Quarterly newsletter of the Colorado sane project Colorado SANE THE STATE OF SANE IN COLORADO Above: Map of existing SANE programs located in Colorado There are currently 13 SANE programs in 15 locations in the state of Colorado; 5 programs are located in urban areas, and 10 are located in rural areas. Two new programs are in development at Children’s Hospital Colorado in Aurora and North Colorado Medical Center in Greely. SANE coordinators at each hospital participate in quarterly conference calls and peer review opportunities to help coordinate programs at a statewide level. Each program collaborates with local law enforcement agencies, the legal system, and advocate groups. In 2011, more than 30 nurses completed a SANE education course, and 7 completed the Advanced Forensic Nurse Examiner course. Already in 2012, 32 nurses have completed SANE training. The Colorado SANE Advisory Board continues to provide support to communities wishing to develop new SANE programs, as well as those requesting support with existing programs. See the announcements at the end of the newsletter for information on upcoming SANE education opportunities and applications to develop a new SANE program. Issue 4 In this issue: april 2012 Special points of interest: Sustaining Your SANE Program 2 What Would You Do? 3 * Non-reporting sexual assault patients have a right to a free medical-forensic exam and DFSA test DFSA Drug Highlight 3 Tetrahydrozoline is used to facilitate sexual assault Forensic Evidence Collection Payment 4 SANE program coordinators should employ steps to build management skills in potential successors Research Review 5 Education Opportunities 6 CNEs are now available for completion of the DFSA webinar Announcements 6 Several forensic educational opportunities are available in 2012—register soon! www.uccs.edu/bethel/sane.html 2 SUSTAINING YOUR SANE PROGRAM PART 2: Succession Planning Valerie Sievers, Colorado SANE Project Director “Insanity is doing the same thing over and over again and expecting different results.” Albert Einstein Succession planning is addressed by most major business firms but is virtually non-existent in many healthcare organizations and clinical practice settings. Effective succession planning is an essential business strategy that should be utilized by successful Sexual Assault Nurse Examiner programs. Since the SANE Program Coordinator/Manager position is critical to the development, expansion & continuation of SANE program services, the current program manager should consider who is capable of assuming a leadership role when there are staffing changes. Some of the steps that can be taken to mentor forensic nursing leaders include; •Encourage SANE staff to seek out & attend professional development opportunities in the arena of leadership & business. •Involve SANE staff in the development of program policies, procedures and strategic planning. •Promote opportunities for staff to meet and interface with hospital administrators & community members; attending meetings, participating on committees and providing interdisciplinary education. •Expose experienced staff to the program budget basics, sources of reimbursement, billing procedures, service contracts and financial contacts within the healthcare facility. •Involve SANE staff in interviews of potential, new team members as well as HR policies & procedures for equitable recruiting, interviewing and hiring qualified personnel. •”Spread the wealth” of tasks that are part of the framework of a functioning SANE program to include; QA, photography review, scheduling, policy development, data collection, mentoring of novice nurse examiners, development of outreach education. Some final thoughts about SANE Program Sustainability and Fiscal Responsibility: SANE Program Coordinators/Managers should develop a business plan for the SANE Program that addresses expanding forensic services, an ethical & equitable fee for forensic services structure and plans for community outreach & marketing. Some programs have been innovative in obtaining grant funding for their individualized SANE programs. While it may be innovative to secure grant funds for the initiation of the SANE program, purchase of equipment and initial education of the nurses hired for the team, the provision of ongoing healthcare services should be supported by the sponsoring hospital or healthcare agency as they realize the benefit of having a group of specialized experts providing forensic healthcare services in their facility and community. To echo what was included in the previous newsletter article on sustainability; sexual assault nurse examiner programs continue to be recognized as the standard of care for our patients who are victims of physical and sexual violence. Providing a sustainable SANE response involves planning, community collaboration, ongoing education and a commitment to excellence in the community response to violence. References Bolton, J. & Roy, W. Succession planning; securing the future. Journal of Nursing Administration. 2004; 34 (12): 589-593. Markowitz, J. Sustainability 101; long range planning for sexual assault program managers. 2009; NSVRC. www.uccs.edu/bethel/sane.html 3 What Would YOU Do? Collection of Clothing as Evidence in Cases of Sexual Assault Consider this scenario and your response: A survivor of sexual assault presents to your hospital for a forensic exam. While the SANE conducts the exam and history, the patient reports that her assailant ripped the hooks off her bra when removing it, and that he did not wear a condom during the assault. She is wearing the underwear she donned after the assault, and there is blood on her shirt. In addition to the kit, what clothing would you collect as evidence? Now assume that the patient states she does NOT want to report the case to law enforcement – would you change what you collect as evidence? The Colorado SANE Project has received reports from SANEs and law enforcement that suggests some confusion and/or disagreement about whether clothing should be collected and provided to law enforcement officers in cases when the sexual assault is not reported. To enhance development of a standardized state response, we would like to collect additional information about this issue. Please click on the appropriate link for your job type (Law Enforcement/Criminal Justice or Health Care) to complete a VERY brief and anonymous survey on this topic. The survey will take less than 5 minutes to complete and has been approved as Exempt by the UCCS IRB (Protocol #: 12-197). DFSA Drug Highlight: Tetrahydrozoline Spiller, H; Siewert, D. (2011). “Drug-Facilitated Sexual Assault Using Tetrahydrozoline,” Journal of Forensic Science, doi: 10.1111/j.1556-4029.2011.02026.x This article describes two case studies of drug-facilitated sexual assault in which tetrahydrozoline was detected in the victims’ urine. As an over-the-counter medication (Visine), tetrahydrozoline is readily available to would-be assailants. In the first case, the drug was mixed into the victim’s drink, and her blood and urine were collected 20 hours post-ingestion. Tetrahydrozoline was detected in the urine by gas chromatography and confirmed by gas chromatography/mass spectroscopy. The second case involved a victim who was kidnapped and repeatedly exposed to drugs via injection or pouring powder over her face. Tetrahydrozoline, in addition to several other drugs (marijuana metabolite, cocaine, benzoylecgonine, alprazolam, alpha-hydroxyalprazolam, citalopram, and diphenhydramine), was found in her urine several hours after a sexual assault by her captor. The research provides support for the concept that tetrahydrozoline is used in DFSA and that GC/ MS is an effective method for detecting the drug in urine, at least up to 20 hours after an assault. When ingested, tetrahydrozoline can reduce “neuronal activity” resulting in “drowsiness, coma, respiratory depression, bradycardia, hypotension, hypotonia, muscle flaccidity, and hypothermia” (p. 3). The authors note that, “As a colorless, odorless, and tasteless liquid, it can easily be added or dissolved into drinks or food” (p. 3) and that “tetrahydrozoline will not be detected by common urine immunoassays if postassault testing occurs” (p. 3). Tetrahyrozoline is included in the DFSA panel tested by the Colorado Department of Public Health and Environment Toxicology Lab if providers select that option on the DFSA specimen collection kit. The Colorado Drug-Facilitated Sexual Assault Training webinar has been approved for 1.0 continuing nursing education credits. Click the link above to view the modules and earn your CNEs. Beth- El College of Nursing and Health Sciences at the University of Colorado at Colorado Springs is an approved provider of continuing nursing education by the Colorado Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Provider #: BEC-0114, Exp. Date: 01/31/2014 www.uccs.edu/bethel/sane.html 4 Who pays for forensic evidence collection in sexual assault cases? Recent changes to Colorado statues provide full access to medical forensic exams for victims of sexual assault. Resulting changes in practice have created a challenging shift for multi-disciplinary responders. Unfortunately statewide entities like The Colorado Coalition Against Sexual Assault (CCASA), the End Violence Against Women (EVAW) Project, and Colorado Division of Criminal Justice (DCJ) continue to hear from responders that victims are still receiving inaccurate information about costs associated with medical forensic exams. This is particularly an issue for victims who have not yet chosen to cooperate with a law enforcement investigation. As a step to help mitigate this problem, CCASA, EVAW, and DCJ have synthesized the current related statutes for clarification. Under Colorado law (C.R.S. §18-3-407.5), a victim of sexual assault can receive a medical forensic exam without having to cooperate with law enforcement. The evidence collection portion of the medical forensic exam for medical reporting victims (those not cooperating with law enforcement at the time of the medical forensic exam) is paid for by DCJ (C.R.S. §18-3-407.5(1)(b)). However, it is important to note that any additional medical expenses (e.g., emergency department fee; medications; sexually transmitted infections testing; and other treatment costs based on injury, disease or pregnancy) may be the responsibility of the patient. Please refer sexual assault victims to the hospital billing department for details on these charges. If the attending medical professional determines a need for DFSA testing, then DCJ will pay for the testing in medical reporting cases. Only the victim will be able to access the test results. If a victim wants a medical forensic exam and wants to report the crime, the law enforcement agency where the crime occurred is obligated to pay for the medical forensic exam and DFSA testing as part of evidence collection (C.R.S. §18-3-407.5(1)). Law enforcement will receive the DFSA test results. An initially medical reporting victim can decide at a later date that she/he wants to have the crime investigated and prosecuted. Under Colorado law (C.R.S. §18-3-407.5(3)(c)), law enforcement must store the evidence for a minimum of two years. The Victim Compensation Program administered by the Colorado Department of Criminal Justice provides assistance with medical bills that result from being the victim of a crime. One requirement of receiving victim compensation is that the victim has cooperated fully with law enforcement officials, but the victim compensation board can waive this requirement. Community-based victim advocates can help victims address concerns and provide information regarding costs, resources and available victim assistance services. Organizations like CCASA and EVAW continue to offer multidisciplinary trainings and provide technical assistance regarding access to services and appropriate response to victims who have not yet decided to report an assault to law enforcement. CCASA has created a twopage fact sheet that describes the above payment issues and reporting requirements. To request the fact sheet so you can distribute it to your staff, please contact Karen Moldovan. www.uccs.edu/bethel/sane.html 5 Research Review Campbell, R; Greeson, M; Patterson, first responders in their community to ad- overstepping of boundaries” (pg 13) such as D. “Defining the boundaries: How dress issues such as misperceptions about pushing victims to report to law enforcesexual assault nurse examiners the prevalence of injury in sexual assault ment or offering medical advice. (SANEs) balance patient care and law Several articles have been published recently related to how SANEs manage their enforcement collaboration,” Journal collaborative relationships with other professionals who respond to sexual assault of Forensic Nursing, 7 (2011) 17–26_c 2011 cases. Understanding these relationships can improve your practice, your program, This article discusses how SANEs manage the conflicting demands of maintaining separation between nursing and law enforcement roles, and coordinating with the law enforcement and legal systems for the benefit of their patients. The article reviews existing literature that describes the roles and goals of the SANE and of SANE programs; the findings demonstrate that nurses must focus on patient care and maintain independence from law enforcement, both for the good of their patients, and for that of the justice system. The authors interviewed nurses and law enforcement/legal personnel in a community that has had a SANE program since 1999. Through interviews with experienced SANEs, the researchers determined that while nurses must remain neutral in terms of encouraging or discouraging prosecution, the provision of excellent care for the physical, mental, and emotional aspects of the assault (including the exam, evidence collection and education) can indirectly influence patients to proceed with prosecution by making the patient feel safe, comforted, confident in the strength of his or her case, and aware of available resources. The nurses described the need to avoid discussing personal opinions about cases with law enforcement personnel; they distinguish the difference between the police’s role of investigating the crime and the nurse’s role of caring for the patient (of which evidence collection is one part). They stressed the point that evidence collection by a SANE is only one piece of the investigation that police must carry out. and your community response to sexual assault. cases and the prevalence of false reporting of sexual assault. The article suggests policies and procedures that a SANE program can put in place to minimize the conflict inherent in a SANE’s daily practice. SANEs and ED Doctors: SANEs reported historical problems with ED physicians, before the SANEs’ role was clearly understood, that primarily resulted from belief that nurses were overstepping their bounds by prescribing medications Maier, S. “Sexual Assault Nurse Examiners’ Perceptions of Their Rela- and completing exams independently. tionship with Doctors, Rape Victim However, current relationships were priAdvocates, Police and Prosecutors,” marily positive because ED doctors appreJournal of Interpersonal Violence, pub- ciate the ability of the SANEs to spend the time necessary to complete a full exam and lished online December 26, 2011. collect necessary evidence. The author interviewed 39 SANEs in four SANEs and Police Officers: states and found that SANEs had positive and negative relationships with other pro- Positive relationships with law enforcement personnel were primarily a result of fessionals who respond to sexual assault. appreciation for the evidence and patient The author describes the importance of coordination of care between medical per- history collection completed by the SANE. Overstepping boundaries by asking the sonnel, law enforcement personnel and advocates in order to best serve the needs SANE for personal opinions about the asof sexual assault survivors. The difference sault account, territory squabbles, and vicin roles, objectives, and standards of prac- tim-blaming behavior were the primary tice between these groups of professionals issues SANEs reported with law enforcecan create confusion and frustration for all ment personnel. SANEs and Prosecutors: responders. SANEs reported primarily positive relaSANEs and Advocates: SANEs valued the role of victim advocates tionships with prosecutors as a result of as they are able to provide the support and open communication and both parties appreciating the role of the other party. The confidentiality the victim needs, which few negative accounts resulted from enables the SANE to focus on assessment and evidence collection while maintaining SANEs feeling unprepared to testify at trian appropriate patient relationship. Advo- al. cates also provide follow-up care to patients, enabling SANEs to remain unbiased as potential witnesses in legal proceedings. “…positive relationships with advocates result from open communication...” (pg The SANE program in question provides an 12) and a feeling that both professionals are annual education opportunity to sexual on the same team. “...negative interactions assault detectives, legal professionals, and are characterized by control issues or the In general, SANEs reported primarily positive relationships with all professional groups. Understanding of and appreciation for the various roles played by each type of professional and open communication among responders were the most effective methods of achieving a positive working relationship with each group. www.uccs.edu/bethel/sane.html 6 EDUCATIONAL OPPORTUNITIES Spring 2012 SANE Education Course at UCCS Colorado IAFN Adult/Adolescent: April 16-19 Pediatric: May 15-17 Day of Education: Forensic Nursing Spring 2012 SANE Education Course in Denver For more information, visit: community.iafn.org/ colorado/home November 9, 2012 Adult/Adolescent: April 30-May 3 Pediatric: June 4-6 Summer 2012 SANE Education Course at UCCS Colorado ENA Adult/Adolescent: August 13-16 Pediatric: September 12-14 2012 Colorado ENA Conference September 5, 2012 Fall 2012 Advanced Forensic Nurse Examiner Course at For more information, visit: www.coloradoena.com/2011_Website/2012COENACon UCCS ference.html Save the Date: November 6-8, 2012 More information to come soon! For more information or to register for these courses, visit: www.uccs.edu/bethel/sane.html Colorado Advocacy in Action Colorado SANE Online Peer Review Call July 11, 2012 9:30 a.m. June 10-13, 2012 Contact your SANE Program Coordinator to participate. For more information, visit: www.coloradoadvocacy.org Colorado sane project Nursing & Health Sciences 1420 Austin Bluffs Parkway Colorado Springs, CO 80918 www.uccs.edu/bethel/sane.html Colorado SANE Project Director Val Sievers: 719-255-3585 vsievers@uccs.edu Colorado SANE Project Assistant Kori Magallanez: 719-255-4354 kmagalla@uccs.edu Vail, Colorado ANNOUNCEMENTS Offices for the Colorado SANE Project are located at: University of Colorado, Colorado Springs (UCCS) Beth-El College of 2012 Conference of CCASA and CCADV The Colorado SANE Advisory Board has released a Call for Proposals for communities interested in developing a SANE program. Applications must be submitted to the Board by June 5. April is Sexual Assault Awareness Month. Please support the related events in your area: St Anthony Summit Medical Center is sponsoring its 4th Annual Fun Walk/ Run and Open House on April 28, with proceeds benefitting the hospital’s SANE program. Contact Linda Lichtendahl for more information. The Colorado Drug-Facilitated Sexual Assault Training webinar has been approved for 1 continuing nursing education (CNE) credit. Click the link above to view the modules and earn your CNE. The Colorado SANE Program would like to welcome our state’s newest SANE programs: North Colorado Medical Center in Greely, Ani Matt, Coordinator Children’s Hospital Colorado in Aurora, Coordinator TBD SANE Program Coordinators trying to set-up clinical experiences for new SANEs should contact Kimberly Penney at 9HealthFair to coordinate nurses volunteering at a local health fair to conduct well women pelvic exams with or without a mentor. Email future educational opportunities or announcements to Kori Magallanez at: kmagalla@uccs.edu www.uccs.edu/bethel/sane.html