Background Due to the increasing demand for sexual abuse evaluations in the emergency department (ED) we have instituted a pediatric Sexual Assault Nurse Examiner (SANE) program. All examinations performed by the SANE are fully videodocumented with a Medscope and are reviewed in entirety by the program medical director within 48 hours. This study was performed to describe the number and types of cases seen and to compare SANE examination interpretation with the assessment of the physician peer reviewer.
Methods A chart review (standardized form) of pediatric patients seen in the ED from 4/25-9/30/04 for suspected sexual abuse (SSA) by the SANE was performed. Demographic data were entered into the database. Examination findings were assigned a classification according to the criterion published by Joyce Adams, MD, in “Evolution of a Classification Scale: Medical Evaluation of Suspected Child Sexual Abuse” (Child Maltreatment 2001;6). The SANE examination findings and physician reviewer correlation were compared using kappa statistics. Data were analyzed using Epistat®.
Results A total of 103 patients were seen in this 5-month period for SSA. 88% were female with a racial distribution of 59 African American, 39 Caucasian, 2 Hispanic and 3 other. Mean age was 7 years (median 5). 52% of patients presented in the evening (3-11 pm) with 29% in the day (7 am til 3 pm) and 16% at night (11 pm til 7 am) (3 charts missing time). Median time to presentation was 30 hours (range 2 hours to 2 years).SANE examination findings were normal (41), nonspecific (51), highly suspicious (3) and clear evidence (8). Physician review was normal (34), nonspecific (60), highly suspicious (2) and clear evidence (7). Physician classification agreed with SANE completely in 84% of cases. Of the 16 cases in which the SANE and physician did not agree there were 10 undercalls and 6 overcalls by SANEs (majority were a difference in normal versus nonspecific, 10/16). In class 1 cases there was good agreement (k = 0.77,z = 7.9), class 2 (k = 0.71, z = 7.3) class 3 (k = 0.39, z = 3.89) and class 4 (k = 0.78, z = 7.9); all p values < .0001. Overall agreement was good (k = 0.73, z = 9.5 p = .0001).
Conclusion Pediatric sexual abuse is a growing problem and causes a significant drain on ED resources. Pediatric trained SANEs can reliably perform sexual abuse examinations. A pediatric based SANE program that utilizes physician review of the video examination meets the standard of photodocumentation with peer review for sexual abuse examinations. Pediatric trained SANEs can provide the time and sensitivity needed for a proper pediatric sexual abuse evaluation in the setting of a chaotic ED environment.
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