patient to a separate clinical space or discharging them from your care, consider doing this now. If the patient is remaining in the examination space and the clinician is leaving, identify a suitable location within that space to complete labelling and packaging of the SAIK that complies with local infection prevention and control protocols and reduces length of time spent in the patient contact zone.
  2. Seal the padded bag while leaving it inside the gold envelope inside the plastic zip lock bag. Avoid touching the outside of the gold envelope.
  3. Complete MFER. Label all pages. Remove the pink (and if appropriate yellow) pages. Put the pink pages in the gold SAIK envelope. Put the yellow pages in the toxicology biohazard bag. Leave the blue pages.
  4. Put anything that will not be taken out of the room into the bin. If the patient will be discharged, clean any surfaces or equipment in the room that were touched by the patient or examiner following local DNA decontamination procedures then discharge the patient following local ED procedures.
  5. Put the SAIK kit, MFER and any other bagged evidence on the trolley.

Exiting, doffing, final packaging

  1. Bring the trolley away from the patient contact zone.
  2. Ask the SAS worker (or other Health worker who can assist) to don gloves and a gown or apron. Get the plastic bag with the SAIK envelope and hold it open. Ask the worker assisting to remove the gold envelope without touching the plastic bag. Discard the plastic bag safely.
  3. Ask the SAS worker to hold open individual tamper-evident bags. Put the biohazard bags (e.g. with an oral rinse, tampon, or toxicology samples) into the tamper-evident bags.
  4. Ask the SAS worker to hold open paper evidence bags so the evidence bags containing clothes can be placed inside the second paper bag.
  5. Ask the SAS worker to hold open a clean large envelope or paper bag and put the MFER inside the envelope or paper bag.
  6. Doff PPE (gloves, gown, hand hygiene, eye protection (clean before putting down if reusable then perform had hygiene), mask, hand hygiene) and safely discard.
  7. The SAS worker can doff their gloves and gown/apron.
  8. Seal the SAIK envelope and apply evidence tape, completing the information on the front if not already done: complete and seal the tamper-evidence bags; complete and seal the paper evidence bags; label the envelope containing the MFER with identifying details and the date and time. Store the evidence following local policies; store the MFER in secure dry storage.
  9. The MFER can be removed after 24 hours and the envelope discarded (For evidence regarding the stability and decay rates of SARS-CoV-2 on various surfaces, see research letter: “Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1”, N Engl J Med 2020; 382:1564-1567. DOI: 10.1056/NEJMc2004973). The blue pages should then be removed and handled following local processes. The MFER should then be added to the client file.
  10. Discharge patient following local ED protocols if well enough; otherwise, hand care over to the ED OR follow local discharge processes. Ensure that ED is informed of any medication prescribed or given to patient, particularly as there may be adverse interactions with experimental medication used for COVID-19.
  11. Perform a DNA decontamination clean on the trolley then follow local ED processes for terminal cleaning.

Appendix 1 – List of suggested equipment

In the telehealth area

If undertaking a consultation by telehealth, the examiner should have with them:

  • an MFER
  • some progress notes
  • other site specific paperwork.

Donning

The examiner should have the following material in the donning area:

  • cleaning products for decontamination eg bleach wipes
  • a DNA decontamination kit
  • a SAIK
  • PPE equipment provided by ED (hand sanitiser, gloves, face protection, masks, gowns or aprons).

Depending on the patient’s history, the examiner may also need:

  • a spare swab kit
  • a spare slide kit
  • a nail kit
  • a traffic accident tox kit with both blood and urine collection vials or a forensic toxicology kit; a tourniquet; a bandaid
  • additional blood tubes for HIV baseline screening
  • a speculum
  • an anoscope
  • a vial of sterile water
  • a sachet of lubricant
  • HIV PEP
  • emergency contraception
  • additional micro or viral swabs for medical care if clinically indicated.

Doffing

The examiner should have the following material in the doffing area:

  • a piece of red evidence tape
  • a paper evidence bag large enough to take an MFER comfortably
  • bleach and sterile gauze wipes.

The examiner may also need:

  • a paper evidence bag big enough to take several evidence bags with clothing
  • plastic evidence bags (one for an oral rinse, one for toxicology).

Appendix 2 – Reference list

Current as at: Tuesday 14 July 2020
Contact page owner: Health Protection NSW