Patient Care, Training, Trauma

SAFE Program Fights Sexual Assault

Issue 8 and Volume 36.

Unfortunately, sexual assault is a reality and a social issue that often goes unreported. Rape Abuse and Incest National Network (RAINN) reports one in six women, and one in 33 men, will be sexually assaulted in their lifetime, with college-aged women being four times more likely to be sexually assaulted.1

In 2007, there were approximately 250,000 survivors of sexual assault.2 These statistics equate to a sexual assault occurring in the U.S. every two minutes, and it’s estimated only 40% of these assaults are reported to law enforcement officials.3

Because they’re seeing so many patients involved in sexual assaults, many EMS agencies have developed training programs to better care for this patient population. The programs focus not only on medical care, but also on social and emotional support and forensic evidence collection to help increase the success rates of prosecuting the offenders of these crimes.

In New York City, some of the 9-1-1-receiving emergency departments (EDs) began offering specialized training in sexual assault forensic examinations. These facilities developed sexual assault response teams (SARTs) with teams comprising physicians, nurses, social workers and volunteers dedicated to providing the highest level of medical, social and forensic evidence collection capabilities.

These programs teach healthcare providers how to expertly manage the medical treatment of sexual assault patients. They also learn to conduct forensic examinations for evidence collection and expert testimony. Each program offers trained sexual assault examiners, specialized equipment to detect and document injuries, dedicated examination and shower rooms, trained advocates and full-time social workers for follow-up counseling services and emotional support on a 24/7 basis.

This availability allows for a seamless integration of all medical, forensic and counseling care.4 Through the New York State Department of Health, Bureau of Women’s Health, those facilities determined to have met appropriate training requirements are given Sexual Assault Forensic Examiner (SAFE) Centers of Excellence status.

Pilot Program
Initially, the New York State Department of Health Bureau of EMS, which designates specialty hospitals, didn’t recognize this SAFE status and didn’t allow EMS to bypass the closest 9-1-1-receiving EDs for such facilities. After a prolonged review, the Bureau of EMS allowed the designation as a pilot program, providing beneficial numbers of transport.

Beginning June 8, 2008—with the approval of the New York State Department of Health, Bureau of Emergency Medical Services and the New York City Regional Emergency Medical Services Council—New York City 9-1-1 ambulances were allowed to transport known survivors of sexual assault to one of 19 SAFE Centers of Excellence attached to a 9-1-1-receiving ED facility as part of a pilot program. Due to funding and hospital mergers, as of the date of this article, there are currently 18 such SAFE Centers of Excellence. One of the original facilities eliminated its program when it merged with another hospital facility.

The New York City EMS system, which has been operated by the New York City Fire Department since March 1996, is a busy system with 3,000–3,500 requests for ambulances on a daily basis, which equates to 1.2–1.5 million calls per year. Of these calls, the system responds to approximately 800 calls for victims of sexual assault.

A retrospective analysis of all calls to the 9-1-1 system for “rape” or an allegation of an injury resulting from a sexual assault was conducted one year prior to and one year after the June 8 implementation date.

Prior to the date of implementation, data show that 64.03% (477 out of 745) of “rape” patients were transported to a SAFE Center of Excellence. After the implementation date, 87.82% (721 out of 821) of patients were transported to these centers (see Figure 1, below).

Using SPSS-17, a T-test (a specialized statistical analysis) was performed to determine if the change was significant. A T score of 10.678 with a p value of 0.000 was produced, indicating the protocol change was effective in routing patients to EDs with SAFE Centers of Excellence.

Although any system would strive to transport all sexual assault survivors to SAFE Centers of Excellence, due to the nature of the call, we’ve learned that prehospital providers don’t always know that there was a sexual assault during their patient encounter. The call may have come into the system as an injury or assault with healthcare providers discovering the true nature of the sexual assault only at the ED.

Also, patients who were sexually assaulted but were unstable or had other injuries, such as trauma or burns, would warrant transport to a specialty center. Some patients, even after being advised of a SAFE center, may have preferred transport to a non-SAFE facility due to issues, such as closeness to home, convenience of follow-up care or past history with the hospital facility.

In our study, which was conducted by the FDNY, we found that 8.02% of patients refused transport to any medical facility, 1.58% of patients were taken by police officers for a search of the area for the perpetrator—and therefore not taken to a hospital by ambulance resources—and 0.365% of patients required transport to a specialty referral trauma center. Based on the documentation, 0.244% of patients were offered transportation to a SAFE center but declined and were instead transported to a non-SAFE ED as a patient choice.

Another potential weakness in getting these patients transported to SAFE centers may be a lack of prehospital provider knowledge of these facilities and their benefits. An educational component is under development in our system to educate providers about the benefits of SAFE centers.

Although EMS crews don’t collect forensic evidence, the training curriculum goes over the capabilities and services available at these SAFE centers, as well as the benefits to the patient in regards to patient care and evidence collection. The training also goes over the assessment and treatment of such patients while minimizing the disruption of forensic evidence, as well as the proper documentation during these encounters. Evidence collection is left up to the New York Police Department.

Crews are educated that life threats are still priority but providers must disturb the evidence as little as possible. Once such education is completed, we plan to repeat this study to see if there’s a further increase in compliance of getting survivors of sexual assault to SAFE Center facilities. JEMS

1. RAINN. (2009). Statistics. In Rape Abuse and Incest National Network.
2. The New York City Allliance Against Sexual Assault. (2010–2011). About the Research at the Alliance. In NYC Alliance Against Sexual Assault.
3. Sexual assault: In: Marx J, Hockberger R & Walls R. Rosen’s Emergency Medicine: Concepts and clinical practice. 3rd ed. Mosby: St. Louis. 2001.
4. “Sexual Assault Forensic Examiner Programs.” FDNY Bureau of Operations EMS Command Order 2008-094. June 6, 2008.

This article originally appeared in August 2011 JEMS as “Keeping Patients SAFE: New York City providers respond to sexual assault victims.”