Even in a COVID-19 hot zone, the principles of DNA contamination minimisation are paramount in order to prevent inadvertent transfer of DNA material. The standard sexual assault examination principles, in which sources of DNA contamination are minimised from the examiner, examination surfaces, and other people in the room, should be adhered to at each step. Similarly, measures ordinarily taken to maintain the integrity of chain of custody must also be followed.
The significant risk of transmission of COVID-19 within the community posed Melbourne-based CFPs with a unique and challenging scenario - forensic medical examinations of S/COVID-19 patients. A sexual assault examination in a designated COVID-19 hot zone represents a precarious balance between a number of concurrent priorities:
- The need to address patient well-being in an unfamiliar and potentially dehumanising environment following an incident of inter-personal violence. Staff are dressed in full PPE and patients are unable to be accompanied by support persons. This can add to the physical and emotional trauma they experience.
- The maintenance of forensic sample integrity in an uncontrolled environment, including preventing DNA contamination and maintaining the chain of evidence.
- The minimisation of COVID-19 exposure to CFPs.
- The prevention of viral contamination of forensic samples and packaging.
- The diversion of hot zone staff from their ordinary duties to facilitate CFP attendance, at a time where health care resources are strained.
- The planning of post-assault management, including sexually transmitted infection screening, emergency contraception and appropriate medical follow up, despite competing acute medical issues.
The task of safely removing biological samples and other evidentiary items (such as clothing) from a COVID-19 contaminated area was arguably the most important modified aspect of conducting a forensic medical examination in a hot zone. Ordinarily, the forensic medical examination kit, a cardboard box containing samples, would be handed to attending police officers at the conclusion of the examination. Without additional precautions, the kit itself, having been inside the hot zone and in contact with surfaces within the hot zone, could potentially act as a fomite (inanimate object that can become contaminated, facilitating viral transmission to another person). Research examining the stability of SARS-CoV-2 on different surfaces suggests that virus can be detected on some surfaces up to 72 hours later [8]. Thus, modifications to normal packaging procedures were imperative, to prevent the forensic samples themselves inadvertently becoming fomites, and presenting a risk to examining practitioners, police and the receiving forensic scientists.
The patient experience during COVID-19: Additional considerations
The experience of the S/COVID-19 patient undertaking a sexual assault examination is unfortunately likely to be markedly different to that provided by the usual best-practice examination conducted within specialised sexual assault units. A designated emergency department COVID-19 hot zone is a foreign and noisy environment. All health care workers will be covered in personal protective equipment including masks and face shields, as well as adhering to physical distancing where possible. All of these measures may be perceived as a dehumanising experience.
Patients may not have the opportunity to receive face-to-face contact with police and sexual assault counsellor advocates that would normally be provided. They may perceive the request to disclose details of their alleged sexual assault via phone or videoconference as confronting. The patient may have been in isolation prior to, or subsequent to the incident, and may not have the means to seek connection with their usual support networks. In addition, they may be in a shared ward, with limitations to privacy. These challenges may be augmented for patients with additional needs i.e. hearing impairment, psychiatric conditions, cognitive impairment and people who require interpreters.
It is of vital importance that the patient’s experience be kept in the forefront of the CFP’s mind. In this unique scenario, CFP’s must be empathic and strive to establish rapport and an authentic human connection within the limitations of their interactions in a COVID-19 hot zone context.
Establishing locally relevant protocol modifications: A collaborative approach
It is commonplace for a significant time period, many months or even years, to lapse between a claim of sexual assault, and the case progressing through the criminal justice system. With current jury trials suspended in Melbourne, it is not clear how timeframes of these cases will be affected in the months and years to come. It is imperative that COVID-19 pandemic-related deviations from routine forensic protocols be clearly documented. This is essential for future court proceedings, to ensure forensic evidence obtained in a COVID-19 context is held to accepted quality standards to guarantee admissibility in the criminal justice system.
The authors note that guidelines have been provided by various clinical forensic representative bodies and jurisdictions which reflect these principles [9, 10]. Published guidelines largely provide for a controlled, ideal situation in which a COVID-19 positive patient can attend a designated sexual assault examination suite or is isolated in a private room. Modified protocols currently support telehealth or telephone consultations with the patient prior to physical examination and forensic sample collection in order to minimise practitioner face-to-face time.
Similarly, in the examinations we conducted, one practitioner explained the purpose and process steps of the forensic procedure, obtained verbal consent, and conducted the history over the phone. A phone consult, although practical in terms of reducing practitioner time in the hot-zone and exposure to the virus, limits visual cues and face-to-face development of rapport. This rapport developing step is usually considered fundamental when conducting an intrusive examination on a traumatised patient and this limitation requires acknowledgement and adjustment by the practitioner.
Additional inherent limitations to taking a phone history that have been encountered in such cases include: hot zones are often open ward settings with wall barriers on each side of the patient with only a curtain separating them from busy passageways; constant background noise and activity; poor telephone reception; poor patient speaking volume due to a sore throat and hoarse voice. All of these limitations required contemporaneous documentation. Even if a dedicated forensic sexual assault examination suite is available for use with adequate PPE and environmental precautions in place, the patient may be too unwell to be transported into that setting, or transfer may not be considered feasible or safe in a COVID-19 positive symptomatic patient.
Prior to entering hot zones and conducting forensic medical examinations, it was essential to practise the modified dual practitioner process and anticipate possible variables that may be encountered. It should be expected that in the context of a pandemic, local hospital procedures will be significantly modified, with makeshift wards and rapidly evolving protocols.
Based on our review of processes after conducting a forensic medical examination in a COVID-19 hot zone, we propose the following considerations in Table 1, which can be modified to suit local circumstances:
Table 1: Considerations for forensic medical examination in COVID-19 hot zones
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1. Establish contact with a hot zone ‘on the ground’ treating staff member (e.g. nurse, doctor, social worker)
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· Establish the patient’s medical status, and the value/urgency of a forensic medical examination
· Obtain information about anticipated examination location
· Request assistance with locating a nearby ‘cold zone’ set up area
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2. Optimise CFP safety in unfamiliar hot zone environment
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· Dual practitioner examination
· Minimise clinician face-to-face time in the hot zone, by first conducting a history via telehealth
· Do not bring personal belongings into the hot zone: only the forensic examination kit (keys, phones in zip-lock plastic bags if necessary)
· Don scrubs
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3. Preparation of forensic samples in a ‘cold zone’, maintaining forensic principles of minimising DNA contamination
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· Prepare and label required samples, on a DNA free surface (e.g. sterile field from forensic examination kit, or bleach-cleaned surface)
· Prepare second receptacle (e.g. smaller cardboard box) within larger outer examination kit, to remain relatively protected during the time in the hot zone
· Place desiccant sachet into smaller box: this will be the receptacle ultimately removed from the hot zone containing the samples
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4. Leave outer packaging outside the doffing station, in a clean zone
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· Before entering the hot zone, leave an outer plastic bag, security seals and COVID-19 stickers at the doffing station. This bag remains clean and will be used to transport the forensic samples out of the hospital
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5. Conducting the examination in the hot zone
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· Don PPE, and ensure each practitioner is being observed (spotted) to don correctly
· Confirm consent for procedure with patient
· Conduct general body examination
· The primary CFP conducts the ano-genital examination, wearing an additional pair of gloves on top of their PPE gloves. Forensic sampling is conducted, adhering to standard forensic double glove technique to prevent DNA contamination, changing outer gloves at each anatomical site being sampled
· The secondary practitioner assists with optimising lighting, receiving and packaging forensic samples into the inner cardboard box (still contained within the larger outer box)
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6. Exiting the hot zone
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· At the conclusion of the examination, exit the hot zone to the doffing station, where the contaminated larger outer box is discarded, followed by hand hygiene
· Doff PPE, and ensure each practitioner is being observed (spotted) to doff correctly
· The small box is sealed with tamper proof seals to maintain evidentiary standards, labelled with COVID-19 risk stickers, and inserted into the clean/clear plastic bag, followed by hand hygiene
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7. Handover of forensic samples to police
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· Avoid police entering a hospital hot zone solely to receive forensic samples: consider an alternative, discrete handover location (such as the hospital car park)
· Complete chain of custody paperwork in the presence of police
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8. Other considerations
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· Consider deferring collection of buccal reference swabs until the patient has recovered
· If photography of injuries is required, place the camera in a disposable plastic bag, use gloves when handling, and clean camera with disinfectant wipes at doffing station
· If injury documentation on a paper examination proforma is required, consider placing the completed proforma into a separate clean plastic pocket upon exiting, at the doffing station. Hand hygiene should be repeated following handling of the documents (the plastic pocket can be sealed and opened after a cautionary three-day decontamination period to prevent fomite viral transmission on paper/cardboard)
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All forensic examination kits in metropolitan Melbourne and regional Victoria are now identified with brightly coloured ‘COVID-19 risk’ stickers, to be clearly displayed on forensic sample collection kits or patient clothing bags when suspected COVID-19 or positive cases are examined. This alerts police and forensic sciences staff to the potential risks of handling the evidence and the need for cold storage of the specimens to prevent DNA degradation from being sealed in plastic.
Forensic practitioner wellbeing
The increased complexity of modifications to usual practice in health care is omnipresent in all areas of patient-facing services in the context of the COVID-19 pandemic. These modifications include additional risk assessment at triage, rapid upskilling in PPE competency, and well-rehearsed modified protocols. The value of practitioner debriefing following examinations in this context is perhaps more crucial than ever. In addition, consideration must be given to a potential reduction in health care staffing levels. For these reasons, our service has restricted COVID-19 positive forensic examinations to day and evening shifts and a formal debrief between clinicians is conducted the following day at a video handover meeting.