COLORADO SPRINGS — UCHealth’s team of forensic nurses cared for 2,515 children and adults in this city last year who were sexually assaulted, choked or beaten and in need of a medical exam that could become evidence in a criminal case.
These exams — more than six per day on average — took place mostly in Memorial Hospital’s emergency department, a Level I trauma center punctuated by the sounds of beeping machines, shouting amongst doctors treating gunshot victims, and law officers standing guard outside of patient rooms.
The atmosphere is chaotic and stress-inducing, the opposite of what’s best for a patient who has just been assaulted.
This spring, though, UCHealth Memorial Hospital will open a first-of-its-kind forensic nursing center in a space separate, but attached to its emergency department. The center, funded through a $3 million grant from the Colorado Division of Criminal Justice, has five exam rooms, each painted a calming blue and one with an in-room shower tiled in gray stone.
There’s also space for TESSA, a local organization that offers emergency shelter, counseling and support groups for victims of intimate partner violence, assault, child abuse and human trafficking.
The unit will house an expanding telehealth program that allows forensic nurses at Memorial to guide nurses in rural areas through sensitive sexual assault exams. The team so far is working with 15 other hospitals across the state, many in mountain and plains towns that perform such exams only a handful of times per year. The nurse performing the exam uses a digital colposcope, sharing their screen with the nurse in Colorado Springs, who is watching on an iPad.
Memorial was the first in Colorado to create an in-house forensic nursing program in 2012, meaning that a nurse who is trained to care for patients who have been assaulted and collect evidence for court began working inside the emergency department. Before that, a forensic nurse was on call, and was dispatched to the ER during the day and night.
As the number of patients increased — and as more patients were coming to the emergency department not just for sexual assault but for intimate partner violence, human trafficking, child abuse, elder abuse and strangulation — so has the program. The team now has 22 people, including two added thanks to the recent grant. The criminal justice grant, through the Colorado Department of Public Safety, comes from federal coronavirus aid dollars that were tagged for victims’ services by the legislature in 2021.
With the new unit, the hospital will become the first in the state to have a forensic nursing center with “trauma informed” exam rooms specifically designed to provide a sense of calm for assault victims, their own waiting room and specially trained nurses on shift. Until the center opens in April, nurses will continue using the single emergency department room dedicated to forensic exams, a cramped space with stacks of donated clothes patients can wear if their clothes were taken for evidence or if they don’t want to wear them anymore.
Forensic exams increased by tenfold in recent years
Megan Lechner, clinical manager of the hospital’s forensic examiner team, started working at the hospital more than 10 years ago, when the number of exams was less than 10% of the 2,515 per year that it is now.
“I remember when we had 200,” she said. Now, there is so much evidence collected at the hospital that the Colorado Springs Police Department and the El Paso County Sheriff’s Office keep a secure, refrigerated storage there, retrieving sexual assault evidence kits and other evidence collections three times per week. Prior concerns about a backlog in processing the evidence kits have been addressed, and they’re now processed within a few days.
Victims and survivors of violence have options regarding police involvement when they come to the hospital, however. They can ask for a full report, requesting a law enforcement officer come to the hospital if they haven’t talked to one already, or they can ask for an exam but no police interview, in which case the evidence goes into the on-site locker for later. They can also request that the hospital store their evidence collection anonymously, though they are allowed to change their mind later.
In cases of child abuse or elder abuse, however, nurses are required by law as mandatory reporters to inform authorities.
As the science behind evidence collection has evolved, the window for evidence collection has grown from three days to five in recent years. Forensic nurses look for skin cells left behind on victims’ necks or other parts of the body. They document bruises and wounds. They are trained to recognize the more subtle injuries of child abuse. And in cases of sexual assault, they use a colposcope to perform a genital exam, as well as collect any DNA evidence that might exist.
Regardless of whether the patient wants to pursue a criminal case, or whether it’s within the five-day window, the exam is worthwhile, said Sarah Hagedorn, the team’s other clinical manager.
“We really want to make sure that the patient has the opportunity to have an actual physical exam to reassure them that their body is healthy,” she said. “We may have a completely normal genital exam, but people need to hear that their body is OK, and that if there is an injury, that it will heal. Coming into the speciality, that’s not something I ever thought about — the power of that.”
Telehealth is expanding forensic exams throughout the state
The number of telehealth exams is growing fast, too. Nurses at Memorial assisted with 11 exams in 2021 and 44 last year. This year is already on track to surpass that, with 19 exams so far.
Telehealth sites so far include Montrose, Telluride, Salida, Vail, Steamboat Springs, Craig, Cortez, Gunnison, Glenwood Springs, Trinidad, Burlington, Hugo, Springfield and Lamar.
Initially, the exams were all sexual assaults, but because of two previous, smaller grants, the program expanded to include exams following intimate partner violence, including strangulation. When a person is strangled, forensic nurses attempt to collect “surface DNA,” or genetic material left behind on the victim’s neck.
UCHealth Memorial Central is the go-to site for training for Colorado medical professionals who want to become certified as sexual assault forensic examiners, offering a free, grant-funded training program. Nurses and other medical professionals in the program’s 15 telehealth sites have completed or are working on the training, though it’s not a requirement.
“There is a massive shortage of (sexual assault nurse examiners) and forensic nurses, and clearly no shortage of patients,” Hagedorn said. “Obviously, the best case scenario is that we have trained nurses in every community.”
The course is 64 hours online and then a two-day in-person clinic at Memorial, where nurses practice giving exams to volunteer patients.
Violence is a “health care issue”
Forensic nursing is a relatively young speciality, only about 30 years old. It was pushed by rape crisis centers, which recognized that survivors of sexual assault needed specialized care.
Forensic nurses are trained in “person-first language,” making the patient’s well-being the focus of the exam, and the evidence collection the secondary point. They avoid using the term “rape kit” and instead describe how they will collect DNA and examine body parts. Sexual assault nurse examiners can offer antibiotics or the HIV prevention drug PrEP to patients who fear they will develop a sexually transmitted disease. They can also contact the hospital’s mental health team to set up therapy.
“Violence is genuinely a health care issue,” Hagedorn said. “A lot of people think about violence as a single event or a criminal justice issue. But it’s something that has all kinds of ripple effects for the patients, their families, for the community. To fully do that justice, it requires a special focus.”
In some ways, the fact that the number of exams is climbing at Memorial and in other hospitals across the state is a good thing, said Kelly Kissell, manager of the Office for Victims Programs at the state Division of Criminal Justice. It means that more people are seeking medical exams after being assaulted.
The entire UCHealth system has seen an increase in forensic exams, which reached more than 2,700 last year at University of Colorado Hospital in Aurora and Highlands Ranch Hospital. In the health system’s northern region, which includes hospitals in Loveland, Fort Collins, Greeley and Longmont, forensic exams totaled about 625 last year.
Kissell, whose office awarded Memorial the grant to build its forensic center and expand telehealth, said people in towns where there is no forensic nurse are even more likely not to report the crime.
“A victim is already traumatized after the assault has occurred and we don’t want to tell them, ‘You’ll have to drive two or three hours’” to see a sexual assault nurse examiner, she said.
“We know that statistically, a lot of victims don’t report their sexual assault. We want victims seeking that medical attention to make sure that they are physically safe and that they get the resources they need.”