Emergency Medicine

Emergency department visits in Connecticut for survivors of sexual assault before and during the COVID-19 pandemic

a b s t r a c t

Study objective: We evaluate the impact of the COVID-19 pandemic on care for survivors of sexual assault in three urban Emergency Departments (ED) in the United States.

Methods: A retrospective chart review was conducted on patients who presented after sexual assault to three EDs during 6-month intervals before and during the COVID-19 pandemic. We excluded individuals <18 years old. We performed a structured chart review to ascertain demographics, ED treatments, and adherence to guidelines for care of sexual assault survivors.

Results: Of 105 patients who received care after a sexual assault, 57 presented during the COVID-19 pandemic. The majority were female, White/Caucasian, and presented within 120 h of sexual assault. There was an increase in ED presentations for sexual assault during the pandemic. While there was no difference in medical care, there were fewer sexual assault advocates called during the pandemic. In addition, there was an increase in non-White survivors in the first 3 months of the pandemic that did not remain at 6 months.

Conclusion: The care of survivors in the ED was disrupted by the COVID-19 pandemic. While medical care

remained similar, fewer calls to sexual assault advocates, a key component of ED and long-term care of survivors, demonstrate a disruption in their care.

(C) 2023

On March 6, 2020, the first case of COVID-19 was announced in Con- necticut [1]. Prior research from Canada and Rhode Island suggests an initial decrease in Emergency Department (ED) visits for sexual assault during the first few months of the pandemic despite an increase in domestic and intimate partner violence [2,3]. An interdisciplinary team inclusive of emergency physicians and nurses, Sexual Assault Fo- rensic Examiners (SAFE), sexual assault patient advocates, and social workers are essential to the care of survivors of sexual assault. We will use “survivors” in this text for uniformity. A gap in the literature remains in understanding how a survivor’s care in the ED was affected through the course of the pandemic.

The aims of this study were to 1) assess the impact of the first six months of the COVID-19 pandemic on ED presentations for sexual as- sault and 2) assess the care provided to these patients during the first six months of the pandemic relative to six months of the year preceding the pandemic. We hypothesized that ED visits for sexual assault would be decreased at 6 months into the pandemic and that survivor length of

* Corresponding author.

stay (LOS) would increase secondary to external factors like sexual assault patient advocate communication and SAFE nurse recruitment becoming more difficult as they were staffing assignments to care for patients with COVID-19.

We conducted a retrospective chart review (Yale’s Epic Electronic Health Record) of adult patients evaluated and treated at three urban EDs who presented with a chief complaint of “sexual assault” or had an ICD-10 code (Table S1) specific for a diagnosis of “sexual assault” from March 6, 2020 to September 5, 2020 and March 6, 2019 to Septem- ber 5, 2019. Patients were excluded if they were <18 years old.

Data were extracted by two trained reviewers. Data included demo- graphic information such as patient age, gender, race, ethnicity, primary language, and time of presentation to ED after assault. We also collected information about ED care based on the American College of Emergency Physicians Clinical Policy and Connecticut Technical Guidelines [4,5]. This information included sexually transmitted infection (STI) treat- ment, human immunodeficiency virus post-exposure prophy- laxis, pregnancy prophylaxis, collection of an evidence kit, contacting a sexual assault patient advocate, and establishing appropriate follow- up. Notably in Connecticut, sexual assault evidence collection kits are

https://doi.org/10.1016/j.ajem.2023.02.010

0735-6757/(C) 2023

not recommended for any survivors who present 120 h after the assault occurred. STI treatment was defined as having STI treatment medica- tions ordered during the visit or documentation that patient was offered STI treatment, but declined. A subset of 10 charts was coded by both re- viewers to establish interrater reliability, and kappa was calculated with the data extraction form considered as a single variable, where variation between reviewers counted as disagreement. The characteristics of the survivors and of treatment were compared between the two periods using Fisher Exact t-tests and chi-square tests where appropriate. We initially compared the survivor characteristics and treatment in the first three months of the pandemic before repeating the analysis in the first six months of the pandemic. All cases were included and every record was analyzed. All statistical analyses were carried out in Stata 17.0. This study was IRB approved.

Table 1 shows characteristics of survivors presenting to the ED be- fore and during the COVID-19 pandemic at a 3-month and a 6-month time period. For data extraction, the kappa score for interrater reliability

was 0.93 (95% confidence interval [CI] = 0.89 to 0.98). More survivors presented to the ED during the pandemic than before the pandemic. There was a 97% and 70% proportional increase in ED presentations for sexual assault from 2019 to 2020 relative to total ED census in the 3-month and 6-month time period, respectively. In the 3-month and 6-month period, there was no significant difference in age, sex, ED length of stay, medical care for STI treatment, HIV post-exposure prophylaxis, and pregnancy prophylaxis.

During the first three months of the pandemic, there was a signif- icant change in the racial demographics of the survivors and in documentation that a patient advocate was called during a survivor’s stay in the ED. When analysis was extended to include the first six months of the pandemic, there was no change in racial demographics of the survivors but the significant decrease in advocates being contacted persisted. These results remained unchanged even if isolated to those who completed the sexual assault evidence collection kit.

Table 1

Demographics and care characteristics of sexual assault survivors presenting to three Connecticut EDs.

First 3 months (March 6-June 5) First 6 months (March 6 – Sept. 5)

Total

Before Covid began

After Covid began

p-value

Total

Before Covid began

After Covid began

p-value

Total ED1 census

50,973

31,247

100,743

70,578

Total ED presentations for survivors

42

19 (45%)

23 (55%)

105

48 (46%)

57 (54%)

Proportion of survivor presentation relative to total ED Census

0.00037

0.00074

<0.05

0.00048

0.00081

<0.05

ED length of stay

0.14

0.79

Less than or equal to 6 hours

25 (60%)

9 (47%)

16 (70%)

54 (51.4%)

24 (50.0%)

30 (52.6%)

>6 h

17 (40%)

10 (53%)

7 (30%)

51 (48.6%)

24 (50.0%)

27 (47.4%)

Age (year)

0.85

0.19

18-25 years old

17 (40%)

8 (42%)

9 (39%)

41 (39.0%)

22 (45.8%)

19 (33.3%)

26 years old or greater

25 (60%)

11 (58%)

14 (61%)

64 (61.0%)

26 (54.2%)

38 (66.7%)

Race

0.009

0.36

Other

13 (31%)

2 (11%)

11 (48%)

51 (48.6%)

21 (43.8%)

30 (52.6%)

White

29 (69%)

17 (89%)

12 (52%)

54 (51.4%)

27 (56.2%)

27 (47.4%)

Gender (as noted in chart)

0.84

0.51

Male

4 (10%)

2 (11%)

2 (9%)

5 (4.8%)

3 (6.2%)

2 (3.5%)

Female

38 (90%)

17 (89%)

21 (91%)

100 (95.2%)

45 (93.8%)

55 (96.5%)

Sexual assault evidence collection kit done

0.52

0.54

No

6 (14%)

3 (16%)

3 (13%)

10 (9.5%)

3 (6.2%)

7 (12.3%)

Yes

25 (60%)

13 (68%)

12 (52%)

66 (62.9%)

31 (64.6%)

35 (61.4%)

Declined, if offered

10 (24%)

3 (16%)

7 (30%)

23 (21.9%)

10 (20.8%)

13 (22.8%)

outside 120 h

window2

1 (2%)

0 (0%)

1 (4%)

6 (5.7%)

4 (8.3%)

2 (3.5%)

Time between sexual assault and ED visit

0.36

0.44

<120 h

40 (95%)

18 (95%)

22 (96%)

99 (94.3%)

44 (91.7%)

55 (96.5%)

>120

hours

1 (2%)

0 (0%)

1 (4%)

5 (4.8%)

3 (6.2%)

2 (3.5%)

Not documented

1 (2%)

1 (5%)

0 (0%)

1 (1.0%)

1 (2.1%)

0 (0.0%)

Patient advocate called (Y/N)

0.002

<0.001

No

18 (43%)

3 (16%)

15 (65%)

38 (36.2%)

8 (16.7%)

30 (52.6%)

Yes

14 (33%)

11 (58%)

3 (13%)

42 (40.0%)

25 (52.1%)

17 (29.8%)

Patient declined

advocate when

offered

Pregnancy prophylaxis offered3

10 (24%)

5 (26%)

5 (22%)

0.44

25 (23.8%)

15 (31.2%)

10 (17.5%)

0.47

No

16 (42%)

6 (35%)

10 (48%)

34 (34%)

17 (37.8%)

17 (30.9%)

Yes

HIV4 post-exposure prophylaxis offered

22 (58%)

11 (65%)

11 (52%)

0.94

66 (66%)

28 (62.2%)

38 (69.1%)

0.13

No

13 (31%)

6 (32%)

7 (30%)

27 (25.7%)

9 (18.8%)

18 (31.6%)

Yes

STI5 treatment6

29 (69%)

13 (68%)

16 (70%)

0.33

78 (74.3%)

39 (81.2%)

39 (68.4%)

0.17

No

7 (17%)

2 (11%)

5 (22%)

14 (13.3%)

4 (8.3%)

10 (17.5%)

Yes

35 (83%)

17 (89%)

18 (78%)

91 (86.7%)

44 (91.7%)

47 (82.5%)

Discharge follow-up

0.80

0.76

No follow-up

5 (12%)

2 (11%)

3 (13%)

12 (11.4%)

5 (10.4%)

7 (12.3%)

Follow-up indicated

37 (88%)

17 (89%)

20 (87%)

93 (88.6%)

43 (89.6%)

50 (87.7%)

1 ED – Emergency department.

2 In Connecticut, Sexual assault evidence collection kits are not recommended for any sexual assault presenting outside of 120 h.

3 Female sex only as defined by EHR.

4 HIV = Human Immunodeficiency Virus.

5 STI – Sexually transmitted Infection.

6 STI treatment includes those who were ordered STI medication or had documentation that they were offered but refused treatment.

In this study, we observed an increase in survivors presenting to the EDs during the first three months of the pandemic compared with the first three months in the matched time period during 2019. This in- crease in number was both in absolute numbers and also proportional to the ED census. These findings persisted six months from the start of the pandemic. The increase in presentations suggest that like the increase in domestic violence and intimate partner violence cases reported in prior studies [3], there was an increase in Sexual assaults in the first three and first six months of the pandemic in Connecticut. These findings are contrary to previous research demonstrating a de- crease in ED presentations for sexual assault [2,6,7]. Further research must be done to understand differences in our healthcare networks, state laws and regional infrastructure versus those of the other studies related to the care of sexual assault patients.

We found that there were fewer calls to sexual assault advocates when a survivor presented to the ED during the pandemic during the first three months and six months. This is consistent with a recently published study that outlined the disruption that sexual assault advo- cacy services experienced during the pandemic [8]. In our ED, sexual assault advocates were available via video chat on tablets provided by the advocacy centers in the area throughout the pandemic or by phone. We observed a decrease in utilization of advocate services, which is especially concerning given that advocates have been shown to help survivors receive medical services while mitigating survivor stress in dealing with medical providers [9]. One limitation is that advocates may have been called, but providers may not have documented that they were called. Especially since the ED is often the first point of contact after a sexual assault, future research should investigate whether this change continues to persist and the impact this has on the long-term care of survivors. In addition, this finding demonstrates a potential intervention for the interdisciplinary team – training on the value of

advocates and early communication with advocates.

We also found that, in the first three months, there was a significant increase in non-white survivors presenting to the ED. This finding did not remain at six months and further research must be done to investi- gate potential differences in 1) access to post-sexual assault services for different minoritized communities and 2) access to emergency care in the setting of a pandemic for different minoritized communities.

The generalizability of this study is limited both by retrospective de- sign, by the inclusion of data from a single hospital system in the north- eastern United States, and the small sample size. However, the data are based on multiple EDs within this large multi-hospital health system, which is a referral center for forensic evidence collection in the state. Re- gardless, patients may have chosen to seek care after sexual assault at an urgent care or at a physician office, both of which were affected by the COVID-19 pandemic. Future studies should include collecting data that includes other health systems across the country to address these limitations. Our results demonstrate that the COVID-19 pandemic has illuminated gaps in care and an overall increase in sexual assaults and a decrease in access to services for survivors. These data provide us with an important snapshot of the complexities of interdisciplinary care among sexual assault survivors that should be considered for future research and our collective efforts to improve the care we provide for this population.

Prior presentations

Yang, D., Cordone A., Sun, W., Gawel, M., Sangal, R., Dodington, J. Decreased Use of Sexual Assault Advocates During the COVID-19 Pandemic. New England Regional Meeting of the Society for Academic Emergency Medicine. 2022.

Yang, D., Cordone A., Sun, W., Gawel, M., Sangal, R., Dodington, J. Decreased Use of Sexual Assault Advocates During the COVID-19 Pandemic. Society for Academic Emergency Medicine, Annual Meeting. 2022.

Funding sources/Disclosures

D.Y. reports no conflicts of interest.

A.C. reports no conflicts of interest.

W.W.S. reports no conflicts of interest.

M.G. reports no conflicts of interest.

R.S. reports no conflicts of interest.

J.D. reports no conflicts of interest.

CRediT authorship contribution statement

David Yang: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Alexis Cordone: Writing – review & editing, Data curation, Conceptualization. Wendy W. Sun: Writing – review & editing, Data curation, Conceptual- ization. Marcie Gawel: Writing – review & editing, Data curation. Rohit

B. Sangal: Writing – review & editing, Supervision, Formal analysis. James Dodington: Writing – review & editing, Supervision, Formal analysis, Data curation.

Acknowledgments

N/A.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.02.010.

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