Establishing Pediatric Reference Ranges for Rotational Thromboelastometry.

OBJECTIVES: The aim of our investigation was to establish normal pediatric reference intervals (PRIs) for rotational thromboelastometry (ROTEM) Delta assays in a representative group of healthy children, 0 to 18 years of age, at our institution. METHODS: This was a prospective study of healthy pediatric patients undergoing elective minor surgery requiring placement of an intravenous cannula. The sample size for patients was 20 per age group of either sex from 5 different age groups based on coagulation system maturity: 0 to 6 or fewer months, more than 6 to 12 or fewer months, more than 1 year to 5 or fewer years, more than 5 to 11 or fewer years, and more than 11 to 18 or fewer years. ROTEM Delta assays assessed include the EXTEM, INTEM, and FIBTEM. RESULTS: We defined 2 sets of ROTEM PRIs for our patient population: one for patients 11 years or younger and one for children more than 11 years of age. For those 11 years or younger, the PRIs were derived from the 2.5th and 97.5th percentiles from the 0 to 11 age groups. For those older than 11 years, previously published adult reference intervals validated internally with adult normal samples were used. CONCLUSIONS: The 2 sets of PRIs were embedded into our electronic medical record, allowing clinicians to easily interpret their patient's ROTEM results against age-verified reference ranges, enabling them to make informed transfusion decisions.

Can a workbook work? Examining whether a practitioner evaluation toolkit can promote instrumental use.

In large-scale, multi-site contexts, developing and disseminating practitioner-oriented evaluation toolkits are an increasingly common strategy for building evaluation capacity. Toolkits explain the evaluation process, present evaluation design choices, and offer step-by-step guidance to practitioners. To date, there has been limited research on whether such resources truly foster the successful design, implementation, and use of evaluation findings. In this paper, we describe a multi-site project in which we developed a practitioner evaluation toolkit and then studied the extent to which the toolkit and accompanying technical assistance was effective in promoting successful completion of local-level evaluations and fostering instrumental use of the findings (i.e., whether programs directly used their findings to improve practice, see Patton, 2008). Forensic nurse practitioners from six geographically dispersed service programs completed methodologically rigorous evaluations; furthermore, all six programs used the findings to create programmatic and community-level changes to improve local practice. Implications for evaluation capacity building are discussed.

Evaluating the legal impact of Sexual Assault Nurse Examiner programs: an empirically validated toolkit for practitioners.

There has been sustained interest in the academic literature and in policy circles regarding how Sexual Assault Nurse Examiner (SANE) programs may bolster sexual assault prosecution rates in their communities, in addition to the health care they provide to their patients. To build evaluation capacity among forensic nurses so that they can evaluate their own programs, a practitioner-oriented, step-by-step evaluation toolkit (the SANE Practitioner Evaluation Toolkit) that can be used by SANE-A and SANE-P programs, and their community partners, to examine sexual assault prosecution rates in their local jurisdictions was created and validated. This article describes the process of creating and empirically validating the toolkit and presents the toolkit itself and accompanying resources that are available to practitioners. This article also provides recommendations regarding program readiness to engage in evaluation activities, without compromising program sustainability and patient care.

The Impact of Sexual Assault Nurse Examiner Programs on Criminal Justice Case Outcomes: A Multisite Replication Study.

To address the underreporting and underprosecution of adult sexual assaults, communities throughout the United States have implemented multidisciplinary interventions to improve postassault care for victims and the criminal justice system response. One such model is the Sexual Assault Nurse Examiner (SANE) Program, whereby specially trained nurses provide comprehensive psychological, medical, and forensic services for sexual assault. In this study, we conducted a multisite evaluation of six SANE programs (two rural programs, two serving midsized communities, two urban) to assess how implementation of SANE programs affects adult sexual assault prosecution rates. At each site, most sexual assaults reported to law enforcement were never referred by police to prosecutors or were not charged by the prosecutor's office (80%-89%). Individually, none of the sites had a statistically significant increase in prosecution rates pre-SANE to post-SANE. However, when the data were aggregated across sites, thereby increasing statistical power, there was a significant effect such that cases were more likely to be prosecuted post-SANE as compared with pre-SANE. These findings suggest that the SANE intervention model does have a positive impact on sexual assault case progression in the criminal justice system. Nevertheless, there is still a pressing need for improvement as the vast majority of both pre-SANE and post-SANE resulted in nonreferral/no charges filed.

Organizational correlates of secondary traumatic stress and burnout among sexual assault nurse examiners.

This study explores correlates of secondary traumatic stress (STS) and burnout among SANE nurses. Cross-sectional interviews were conducted with nurses from a random sample of SANE programs. The interview measured organizational and demographic variables and current levels of STS and burnout. STS and burnout were found to be related but not identical processes. Organizational variables played a significant role in predicting both outcomes. The results have implications for increasing organizational support as a way of lessening the impact of STS and burnout.

Identifying common practices in community-based rape prevention programs.

Community-based rape prevention programs have received little attention in the research literature. In this study qualitative methods were used to describe such programs and to assess the degree of homogeneity in their practices. In-depth interviews were conducted with representatives of 10 community-based prevention programs in a single state. Findings suggest that two typologies exist: short programs and extended programs. Homogeneity across programs was common as most programs emphasized secondary and tertiary prevention and relied on short curricula that are implemented with mixed-gender groups of students. A comparison to practices found in the research literature indicate that they are mostly using the same practices and these practices have not been demonstrated to have sustained behavioral effects that would reduce the incidence of sexual violence. Implications for future practice are discussed.

Psychosocial correlates of PTSD symptom severity in sexual assault survivors.

This study's goal was to assess the effects of preassault, assault, and postassault psychosocial factors on current posttraumatic stress disorder (PTSD) symptoms of sexual assault survivors. An ethnically diverse sample of over 600 female sexual assault survivors was recruited from college, community, and mental health agency sources (response rate = 90%). Regression analyses tested the hypothesis that postassault psychosocial variables, including survivors' responses to rape and social reactions from support providers, would be stronger correlates of PTSD symptom severity than preassault or assault characteristics. As expected, few demographic or assault characteristics predicted symptoms, whereas trauma histories, perceived life threat during the assault, postassault characterological self-blame, avoidance coping, and negative social reactions from others were all related to greater PTSD symptom severity. The only protective factor was survivors' perception that they had greater control over their recovery process in the present, which predicted fewer symptoms. Recommendations for intervention and treatment with sexual assault survivors are discussed.

Sexual assault nurse examiners' experiences providing expert witness court testimony.

Nurses from a national random sample of SANE programs were interviewed about their most recent experience providing expert witness court testimony (N = 110). Forty-three percent of the SANEs characterized this experience "fine" with no difficulties, but 58% mentioned that they had encountered problems. Challenges they faced while testifying are explored in depth and implications for forensic nursing practice are discussed.

Barriers to working with sexual assault survivors: a qualitative study of rape crisis center workers.

To better understand barriers service providers may face when advocating for survivors, a study using grounded theory and qualitative, semistructured interviews was conducted of rape victim advocates (N= 25) working in rape crisis centers in a large metropolitan area. Broader societal attitudes framed and were reflected in institutional responses to victims and in barriers faced by advocates working with survivors. Organizational barriers noted by advocates related to resources, environmental factors, professionalization, and racism. Staff burnout was a major barrier affecting advocates' ability to help survivors. Finally, the most salient direct service barrier was secondary victimization by criminal justice and medical or mental health systems.

Responding to sexual assault victims' medical and emotional needs: a national study of the services provided by SANE programs.

We measured the consistency with which a national random sample of 110 Sexual Assault Nurse Examiner (SANE) programs provided 17 services to sexual assault victims. SANE programs consistently offered forensic evidence collection, sexually transmitted infection (STI) prophylaxis, information on HIV, information on pregnancy risk, and referrals to community resources. Reasons programs did not routinely offer particular services (e.g., STI cultures, HIV testing/prophylaxis, emergency contraception (EC)) included financial constraints, difficulties balancing medical care with legal prosecution, and affiliations with Catholic hospitals.

Sexual Assault Nurse Examiner (SANE) program goals and patient care practices.

PURPOSE: To examine Sexual Assault Nurse Examiners (SANE) programs' goals and guiding philosophies and how they influence patient care practices for sexual assault victims. DESIGN: Data were collected from a national random sample of SANE to examine whether programs differed significantly in their goals and patient care practices. METHODS: Iterative cluster analysis was used to identify types of programs distinct in their stated goals. FINDINGS: Three types of emphasis in SANE programs were identified: (a) prosecution of cases as a primary goal; (b) attending to patients' emotional needs, supporting feminist values, empowering patients, and changing the community response to rape; and (c) least importance on prosecution of cases and average importance on the other goals. Programs that were more focused on prosecution goals provided less comprehensive patient services. CONCLUSIONS: Programs focused on prosecution as a primary goal were less likely to provide comprehensive services, especially those involving patient education. Such information is important for patients because their health concerns (e.g., pregnancy, STIs) have long-term implications for their well-being. Historical and structural differences among SANE programs might explain these different patient care practices. Researchers should examine the underlying processes in SANE programs that shape both their goals and patient care approaches.

The role of victim-offender relationship in women's sexual assault experiences.

This study's goal is to identify differences in background, assault, and postassault factors according to the victim-offender relationship. A mail survey is conducted with more than 1,000 female sexual assault survivors (response rate 90%) recruited from college, community, and mental health agency sources. Stranger assailants are associated with a greater victim perceived life threat, more severe sexual assaults, and ethnic minority victims. Positive social reactions do not vary according to the victim-offender relationship, but stranger victims report more negative social reactions from others than do victims of acquaintances or romantic partners. Assaults by strangers and relatives are associated with more posttraumatic stress disorder (PTSD) symptoms than assaults by acquaintances and romantic partners. As expected, survivors' social cognitive responses to rape and social reactions from support providers are stronger correlates of PTSD symptoms than demographic or assault characteristics in general, but correlates vary across victim-offender relationship groups.

Correlates of comorbid PTSD and drinking problems among sexual assault survivors.

Numerous studies show that sexual assault victims are likely to develop PTSD and have a greater risk of drinking problems than nonvictims. However, little is known about what differentiates survivors with PTSD only from those with comorbid PTSD and drinking problems. In this study, a large, diverse sample of community-residing women who had experienced adult sexual assault was surveyed. Logistic regression analyses were conducted to identify pre-assault, assault, and post-assault factors differentiating survivors with PTSD only from those with PTSD and drinking problems. Results showed that survivors with less education, histories of other traumas, who blamed their character more for the assault, believed drinking could reduce distress, drank to cope with the assault's effects, and received negative social reactions were more likely to have comorbid PTSD and drinking problems than those with PTSD only. Implications for future research and treatment with sexual assault victims are discussed.

Correlates of comorbid PTSD and polysubstance use in sexual assault victims.

A diverse sample of community-residing women in a large metropolitan area who had experienced adult sexual assault was surveyed using standardized measures in an NIAAA-funded study (2003-2004). Four groups (N = 503) of victims: (1) post-traumatic stress disorder (PTSD)-only, (2) PTSD and illicit drug use, (3) PTSD and drinking problems, and (4) PTSD and polysubstance use were compared using bivariate analyses. Victims with PTSD/polysubstance use had lower socioeconomic status, more extensive trauma histories, worse current psychological functioning, more problematic post-assault psychosocial experiences, and more sexual revictimization at follow-up than those with PTSD only. Implications for future research are discussed.

Trauma exposure, posttraumatic stress disorder and problem drinking in sexual assault survivors.

OBJECTIVE: Sexual assault history is associated with higher risk of problem drinking in women, yet little is known about mechanisms linking trauma histories to women's problem drinking. This study examined how trauma histories, alcohol-related cognitive mediators and posttraumatic stress disorder (PTSD) relate to past-year problem drinking in adult female sexual assault survivors. METHOD: Data from self-report questionnaires completed by a large, diverse sample (N = 865) of community-residing women who had experienced adult sexual assault were analyzed. Structural equation modeling was used to test a theoretical model examining the relationship between trauma exposure, alcohol-related cognitive mediators, PTSD symptoms and past-year problem drinking. RESULTS: These analyses suggested that trauma exposure, drinking to cope with distress and tension-reduction expectancies are the most consistent factors associated with problem drinking, whereas PTSD symptoms are not. Drinking to cope and tension-reduction expectancies were both related to greater PTSD symptoms, consistent with self-medication theory. CONCLUSIONS: These results suggest that trauma histories, drinking to cope and tension reduction may be important risk factors distinguishing sexually assaulted women who develop problem drinking from those who do not. Screening women for trauma histories even within samples of victims and assessment of women's ways of coping and beliefs about alcohol's effects may help to identify those at greater risk for problem drinking.

Correlates of women's sexual assault disclosure to informal and formal support sources.

Deciding which people to tell about sexual assault is an important and potentially consequential decision for sexual assault survivors. Women typically receive many different positive and negative reactions when they disclose sexual assault to social support sources. A diverse sample of adult sexual assault survivors in the Chicago area was surveyed about sexual assault experiences, social reactions received when disclosing assault to others, attributions of blame, coping strategies, and PTSD. Analyses were run to identify demographic, assault, and postassault factors differentiating women disclosing to informal support sources only from those disclosing to both informal and formal support sources. Women disclosing to both formal and informal support sources experienced more stereotypical assaults, had more PTSD symptoms, engaged in less behavioral self-blame, and received more negative social reactions than those disclosing to informal support sources only. Implications for future research and intervention are discussed.

Organizational characteristics of Sexual Assault Nurse Examiner programs: results from the national survey project.

A random sample of representatives from Sexual Assault Nurse Examiner (SANE) programs throughout the United States were contacted to participate in in-depth telephone interviews about program operations and services for sexual assault patients. Programs that had been in operation 5 years or less at the time of this study are compared to older programs to examine trends.