Article

Effect of menstrual bleeding on the detection of anogenital injuries in sexual assault victims

Correspondence / American Journal of Emergency Medicine 37 (2019) 11911213 1203

faced by many hospitals, costs of wasted inpatient capacity, and negative upstream effects on ED capacity and length of stay [7], our findings have several potential important implications.

First, a multi-disciplinary group utilizing systems engineering tech- niques can sustainably and significantly improve capacity utilization in a complex Academic hospital setting. Secondly, while this success was noted only with our Department of Medicine, such improvements might be gen- eralizable to other services within our hospital. In addition, given the rela- tively standard process of patient handoff at most hospitals, it is likely these techniques are generalizable to other institutions who could realize similar gains. This pilot study also further underscores the value of using Lean methodologies (including focus on reducing waste in all forms, and de- creasing process complexity) to optimize an unnecessarily complex process. We also found that mapping the process with “swim lanes” (a Lean tech- nique in which role group specific actions are explicitly mapped [11]) allowed identification and leveraging of parallel processing opportunities.

Our study has several limitations. First, it is possible that the signifi-

cant improvement in handoff times were due to other external factors. However, we were unable to identify any such factors and the sustain- ability of our results suggest otherwise. Second, as a single-center study, our findings may not generalize to hospitals with different hand- off processes or underlying technological support systems (e.g. elec- tronic medical records, telecommunication systems, etc.). However, given most handoff processes likely follow a relatively similar course, at least some “lessons learned” might be broadly applicable. Finally, our pilot did not estimate the cost savings associated with improved handoff efficiency and capacity utilization, but in a capacity- constrained system such as ours, a cumulative gain of ~10 bed hours daily is of significant value to the hospital and the ED.

In summary, in this single-center study, a multidisciplinary Lean-

based reorganization of patient handoff practices improved perfor- mance measures and process efficiency. This represented a cumulative gain of ~10 ED bed hours daily. Broad, multi-centered application of sys- tems engineering science might further improve ED throughput and ca- pacity. Further study should quantify resource use implications.

Benjamin A. White* Maryfran Hughes

Ali S. Raja

Department of Emergency Medicine, Massachusetts General Hospital,

United States

*Corresponding author at: Department of Emergency Medicine, MGH, Zero Emerson Place, Suite 3B, Boston, MA 02114, United States.

E-mail address: [email protected]

Marjory A. Bravard Kimiyoshi J. Kobayashi Joshua C. Ziperstein Joan L. Strauss

Department of Medicine, Massachusetts General Hospital, United States

30 October 2018

https://doi.org/10.1016/j.ajem.2018.11.003

References

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  2. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008;52:126-36.
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  4. Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med 2003;42:173-80.
  5. Asaro PV, Lewis LM, Boxerman SB. The impact of input and output factors on emer- gency department throughput. Acad Emerg Med 2007;14:235-42.
  6. Rogg JG, Huckman R, Lev M, Raja A, Chang Y, White BA. Describing wait time bottle- necks for ED patients undergoing Head CT. Am J Emerg Med 2017;35(10):1510-3 [2017 May 1].
  7. White BA, Biddinger PD, Chang Y, Greene B, Carignan S, Brown D. Boarding inpa- tients in the emergency department increases discharged patient length of stay. J Emerg Med 2013;44(1):230-5.
  8. Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass; 2009; 36-7.
  9. White BA, Baron J, Dighe A, Camargo CA, Brown DF. Applying lean methodolo- gies reduces ED laboratory turnaround times. Am J Emerg Med 2015;33: 1572-6.
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  11. Graban Mark. Lean hospitals: Improving quality, patient safety, and employee satis- faction. Boca Raton, FL: Productivity Press; 2012.

    Effect of menstrual bleeding on the detection of Anogenital injuries in sexual assault victims

    The physical examination of sexual assault victims is performed to identify and treat injuries, as well as collect forensic evidence for prose- cution. The combination of colposcopy with digital imaging and staining with contrast media such as Toluidine blue, has led to reports of genital injury prevalence approaching 90% following nonConsensual sexual in- tercourse [1]. Such forensic evidence of Anogenital injury influences de- cision making and legal outcomes throughout the criminal justice process. Because the examination is based on scientific evidence, it may influence victims to report their experiences to police, encourage police to file a complaint, and persuade prosecutors to file rape charges and pursue a conviction [2]. For example, McGregor et al. demonstrated that the presence of anogenital trauma was significantly related to filing of charges by the prosecutor as well as conviction [3].

    Additional research is needed, however, to understand those factors that might influence the detection of anogenital trauma. For instance, previous investigators have suggested that individuals with darker skin may be at a disadvantage for injury identification with current ex- amination strategies and color awareness may be an important compo- nent of the sexual assault forensic examination [4,5]. In addition, the presence of menstrual bleeding might also affect the identification of anogenital injury. Therefore, the purpose of this study was to determine the role of menstrual bleeding in the documentation of anogenital in- jury following sexual assault.

    This was a retrospective, matched (1:4) cohort analysis set in a community-based nurse examiner program (NEP) over an eight-year study period. The study was designed to explore differences in fre- quency of identified anogenital injuries among menstruating and non- menstruating women. Most patients came from law enforcement dis- patch and crisis line contacts. Those sexual assault victims presenting directly to the four city emergency departments were transferred to the NEP for evaluation after triage and initial assessment. The NEP was staffed by 9 forensic nurses trained to perform medical-legal examina- tions. Sexual assault victims were selected for inclusion in the study if they were currently menstruating and agreed to a forensic examination. This examination consisted of direct visual inspection, 1% toluidine blue contrast application, followed by colposcopy using a Cooper Surgical Leisegang(C) colposcope system with 30x magnification. After each tech- nique, nurse examiners documented the types and number of anogenital injuries visualized using a standardized classification system [6].

    1 25 Sheldon Blvd. SE, Grand Rapids MI 49503, United States of America.

    1204 Correspondence / American Journal of Emergency Medicine 37 (2019) 11911213

    Each menstruating patient was matched with the next four non- menstruating sexual assault victims presenting to the same clinic using two variables (age, ethnicity). Demographic information, sexual assault history, and clinical findings were retrospectively obtained from NEP records and recorded onto study abstraction forms to guide data collection. Using appropriate safeguards to protect patient confi- dentiality, medical records were reviewed by one research nurse who was trained using a set of “practice” cases. A second investigator per- formed a blinded critical review of a random sample of 10% of the charts to determine reliability. The Interrater agreement for this sample of charts was significant (k-statistic = 0.93).

    A total of 177 cases of sexual assault in menstruating women were

    identified, representing 9.5% (177/1873) of the women presenting to the NEP. The age range among sexual assault victims was 13 to 47 years (mean, 20.5 +- 12 years). There were no significant differences in marital status, time interval to exam, perpetrator factors, or Assault characteristics between the two patient groups (Table 1). A total of 1859 anogenital injuries were documented in the study population. Menstruating women had fewer anogenital injuries compared to non- menstruating victims (58.2% vs. 70.2%, P = 0.003). Menstruating women had a smaller incidence of documented anogenital lacerations (25% vs. 36%, P = 0.007), and fewer abrasions/ecchymosis (18% vs 30%, P = 0.001). The overall injury pattern was not statistically different; common sites of injury in both groups were posterior, including the fossa navicularis, hymen, fourchette, and labia minora.

    This is the first clinical study to evaluate the presence of menstrual bleeding and its effect on the frequency of sexual assault examination findings. We found that menstruating women had 12% (95% CI 4% to 20%) fewer documented anogenital injuries when compared to non- menstruating victims. One explanation for these findings is that sexual assault in non-menstruating women was associated with more Violent behavior. However, the victim demographics were similar regarding weapon use, victim incapacitation, non-genital injuries, multiple assail- ants, or known assailant (Table 1). An alternative but less likely explana- tion is that hormone levels could have confounding effects through influences on vaginal epithelial and mucosal integrity. However, a re- cent study in women following consensual sexual intercourse found that among menstruating women, those in the follicular phase were ap- proximately three times more likely to have any external genital injury than those in the luteal or ovulatory phases [7].

    Table 1

    Patient demographics and assault characteristics (%)

    Menstruating

    Non-menstruating

    Total

    177

    708

    Age of victim, mean (SD)

    20.5 +- 11 yrs

    20.4 +- 12 yrs

    Ethnicity (% white)

    136 (76.8)

    545 (77.0)

    Marital status (% single)

    134 (75.7)

    525 (74.2)

    Last consensual intercourse b72 h

    39 (22.0)

    179 (25.3)

    Time interval to exam, mean (SD)

    17 +- 8 h

    18 +- 9 h

    alcohol or drug use b24 h

    79 (44.6)

    304 (42.9)

    police report filed

    143 (80.8)

    595 (84.0)

    Known assailant

    115 (63.8)

    468 (66.1)

    Multiple assailants

    18 (10.2)

    71 (10.0)

    Type of sexual assault

    Vaginal

    157 (88.7)

    651 (91.9)

    Oral

    37 (20.9)

    170 (24.0)

    Anal

    25 (14.1)

    80 (11.3)

    Digital

    57 (32.2)

    209 (29.5)

    type of coercion Verbal threats

    79 (44.6)

    309 (43.6)

    Physical

    58 (32.8)

    215 (30.4)

    restraint used

    55 (31.1)

    233 (32.9)

    Victim sleeping/drugged

    43 (24.3)

    187 (26.4)

    Use of weapons

    28 (15.8)

    92 (13.0)

    Nongenital injuries

    85 (48.0)

    328 (46.3)

    Anogenital injuries?

    301 (58.2)

    1558 (70.2)

    Anogenital injuries, mean (SD)?

    1.7 +- 1.9

    2.2 +- 2.0

    * Indicates significance at the P b 0.05 level.

    The retrospective study design prevented the control for the clinical evaluations by different examiners. It could be that documentation was not uniform, although the nine nurse examiners had a similar level of training and experience. Variability in examination technique and the data that were collected as part of a clinical rather than research proto- col both introduce error. The findings of the examiners were recorded on state mandated reporting forms and were taken as the most accurate representation of the actual physical findings. Finally, colposcopic pho- tographs, although generally are reliable at showing acute trauma such as abrasions and lacerations, may not show the subtler findings of erythema, ecchymosis, or swelling of tissues. Despite these limita- tions, it seems reasonable to conclude that the presence of menstrual blood may mask anogenital injuries such as abrasions, ecchymosis and superficial lacerations. Further prospective research is needed to con- firm these findings from a single center.

    Linda Rossman Stephanie Solis Janda Stevens Barbara Wynn

    YWCA West Central Michigan Nurse Examiner Program, Grand Rapids, MI,

    United States

    Jeffrey S. Jones

    Department of Emergency Medicine, Spectrum Health Hospitals, Grand

    Rapids, MI, United States

    Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids, MI

    49503, United States.

    E-mail address: [email protected].

    30 October 2018

    https://doi.org/10.1016/j.ajem.2018.11.005

    References

    Sommers MS. Defining Patterns of genital injury from sexual assault: a review. Trauma Violence Abuse 2007;8(3):270-80.

  12. Sommers MS, Fisher BS, Karjane HM. Using colposcopy in the rape exam: health care, forensic, and criminal justice issues. J Forensic Nurs 2005;1(1):28-34.
  13. McGregor M, Du Mont J, Myhr T. Sexual assault forensic medical examination: is ev- idence related to successful prosecution? Ann Emerg Med 2002;39(6):639-47.
  14. Sommers MS, Zink TM, Fargo JD, Baker RB, Buschur C, Shambley-Ebron DZ, et al. Fo- rensic sexual assault examination and genital injury: is Skin color a source of health disparity? Am J Emerg Med 2008;26(8):857-66.
  15. Baker RB, Fargo JD, Shambley-Ebron DZ, Sommers MS. Source of healthcare disparity: race, skin color, and injuries after rape among adolescents and young adults. J Foren- sic Nurs 2010;6(3):144-50.
  16. Slaughter L, Brown CRV, Crowley S, Peck R. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol 1997;176(3):609-16.
  17. Brawner BM, Sommers MS, Moore K, Aka-James R, Zink T, Brown KM, et al. Exploring genitoanal injury and HIV risk among women: menstrual phase, hormonal birth con- trol, and injury frequency and prevalence. J Acquir Immune Defic Syndr 2016;71(2): 207-12.

    Evaluation of Abdominal aortic aneurysm in patients with nonvariceal Upper gastrointestinal hemorrhage

    Although potentially life-threatening, and potentially treatable, pri- mary aortoduodenal fistula(PADF), a disorder most commonly second- ary to abdominal aortic aneurysm(AAA), is notable for the absence of its mention in guidelines for management of nonvariceal upper gastro- intestinal hemorrhage(NVUGH) [1-4].

    Even when “second look” endoscopy is mentioned for recurrent bleeding [5], or surgical intervention is contemplated [6], no mention is made that the precaution should be taken to rule out PADF.

    The relationship between AAA and NVUGH is a complex one. Firstly, there is an association between AAA and Peptic ulceration [7]. In the

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