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.