As a resident, David Yang took care of numerous survivors of sexual assault in the emergency department (ED). Often, he would notice that these individuals had difficulty accessing advocates who could help them navigate both their medical and legal needs.
At the time, there was also a shortage of forensic nurses available in the ED to perform forensic collection kits, which are used to gather and preserve physical evidence in cases of suspected sexual assault.
Seeing a need, Yang worked with his mentor Rohit Sangal, assistant professor of emergency medicine at Yale School of Medicine (YSM), to create and implement a new clinical decision support (CDS) tool in an effort to improve the care of sexual assault survivors in the ED.
Use of this tool led to improved medical and forensic care of survivors, according to a new study published in the journal Academic Emergency Medicine.
"More survivors received forensic kits, were connected to advocates, and got better medical care," said David Yang, clinical instructor in the Department of Emergency Medicine at YSM and lead author of the study.
Every 74 seconds, someone is sexually assaulted in the United States, according to U.S. Justice Department data. EDs are often the first point of care for survivors seeking medical services after being assaulted. For these patients, the recommended care includes addressing the immediate physical and psychological needs of the survivor, conducting a forensic examination (such as those provided by sexual assault forensic examiners), and offering a sexual assault victim advocate to the survivor. But adherence to this recommended care in the ED remains low.
To address this gap, the researchers developed an electronic health record (EHR)-integrated clinical tool that combines guidelines, expert consensus, orders, and resources specific to the evaluation and management of adults seeking care in the ED after sexual assault.
"The tool was created with an interdisciplinary group of forensic nurses, ED physicians, pharmacists, and social workers," Yang said. "Because there's a large team involved with caring for these patients, the goal of the tool was to involve each team member early in a structured pathway that focused on providing consistent and trauma-informed management for each patient."
The researchers first implemented the tool in a large health system in southeast Connecticut on July 13, 2021. They then reviewed medical charts of 552 adult survivors of sexual assault - covering the period between Jan. 1, 2020, and Dec. 31, 2022 - to understand the quality of care before and after implementation and whether the use of the tool improved care. After it was implemented, the tool was used in 51% of patient ED visits.
They then measured the quality of care using six key outcomes. The two non-clinical outcomes included the number of patients who had been offered consultation with a sexual assault advocate and sexual assault forensic evidence kits collected within 120 hours of assault. The four clinical outcomes included pregnancy tests ordered, emergency contraception ordered, HIV postexposure prophylaxis (PEP) ordered within 72 hours of assault, and sexually transmitted infection (STI) prophylaxis ordered.
"Because an individual physician will only see a handful of these patients annually, we thought that an on-shift resource would be useful to improve their care so that we could streamline care and so physicians could see when each treatment was indicated so that we could maximize adherence to recommended care," Yang said.
Overall, the researchers found that patients' medical and forensic care improved when physicians used the tool. These findings, they say, mark a vital step forward in optimizing the care for this vulnerable population - and has the potential to influence clinical practice and inform policies to improve the care of survivors moving forward.
Other Yale authors include Raphael Sherak, Megan Chin, Emelia Pagano, John Tyrrell, Tami Sullivan, Rachel Henderson, Karen Jubanyik, James Dodington, Deborah Rhodes, Marcie Gawel, and Rohit Sangal.
In addition to the new study, Yang also recently co-authored a position paper in the journal Prehospital Emergency Care to guide emergency medical service agencies and clinicians in the patient-centered management of survivors of sexual assault. The recommendations include trauma-informed care, assessing physical injuries after sexual assault, collaboration with sexual assault forensic examiner organizations, documentation, and more.
"Overall, I hope that this position statement is the first step in a series of changes to improve the care that survivors get in the pre-hospital setting," Yang said.
