Covid-19 Guidance

Sexual assault forensic examiners (SAFEs) are “essential” healthcare professionals, who provide trauma-informed, culturally sensitive, and compassionate care to persons who have experienced sexual or intimate partner violence and collect and document medical forensic evidence specific to that violence.  CalSAFE has developed the following guidelines, to be used by SAFE teams in conjunction with Centers for Disease Control (CDC) guidelines and public health advisories to modify their respective SAFE protocols during the pandemic.

Recommendations

Communication:
       1. Maintain good communication with your county Sexual Assault Response Team (SART)           
          agencies or multidisciplinary team. It is important to understand operational changes             
          that each agency has made. This will ensure the overall SAFE team response can be                 
          modified to meet the patient’s needs. Possible workflow changes include:

  • Telephone or video conferencing with advocate agencies in lieu of in-person response
  • Revised processes with law enforcement agencies for reporting, interviewing, and evidence retrieval
  • Back-up plan for responders (i.e. SAFEs, advocates, or law enforcement officers) that screen positive at arrival to Sexual Assault Forensic Exam facility or if responders have concerns related to their personal health needs (e.g. pregnant or immunocompromised).

 
     2. Provide frequent and regular updates to partner agencies regarding COVID-19 related             
​         changes in program and facility workflows.In general, SART partners should also follow
         their own agency guidelines but defer to SAFE program requirements if a higher level
         of protection is needed.

     3. Inform patients seeking treatment, and the community at large, that the healthcare
         system is open and 
medical forensic exams are available. Provide guidance regarding
         the measures  employed to keep patients safe and the steps to obtain an exam.

Screening:
    1.All patients who request a SAFE exam should be triaged before entering a SAFE facility. This can be done via
      
phone by the on-call examiner or on-site in accordance with hospital or clinic triage policies.
      

  • Notify patients in advance if family members or support persons will be permitted to accompany them into the SAFE exam location and that support persons should not come to the facility if they are sick.

    2. Example screening questions (Please follow (CDC) or hospital Guidelines):

  • Have you been tested for COVID-19 or the flu in the last 14 days?
  • Have you traveled outside of California or the US in the last 14 days?
  • Have you been in contact with anyone who has traveled outside of California or the US in the last 14 days?
  • Have you been in contact with anyone who has been diagnosed with COVID-19 or sick with symptoms? When?
  • Have you been experiencing fever, cough, or shortness of breath?
  • Do you have any other symptoms that are severe or concerning?
  • Universal screening for temperature on arrival is advised

 
    3. A positive answer to any of the questions, or a temperature of 100 F or greater, should guide the decision to             
        
perform a medical forensic exam, or where it should take place, on a case by case basis. Visitors and support         
        persons should also be screened. 

    4. Thermal or temporal thermometers are the preferred choice prior to forensic exam to avoid the interfering                                with forensic evidence.

Personal Protective Equipment (PPE):
     1. For the Sexual Assault Forensic Examiner (SAFE)

  • Standard precautions should be followed at all times
  • Eye protection – goggles/face shield

                   Recommended for use with known or suspected COVID positive patients

                   Should be cleaned and disinfected between use and stored in clean paper bags

                   Should be discarded when visibility is impaired, or if the fit is compromised

  • Masks

                 
                  Masks should be worn during handling of all evidence (collection, packaging, and management)

                  Masks should be worn during all patient interaction but not touched or removed                       
                  for the duration of the exam

                   Cloth masks may be worn over masks being reused but a new, clean cloth mask                         
                   must be used for each patient

                   If the availability of PPE is limited, masks may reused unless moist, torn, or contaminated

                   Surgical masks should be disposed of between SAFE exams to avoid cross transference of DNA between patients                

                   Surgical masks should be worn with patients not identified as above

                   N95 masks should be worn when caring for patients who have active COVID,                               
                   undifferentiated 
influenza like symptoms, or are a COVID person under  investigation (PUI).                               
                   

                   
                  N95 masks should be 
discarded when soiled, wet, or the fit is compromised                             
                   

  • Gowns

                   Non-sterile, disposable patient isolation gowns are appropriate for use with                                 
                   known or suspected COVID positive patients

                   If worn, gowns should be changed in between patients

                   If no disposable gowns are available, use of a cloth gown over your clothing can                         
                   be considered and should be changed in between patients

                   

  • Gloves

                   Worn with any patient care

                   Worn during handling of all evidence (collection, packaging, and management)

            2. Patients, advocates, and support persons (If allowed to be onsite per local policy):

  • Provide the patient with a surgical mask (or clean cloth mask) to wear throughout the medical forensic exam process. Advocates/support persons must also wear a face covering or mask
  • Instruct them to avoid touching the mask or removing, unless instructed, to avoid unintended inoculation
  • Take care and provide clear instructions when the patient needs to remove their mask for oral/perioral/buccal swabs or for facial photography. The mask should be considered contaminated and hand hygiene must be performed any time the mask has been touched

Cleaning considerations
    1. Clean using solutions recommended by the healthcare facility policy or (CDC)  guidelines for COVID-19.                   
       

    2. All surfaces, equipment, and high touch areas should be cleaned immediately after every SAFE exam.           
          

    3. Workflows should be developed based on infection prevention or (CDC) guidelines

  • for interval cleaning of showers, bathrooms, and exam spaces used for patient care
  • for management of linens and disposal of PPE

Hospital based SAFE Teams
     
     1. Emergency Department Based Programs-Designated or private SAFE locations may continue to be available
        but modifications will be needed to ensure the safety of those 
responding             
         

  • Limit points of entry to the SAFE exam location and limit foot traffic

   
     2. Consider options to move SAFE response out of the Emergency Department and/or hospital setting.

  • Off-site clinics or family justice centers are suggested partners
  • Off-site clinics must be equipped and able to provide support for patients, who are at risk for medical of psychiatric decompensation, especially status post strangulation or intoxication, and for patients who screen positive for suicidality or have other co-morbid conditions.
  • A decision to move the SAFE response to a non-ED or hospital setting requires establishing protocols for appropriate medical clearance of patients, both prior to sending the patient to the new SAFE exam location and on referral back to the ED/hospital setting, if the patient decompensates or requires additional medical or mental health care following the SAFE team. 
  • If moving the SAFE team response out of the ED/hospital setting is not possible, develop plan to route patients through or past the ED into another appropriate private patient care space.
  • Recognize that a team approach is necessary for any alternate location and security measures must be taken into consideration.   

   
     3.   Ensure that SAFE workflows align with hospital COVID-19 policies and are revised as 
hospital policies are updated 
                                                  

  • Communicate with administrative staff re: SAFE Team/ departmental needs
  • Review with county or hospital command center or designated COVID-19 information center
  • Collaborate with Infection Prevention for changes and updates re: COVID-19
  • Continue to follow agency protocols with respect to medical clearance of SAFE patients

      
     4.   Post signs at the entrance, waiting room, bathroom, and patient care areas that                         

           
provide instructions on hand and respiratory hygiene, as well as cough etiquette
     5.   Follow pre-screening and PPE guidelines

  • On patient arrival, confirm triage answers provided at phone triage, if applicable
  • After the patient and SART responders are cleared for the exam:
    • instruct everyone locations for hand hygiene
    • limit the patient’s access to the exam room and avoid moving from room to room

       
    6.   Wash hands or use hand sanitizer, with at least 60% alcohol:

  • before and after all patient contact 
  • each instance of donning or doffing PPE

Non-hospital based SAFE Teams
    1. Designated or private SAFE locations may continue to be available but modifications               
       
will be needed to ensure the safety of those responding

  • Limit points of entry to the SAFE location and limit foot traffic
  • Continue to follow agency protocols with respect to medical clearance of SAFE patients

    2. Post signs at the entrance, waiting room, bathroom, and patient care areas that provide                                            instructions on hand and respiratory hygiene, as well as cough etiquette
    3. Follow pre-screening and PPE guidelines

  • On patient arrival, confirm triage answers provided at phone triage, if applicable
  • Once the patient and SART responders are cleared for the exam:
    • instruct everyone about locations for hand hygiene
    • limit the patient’s access to the exam room and avoid moving from room to room

     4. Wash hands or use hand sanitizer, with at least 60% alcohol:

  • before and after all patient contact
  • each instance of donning or doffing PPE

Considerations for the standard sexual assault medical forensic exam related to COVID-19

     1. Limit close personal contact by distancing

  • Conduct the interview from 6 feet away. Carefully consider how you will document/what you will be documenting because any paper brought into the room should be considered contaminated.
  • Perform photography from 6 feet away or with reasonable distance that allows for high quality photography. Other than the examiner, only the patient should assist with holding the forensic ruler to minimize examiner exposure

     2. For COVID+ or high risk/symptomatic patients

  • Full PPE, to include gown, mask, N-95, and eye protection, should be worn by the SAFE at all times
  • Strongly consider having the patient collect their own perioral/oral/buccal swabs. When the patient removes their mask, the examiner has the highest risk of exposure. The SAFE examiner must provide the patient with clear instruction and witness each part of the collection.
  • SAFE examiner should witness the collection for other swabs to include body swabs and blind vaginal swabs on a case-by-case basis. The patient must be given clear instructions and the SAFE examiner should visually witness and supervise all collection.

     3. All variations from protocol must be carefully documented in the CALOES 2-923 or  CALOES 2-930Witnessed                           collection must be clearly documented to include which  swabs were collected by the patient, which were under                     direct visualization, and any witnessed potential
        

Telecommunication Options

     1. Advocate/ Support Person – Every patient is entitled to have an advocate and/or support person                                                    present for the police interview and forensic medical exam (PC§ 264.2)

  • Advocates may consider providing initial and follow up support for victims via telephone or a secure video platform

     2. Forensic Examiners should make every effort to perform the initial exam in person

  • Providers may consider follow-up care using a HIPAA Compliant video platform
  • In extreme circumstances, a trained forensic examiner may use HIPAA compliant platform to  guide another qualified healthcare professional remotely to obtain consent and initial evidence collection

Self-Administered Forensic Exam Kits
    
Statement from Jennifer Harmon, President CACLD, to CalSAFE 

    1. CalSAFE does not support the use of self-administered forensic exam kits. Sexual Assault                                                                 Forensic Examiners provide professional, healing care in a safe  environment, while following scientific principles                     of medical forensic  examinations and evidence collection. When a victim uses these “self” kits, there is no opportunity           for medical evaluation and documentation of injury, STI treatment, and the opportunity to receive emergency                         contraception.

     2. The self-administered forensic evidence collection kits do not adhere to crime lab regulations, nor do they comply                   with  the California protocol for medical forensic care of sexual assault patients.

Self-Care Considerations to Reduce Secondary Traumatic Stress
Essential Healthcare Providers, in the time of COVID-19, face unique challenges. As frontline healthcare staff,  a forensic examiner has a duty and obligation to provide patient care while at the same time navigating the effects of the COVID-19 crisis in our personal lives. Stressors within the forensic health practice can be compounded by the examiners repeated exposure to caring for patients that experience violence. CalSAFE is available to provide support to our members as needed. We also recommend frequent case review and debriefing with a team member or leader after a challenging case.                   Here are some self-care tips you can use to decompress and rejuvenate: Eat healthy meals, move your body by walking or stretching daily, get adequate sleep, take breaks, call or face-time a friend, listen to music, meditate, read, and designate quiet time.

Frequently Asked Questions
    1. Are SAFEs considered essential staff?

  • CalSAFE supports the designation of SAFE examiners as essential due to their unique skill set. A SAFE is a qualified health care professional, limited to an MD, NP, PA, or RN, who has been trained on the standardized sexual assault forensic medical curriculum, specified in state law, and follows the guidelines for medical forensic treatment of victims of sexual assault or attempted sexual assault, including child sexual abuse, and the collection and preservation of evidence (PC§13823.5(e) and PC§13823.7). Healthcare personnel are also mandatory reporters.

    2. What happens if a hospital restricts or closes access for SAFE teams?

  • All public and private general acute care hospitals shall comply with the standards for the examination and treatment of victims of sexual assault and attempted sexual assault, including child molestation, and the collection and preservation of evidence PC§ 13823.11
  • Overwhelmed and impacted EDs may limit access for SAFE exams as temporary measures but should not prohibit essential forensic care from happening. If necessary, divert cases temporarily to other SAFE Centers. A comprehensive list of all examination teams is on the CCFMTC website and the CalSAFE Website. Speak to your hospital administrative staff before ED saturation occurs to discuss other entry and screening options in your facilities.

 
    3. How can a SAFE Team operate when faced with a workforce shortage due to COVID- 19?

  • Workforce shortages may result from COVID-19 illness, quarantine, clinicians being diverted to other areas of the hospital, or team members having to stay home to take care of family members. If this happens, your SAFE Team Director may need to make the decision to reduce Hours of Operation rather than close services completely.

 
    4. What changes are recommended for management of medical forensic evidence?

  • Best practice for avoiding contamination of medical forensic evidence should be continued; however, consideration should be given to:
    • how patient clothing and personal items are handled in the context of the exam and packaging of evidence
    • use or changing of gloves when handling items with potential evidentiary value
    • use of a mask and gloves during management of evidence (collection, packaging, and transference)

    5.   How can SAFE Teams accommodate law enforcement agencies that decline to pick up evidence?

  • SAFE teams should contact the county sheriff or police chief to resolve this matter or develop appropriate workflows that do not compromise the integrity of the chain of evidence
  • Under the CA Sexual Assault Victims’ DNA Bill of Rights, law enforcement agencies continue to have an obligation for proper handling, retention, and testing of sexual assault kits (PC§ 680).
  • When this occurs, some jurisdictions may consider optional secure, locked storage areas with a chain of custody log as a temporary emergency measure

About CalSAFE

CalSAFE represents the 49 sexual assault forensic exam (SAFE) teams in California. The CA penal code defines SAFEs,              who are highly trained and highly skilled healthcare professionals, and identifies which licensed providers are eligible to perform SAFE exams. When a patient arrives at a SAFE facility after being sexually assaulted, their medical needs are assessed and addressed, including strangulation, which unfortunately is common and when undiagnosed, can be fatal.  Screening and treatment to prevent sexually transmitted infections are provided. Advocacy and social services support are engaged to assist our patients. California SAFEs are specially trained in following the State of California protocol for examination of sexual assault victims to comply with the complex regulations regarding medical forensic evidence
collection, documentation, evidence storage and chain of custody.  It is the position of CalSAFE that forensic examiners
are essential healthcare providers as they are defined in the PC as the only qualified healthcare professional to perform these exams in the state of California. Each SAFE program in California has relationships with certified crime labs to analyze evidence, many of which provide DNA results within 120 days. There are strict protocols in place regarding the method and manner of collection and storage and transportation of DNA evidence to which SAFEs must comply.

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