
Forensic Categories Among Patients in the ED
By Georgia A. Pasqualone, MSN, MSFS, RN, CEN, DABFN
In this litigious society, recognition of the forensic issues that accompany patients into the emergency department (ED) is nearly as important as the priorities in rendering life-saving treatment. Research has shown that there are at least 24 types of forensic categories among patients seen at a community hospital ED. By identifying the categories and numbers of patients within these categories, this data will help identify the need for a clinical nurse specialist (CNS) in forensic nursing. A CNS in forensic nursing should be established as an integral component of the ED healthcare staff.
The establishment of forensic categories will further clarify the educational needs of the ED nursing staff. Nurses must be educated with regard to the forensic issues surrounding the victims of trauma and violent crime. If staffing is inadequate, the priorities of treatment may well outweigh the importance of recognizing, documenting and collecting evidence. If important evidence is destroyed and/or overlooked, a serious injustice could be rendered to the patient, suspect or hospital.
The healthcare industry must face the serious problems of our nation. Until recently, the term forensic has conjured up in the minds of the general population morbid thoughts equivalent to "Tales From the Crypt." The O.J. Simpson trial enlightened the American public to a certain degree and introduced some of the various disciplines and technologies of the forensic sciences, such as DNA testing, footwear impressions, fingerprinting, blood spatter patterns and chain of custody. The nursing profession has recently embraced multiple facets of the forensic sciences. Violence has been identified as one of the leading public health hazards of our time. The majority of victims of violence are seen in EDs, which means nurses today must be educated in the proper recognition, interpretation, collection, documentation and photo documentation of not only the ramifications of violence, but also the forensic evidence associated with it. The collection of clothing with blood spatter or gunshot residue, and the photographing of injuries could mean the difference between justice or its miscarriage.
Community hospitals are intensifying their scrutiny of healthcare delivery in an attempt to reduce their healthcare costs. Our healthcare environment is one filled with increasing pressure for appropriateness of care, justification and outcome of medical services, and potential denial of reimbursement for unnecessary treatments. Hospitals are under increasing pressure to improve their efficiency as healthcare providers. The denial of services has the potential for cutting corners and negligence in order to save a few pennies. These negligent acts can expand into malpractice and this only succeeds in providing work for the attorneys.
A general lack of knowledge about forensic issues identifies a need for the categorization of this unique patient base. A systematic approach to the clarification and delineation of forensic categories is compulsory, should the need arise to provide evidence in a litigious situation. Concise, chronological identification and documentation of these evidentiary groupings is essential as a prerequisite of current and future ED nurses' inevitable direct involvement in judicial proceedings. ED nurses' attitudes and familiarities with the majority of forensic issues are, more often than not, limited to their initial dialogue with law enforcement personnel concerning the medical condition of a patient. ED nursing personnel must be aware at all times of the necessity to integrate the appropriate collection of any significant evidence, both demonstrative and testimonial, while providing care. This most assuredly can be accomplished in a proficient manner.
The trail of evidence and the chain of custody are being destroyed far too many times during the flurry of saving a life. It later appears in court that justice is not being served, that the guilty are escaping punishment, and that victims are being victimized once again. Mistakes in forensic cases exist, made and then compounded by ignorance, incompetence or indifference. By initiating a conscientious system of recognizing, assessing, collecting, documenting, photo documenting and reporting, ED nurses can assist their patients, their local police departments and the entire legal community by maintaining chain of custody, being aware of important issues and detailing all evidence in the medical record.
The system must be founded upon a categorization of forensic issues. With the establishment of categorizations of forensic patients in the ED, comes the development of an orderly process affording direct communication among all participants of the medico-legal system. Categorization will assist the ED nurse in the systematic management of any patient with potential forensic implications. It will also assist the nurse in recognizing the mandated reporting that must be completed in certain instances.
Demographics of the Study
The setting for this study was the ED of a small community hospital within 10 miles of a major metropolitan city in eastern Massachusetts. The hospital's ED sees approximately 22,500 patients each year. The categorization system was developed from a retrospective study of ED medical records. The population studied consisted of every person (n = ) admitted to the ED during a 60-day period of time.
The chart represents the 24 categories and the percentages of occurrences. The categories of child, elder and disabled abuse and neglect; human and animal bites; sharp force injuries; organ and tissue donation; burns; and firearm injuries were extrapolated from ED admissions and statistics of mandated reports taken over a one-year period. Although food and drug tampering, gang violence and malpractice and/or negligence were not categories identified among the ED population during the study, they are categories having the potential of occurrence at any time in any ED.
Recommendations
There is a need to place advanced practice forensic nurse clinical specialists into our hospitals, nursing homes, schools, criminal justice system and anywhere else in our communities where nurses can act as the liaisons between medicine and the law. Nurses will be prepared to enter into this new career field as medico-legal consultants for attorneys, insurance companies, law enforcement agencies, medical examiner and coroner systems, school departments, nursing home administrations and hospital EDs. Although the contemporary media has portrayed the forensic scientist as a death-investigating Quincy, able to solve a murder in less than an hour, one can now appreciate the comprehensive involvement of forensic nursing and its far-reaching influence with this science of the 21st century.
The need for a greater consciousness on the part of all healthcare providers with regard to delivery of more cost-efficient medical care cannot be emphasized enough. The forensic needs of the client, though, must not be jeopardized. Efficiency can be improved through a well-coordinated intelligent process that improves performance without compromising quality. More efficient utilization of resources means more resources can be available for those in need.
The Forensic Cart
When interfacing with a forensic patient, the ED nurse must strive to utilize a logical approach and have an algorithmic method in place for the forensic nursing process. The nurse can then recognize, assess, collect, document, photo document, preserve and report, depending on the patient category. An ED forensic cart is one way of taking the initial guesswork out of "what do I do now?" The cart can be similar to those utilized by the ED for code situations. On it should be various sizes of clean paper bags for clothing; plastic containers for leaves, fibers, buttons, paint chips and the like; clean white paper for making bindles for the smallest hairs and fibers; sterile swabs; sterile water; evidence tape; felt-tip pens; labels; clean sheets; and file folders containing all mandated reporting forms. The state's sexual assault evidence collection kit should also be included on the cart.
A 35mm camera or an instant camera system plus film should be available at all times to the ED personnel for photo documentation of injuries. If a hospital policy for chain of custody for film processing is in place, the 35mm system can be utilized with peace of mind. Otherwise, instant photographs can be placed in the medical record immediately. There is both practicality and economy when utilizing the cart when caring for forensic patients.
Inservice education must be an ongoing process. Laws change and ED nurses must be kept informed of legislative ramifications of their care. Policies and procedures should be written and overhauled in order to manage the forensic populations properly. In fact, the study of forensic nursing should be integrated into the most basic of nursing educational processes. Evidence may present itself to paraprofessionals as easily as it is to the professional healthcare provider. If evidence is destroyed unknowingly, cases can be lost in the process.
Hospitals should initiate a tracking mechanism for all the forensic categories. Unawareness of the incidences of forensic situations inhibits the gathering of valuable statistics, as well as deterring the process of addressing educational needs for all staff. Registration personnel could potentially track forensic categories as they register into the ED; however, nursing staff should be making note of the categories as the patients are seen. By identifying forensic categories and the numbers of patients within these categories, the high percentage of forensic patients (27 percent) identifies a need for a forensic CNS in the ED setting. A CNS in forensic nursing should be established as an integral component of the staffing patterns in the ED.
Nurses must be educated about the forensic issues surrounding the victims of trauma and violent crime. Categorization will lead to recognition; recognition will lead to adequate staffing; and adequate staffing will lead to a more complete preparedness and treatment for this unique population of patients. If staffing and education are inadequate, the priorities of treatment may well outweigh the importance of recognizing, documenting, and collecting evidence. If important evidence is destroyed and/or overlooked, a serious injustice could be rendered to the patient, suspect, or hospital.
Our rapidly evolving health-care environment necessitates a change in the way we practice nursing. Nurses aware of mandated reporting cases protect patients' rights as well as maintaining patient safety. Forms should be completed correctly and expeditiously. Statistics should be recorded and this information could be utilized for greatly needed research on the cycle of violence and classification of patients. Nurses aware of the benefits of photo documentation can save their clients time and money within the judicial system due to the accuracy and supplemental recording of injuries. In addition, forensic nurse consultants can save hospitals time and litigation fees with their testimonial expertise. Knowledgeable nurses can truly decrease the number of lawsuits that are actually introduced into the court system. Nailing the evidence could potentially eliminate the need to go to trial. The application of forensic techniques is essential. The structure of the entire forensic nursing process is predicated on maintaining a certain state of mind -- an investigative, interpretive, dogmatic search for the facts and the truth.
Georgia A. Pasqualone, MSN, MSFS, RN, CEN, DABFN is the clinical nurse specialist for the ED at Winchester Hospital in Winchester, Mass.
Percentages of Forensic Categories Seen at a Community Hospital Emergency Department |
Sample Population Based on a 60-day Survey (n = )
914 Patients (27%) Qualified as Forensic Cases |
Forensic Category |
Frequency |
Percentage |
Occupation-related injuries |
289 |
8.41% |
Transportation injuries |
193 |
5.62% |
Substance abuse |
160 |
4.66% |
Personal injury |
125 |
3.64% |
Child abuse & neglect |
464 per year |
2.06%* |
Forensic psych |
49 |
1.43% |
Environmental Hazards |
25 |
0.73% |
Assault & battery |
22 |
0.64% |
Abuse of the disabled |
130 per year |
0.58%* |
Human and animal bites |
90 per year |
0.40%* |
Questioned death cases |
10 |
0.29% |
Elder abuse & neglect |
56 per year |
0.25%* |
Domestic violence |
6 |
0.17% |
Clients in police custody |
2 |
0.06% |
Sexual assault |
2 |
0.06% |
Sharp force injuries |
7 per year |
0.03%* |
Product liability |
1 |
0.03% |
Transcultural medical practices |
1 |
0.03% |
Organ & tissue donation |
6 per year |
0.03%* |
Burns over 5% BSA |
3 per year |
0.01%* |
Firearm injuries |
7 per 3 years |
0.01%* |
Food and drug tampering |
0 |
|
Gang violence |
0 |
|
Malpractice and/or negligence |
0 |
|
*Data Based on a Yearly ED Population of 22,500 |
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