Children’s Hospital Sexual Assault Kit

Robert A Shapiro, MD Charles J Schubert, MD Patricia A Myers, MSW Children’s Hospital Medical Center Cincinnati, Ohio 513-636-7966 Robert A Shapiro, MD, Patricia A. Myers, MSW Children’s Hospital Medical Center

• Children’s Hospital – 300 Beds • Emergency Department – 90,000 visits/year • Sexual Abuse Evaluations – 900 / year Robert A Shapiro, MD, Patricia A. Myers, MSW Problems with existing kits

• Instructions – too verbose, not followed – difficult to comply with in a busy ED • air drying specimens – not correct for pre-pubertal children • specimen collection and exam techniques differ • Supplies – not applicable to pre-pubertal children Robert A Shapiro, MD, Patricia A. Myers, MSW Rape Kit Design Objectives

• One kit for all victims – newborn to 21 years old • Self guided, clear instructions • Efficient • Excellent specimen collection/storage • Accurate documentation/chain of evidence Robert A Shapiro, MD, Patricia A. Myers, MSW CHMC Rape Kit

• Designed with Coroner’s lab serologist – addressed existing problems – limited specimen collection to essentials • Written for victims from newborn - 21 y/o • Text clear, short, illustrated – printed on collection envelopes and bags • On-site tested prior to implementation Robert A Shapiro, MD, Patricia A. Myers, MSW What was left out

• Debris collection • Routine finger nail scraping • Plucked hair Robert A Shapiro, MD, Patricia A. Myers, MSW Chain of Evidence

Chain of Evidence • secured to E) ED Nurse to complete: Patient name: CHMC chart #: Date of exam:

outside of box Location of assault (the City or Police Dept involved):

• # of evidence Box sealed by (RN printed name): (signature) containers Box sealed on (date) (time) Number of clothing bags not included in this box: † 0 † 1 † 2

• duplicate form F) The sealed box and any clothing bags (as above) are transfered to the CHM Protective Services Officer.

• unambiguous Accepted by (Officer's printed name): (signature) chain G) The above officer places the collected evidence in the security cabinet. Evidence secured on (date) (time) (officer's signature)

• clear instructions H) Transfer to Law Enforcement Personnel

Evidence taken by (Officer's printed name):

District: Badge #:

Date Time (officer's signature) Robert A Shapiro, MD, Patricia A. Myers, MSW Robert A Shapiro, MD, Patricia A. Myers, MSW Instructions taped onto a large brown bag

OUTER CLOTHING addressograph stamp

Directions: Place into this bag, any of the patient's clothing that is stained with blood, semen or saliva. Seal the bag using one sealing tape ( tape can be found in the box )

† COLLECTED † NONE TO COLLECT list the clothing articles collected below: 1)

2)

3)

Step 1 4) Robert A Shapiro, MD, Patricia A. Myers, MSW Instructions taped onto a small bag

UNDERWEAR addressograph stamp COLLECT FROM ALL PATIENTS

Directions: Place patient's underwear into this bag. Seal the bag using one sealing tape (tape can be found in the box).

Collect even if patient has changed underwear since the assault.

collected

Step 2 if not, why? Robert A Shapiro, MD, Patricia A. Myers, MSW • Saliva specimen – complete instructions on envelope – proper specimen handling & labeling – self sealing envelope

SALIVA SPECIMEN FOR addressograph stamp COLLECT FROM ALL PATIENTS SECRETOR STATUS

Filter paper Using exam gloves, pick up the enclosed filter paper. Area moistened by patient Do not touch the filter paper with your bare hands. Ask the patient to moisten an area with his/her tongue. Indicate the dampened area with a pen (see diagram). line drawn with Place the moistened filter paper into this envelope. pen by MD or RN

collected Contents: 2x2 piece of if not, why? Step 3 filter paper Robert A Shapiro, MD, Patricia A. Myers, MSW • Oral specimens – instructions for collection – cultures also done at this time – specimen handling

COLLECT FROM ALL ORAL SPECIMEN FOR addressograph stamp PATIENTS SEMEN

Procedure one: Using BOTH of the enclosed swabs, swab along the upper & lower gums. Place these two swabs into this envelope. Procedure two: Oral cultures for GC should be obtained at this time when indicated. Use a 3rd swab for this culture and discard this swab after inoculating the culture media. Send the culture to the CHMC lab. DO NOT place culture into the evidence box.

semen specimen collected

if not, why? Contents: 2 large cotton Step 4 tipped swabs Robert A Shapiro, MD, Patricia A. Myers, MSW • Stain collection – moist gauze used for collection – explanation of Woods lamp use – body location documentation

SEMEN, BLOOD OR SALIVA STAINS addressograph stamp

Examine the skin for stains, especially the areas around the genitalia, thighs & buttocks. Use the Woods lamp in a darkened room to increase your ability to see seminal stains. Look for a green fluorescence. Collect all suspicious stains, if those that don’t fluoresce. If stains are found, moisten the enclosed gauze with sterile saline & wipe the stain thoroughly. Put gauze into envelope & mark on the drawing the location from which the sample was taken. If there are additional stains from other body areas to collect, use other STEP 5 envelopes. 2 other envelopes are provided. Mark them each as collected or not collected.

Step 5 COLLECTED NOT COLLECTED Contents: 2 X 2 sterile gauze Robert A Shapiro, MD, Patricia A. Myers, MSW • Rectal specimens – instructions for collection – cultures also done at this time – specimen handling

COLLECT FROM ALL RECTAL SPECIMEN addressograph stamp PATIENTS FOR SEMEN

Procedure one: Lightly moisten BOTH swabs with sterile saline and insert them into patient's rectum. Wait 5-10 seconds, withdraw swabs and then place both swabs into this envelope. Procedure two: Rectal cultures for GC and chlamydia should be obtained at this time when indicated. Use new, separate swabs for each culture and discard these swabs after inoculating the culture media. Send cultures to the CHMC lab. DO NOT place cultures into the evidence box.

semen specimen collected

Step 6 if not, why? Contents: 2 large cotton tipped swabs Robert A Shapiro, MD, Patricia A. Myers, MSW • Perpetrator Hair Collection – adolescent procedure – pre-adolescent procedure

COLLECT PUBIC HAIRS addressograph stamp COMBED HAIRS (adolescent victim) STRAY HAIRS (if found on the pre-adolescent victim)

Adolescent patient: Place the enclosed paper towel under the patient's buttocks. Comb pubic hair onto the towel with the enclosed comb. Wrap comb in the paper towel and place the wrapped towel into this envelope. Pre-adolescent patient: If stray hairs are found near the child's genitalia or rectum, collect them and wrap the hairs in the paper towel. Place the wrapped towel into this envelope. If hairs were not found, do not return the towel to this envelope.

Contents: paper towel Step 7 COLLECTED NOT COLLECTED comb Robert A Shapiro, MD, Patricia A. Myers, MSW • Patient Hair Collection – adolescent victim only

CUT PUBIC HAIRS addressograph stamp Adolescent victim only

Directions: As close to the skin as possible, cut 5-10 pubic hairs with the enclosed scissors. Wrap cut hairs in the paper towel and place the towel into this envelope Discard the scissors.

COLLECTED NOT COLLECTED

Contents: folded paper towel Step 8 scissors Robert A Shapiro, MD, Patricia A. Myers, MSW • Genital specimens – adolescent / pre-adolescent / sex • semen collection (internal Vs. external) • cultures (endocervix Vs. mucosa)

COLLECT FROM ALL GENITAL SPECIMEN addressograph stamp PATIENTS FOR SEMEN

Procedure one: If adolescent female, use BOTH enclosed swabs to collect vaginal secretions. If male or a pre-pubertal female, lightly moistened the enclosed gauze with sterile saline & swab the external genitalia. Return only used swabs or used gauze into this envelope. Procedure two: Genital cultures for GC and chlamydia should be obtained at this time when indicated. Culture the vaginal mucosa in pre-pubertal children, and the endocervix in adolescents. Use new, separate swabs for each culture and discard these swabs after inoculating the culture media. Send cultures to the CHMC lab. DO NOT place cultures into the evidence box.

Contents: gauze used semen specimen collected swabs used 2 large cotton tipped swabs Step 9 2x2 sterile gauze if not, why? WET PREP FOR SPERM & TRICHOMONAS addressograph stamp

Using swabs and test tubes from this evidence box, collect specimens for sperm and Trichomonas. In females, collect a vaginal specimen unless, because of the child's age, collection would be traumatic. If semen is suspected in the rectum, mouth or other sites, obtain specimens from these areas as well. Place each swab into a separate test tube, add sterile saline to the tube to cover the tip of the swab. Record the collection site onto each tube.

Carry red-topped tube(s) with the evidence box STAT to the lab for sperm & Trichomonas examination. Remain in the lab with the specimens until results have been recorded by the lab tech in the spaces below. Any slides that show sperm should be photographed by the lab tech, placed into a cardboard slide holder, labeled, and placed into the evidence box. Do not save red-topped tubes. Photographs should be labeled and kept with the medical record; they should not be put into the evidence box.

Vaginal specimen Rectal specimen Oral specimen Test not done No trich seen Test not done Test not done No sperm seen No sperm seen No sperm seen Non-motile sperm seen Trich seen Non-motile sperm seen Non-motile sperm seen Motile sperm seen Motile sperm seen Motile sperm seen initials of lab tech ______initials of lab tech ______initials of lab tech ______

LAST STEP MD NOW COMPLETES THE REPORTING FORM AND THE EVIDENCE FORM RN CHECKS THAT BOX IS COMPLETE AND TRANSFERS BOX TO PROTECTIVE SERVICES ( see box lid

Step 10 The following can be found in this evidence box: red-topped tubes, cotton tipped swabs& vial of saline Robert A Shapiro, MD, Patricia A. Myers, MSW Checklist taped onto the inside lid of the evidence box • Prior to BEFORE SEALING THIS BOX, CHECK THE ITEMS BELOW

sealing the 9 that all of these envelopes and bags are in the box.

Assault Kit † 1) outer clothing bag † 4) oral specimen † 5) stains (envelope 3) † 8) cut hairs envelo † 2) underwear bag † 5) stains (envelope 1) † 6) rectal specimen envelope † 9) genital specime – items to † 3) saliva envelope † 5) stains (envelope 2) † 7) pubic hair envelope † 10) wet prep sheet include 9 – items to that these items are in the box. † sexual assault evidence form † microscope slides (if any) from the hematology lab exclude 9 that these items are NOT in the box.

† CAT Reporting form (keep together with the ED chart) † photographs (keep together with the ED chart) † red topped test tubes (stay in hematology lab) † bacterial cultures (send to microbiology lab)

After checking all of the above, seal the box with the provided sealing/security USE THIS EVIDENCE KIT ONLY IF THERERobert HAS BEEN A Shapiro,CONTACT WITH MD, THE PERPETRATOR Patricia A.'S GENITALIA Myers, MSW WITHIN THE PREVIOUS 72 HRS OR IF THERE IS A NEED TO COLLECT SALIVA, PUBLIC HAIR OR OTHER FORENSIC MATERIAL Instructions Evidence Form 1) MD or social worker obtains a history of the assault. 2) MD and RN examine patient and obtain specimens by following steps 1 -10 as described in the Evidence Box. 3) MD completes this form and the CAT Reporting Form for alleged sexual abuse. included in the 4) RN takes wet preps to lab (along with the evidence box), seals box, and transfers box to HOSPITAL security.

History of Assault (4 all that apply) evidence box ‡ Vaginal penetration/contact ‡ Perpetrator's mouth on victim's genitalia ‡ Rectal penetration/contact ‡ Perpetrator's penis in victim's mouth ‡ Ejaculation ‡ Penetration with a foreign object ‡ Fondling (with finger) (specify object and site of penetration) • General Instructions ‡ Other (describe)

Patient History • Check list: Assault 1) Time since the assault hrs 2) During the assault, was the patient menstruating? ‡ yes ‡ no History 3) Since the assault, has the patient bathed? ‡ yes ‡ no 4) Since the assault, has the patient changed clothes? ‡ yes ‡ no

• Check list: Victim History Physical Exam Summary 1) Is the patient menstruating now? ‡ yes ‡ no • Summary: Exam findings 2) Is the patient bleeding from a genital injury? ‡ yes ‡ no 3) Is the patient bleeding from a rectal injury? ‡ yes ‡ no 4) Is the patient bleeding from some other injury? ‡ yes ‡ no if yes, • Check list: Discharge where 5) Are there body stains that fluoresce with the Woods (UV) lamp? ‡ yes ‡ no ‡ not instructions done if yes, specify the body locations:

Check that the following has been done before discharging the patient ‡ Consider prophylaxis against sexually transmitted infection (often offered to an adolescent patient). ‡ Consider pregnancy testing and treatment with Ovral. ‡ Give the patient/family abuse support pamphlet (found in the Evidence Box). ‡ Discuss disposition with the CHMC social worker. name of social worker: ‡ Complete the CAT Reporting Form for alleged sexual abuse and obtain the signature of the ED attending or fellow. ‡ Attach the CAT Reporting Form to the ED headsheet. ‡ The treating MD and RN sign this form in the spaces below.