REGIONAL SANE
PROGRAM DEVELOPMENT
Office of the Illinois Attorney General Lisa Madigan
Scope of the Problem
Scope of sexual assault is staggering
1
in 7 women in Illinois = 670,000 women (2003)
18.6% of Illinois women have been raped = 930,000
(2010)
The
Illinois Coalition Against Sexual Assault Centers
helped 18,349 survivors of sexual assault in FY 2010
But…5,316 rapes reported to Illinois law enforcement
in 2009
Why?
Current System of Care
Emergency department environment
What happens when a sexual assault patient
presents to the emergency department?
How does the staff respond?
How does the patient respond?
Best Practice Patient Care
Patient placed in private waiting room or designated examination room
immediately following triage*
Medical screening examination by physician or other qualified
healthcare professional
Medical-forensic examination and medications ordered by physician*
Specially trained health care provider performs medical-forensic
examination (24/7 availability of SANE)
Patient only has to disclose full account of sexual assault to one health
care provider (SANE)
One provider completes entire medical-forensic examination (SANE)
Medical-forensic examination begins in a timely fashion (within one hour
of ED arrival)
*SASETA requirements
Best Practice Patient Care
Health care provider spends as much time as needed with patient (one-toone patient ratio)
Advocate called right away, automatically and remains with patient during
medical-forensic examination with patient consent
Informed consent*
STI testing if warranted*
STI prophylaxis medication*
HIV risk assessment*
HIV prophylaxis medication (HIV testing, CBC, serum chemistry, 3-5 days of
medication, referral to HIV specialist)*
Hepatitis B/tetanus vaccination if warranted
Pregnancy test*
ECP medication or referral for immediate ECP access*
*SASETA requirements
Best Practice Patient Care
Evidence collection within 7 days of sexual assault*
Drug Facilitated Sexual Assault assessment and evidence collection*
Head-to-toe physical assessment*
Photography of injuries
Nuclear dye (toluidine blue dye) to assist in genital injury detection
Magnification tool to assist in genital injury detection
Strangulation assessment if warranted
Safety assessment
Detailed patient education and discharge instructions*
HFS Authorization for Payment Voucher issued
Referral to local rape crisis agency, counseling, follow-up examination and
victim’s compensation*
*SASETA requirements
Definition of SANE
A registered nurse who has been specially trained
to provide comprehensive care to the sexual assault
patient, who demonstrates competency in
conducting a medical-forensic exam and the ability
to be an expert witness
History of SANE
Evolved out of the women’s movement of the 1970’s
First SANE programs:
Memphis
– 1974
Minneapolis – 1977
Amarillo – 1979
Illinois - 1999
History of SANE in Illinois
Illinois General Assembly charges the Illinois
Criminal Justice Information Authority (ICJIA) to
conduct the SANE Pilot Program in 1999
Findings
Illinois’
include:
SANE Pilot Program substantially improves community
response to victims of sex crimes
Illinois’ SANE Pilot Program improves the quality of evidence
collection
History of SANE in Illinois
Sexual Assault Survivor Emergency Treatment Act
(SASETA) defines SANE in 2002
"Sexual Assault Nurse Examiner” means a registered nurse who has
completed a sexual assault nurse examiner (SANE) training program
that meets the Forensic Sexual Assault Nurse Examiner Education
Guidelines established by the International Association of Forensic
Nurses
A sexual assault nurse examiner may conduct examinations using the
sexual assault evidence collection kits, without the presence or
participation of a physician
History of SANE in Illinois
Office of the Illinois Attorney General (OAG) Lisa Madigan
recognized that the response to sexual assault survivors was
inadequate
OAG receives grant monies to start the SANE Training Program
in 2003
Goal:
Provide free, consistent, high-quality SANE training throughout
Illinois
Improve medical-forensic services to sexual assault survivors
History of SANE in Illinois
SANE Training Program Mission:
To increase the number of SANEs working in Illinois by
providing high quality, consistent education, and support for
registered nurses and other professionals serving sexual
assault survivors
Provides free didactic SANE training
Sets clinical training guidelines and provides assistance
with requirements
Any sexual assault survivor service provider able to
attend
Includes all healthcare providers
History of SANE in Illinois
SANE Training Program Provides:
40-hour Adult/Adolescent (basic) SANE training
16-hours of online content
40-hour Pediatric SANE training
16-hour Advanced SANE training
Adult/Adolescent clinical SANE training
SANE clinical guidelines
To date, over 830 individual nurses attending Attorney
General’s Office hosted SANE training
1194 total attendance
History of SANE in Illinois
OAG partnered with the Illinois Hospital
Association (IHA) to create a statewide SANE
Action Plan
Goals:
Double
the number of fully-practicing SANEtrained medical professionals from 75 to 150
Establish hospital-based SANE programs in each
of the 11 trauma regions of the state
Deadline: one year
Press
conference held October, 2011 as kick-off
Why SANE?
“Forensic Nurses play an integral role in bridging the
gap between law and medicine. They should be in
each and every emergency room.”
Joseph Biden, Vice President, United States
SANE Program Mission and Goals
SANE program mission: To provide compassionate, objective,
comprehensive and timely medical-forensic care to every sexual assault
patient
SANE program goals:
To ensure that SA patient is not re-traumatized by healthcare system
To provide best practice SA patient care and medical-forensic examination,
including evidence collection, photography and thorough documentation
To evaluate risk and provide treatment to prevent STIs and pregnancy
To provide a safety assessment and crisis intervention
To refer SA patient for follow-up services, including local rape crisis agency
To enhance the ability for law enforcement to investigate and prosecution to
successfully prosecute the SA, including expert testimony if needed
SANE Program Obstacles
Inadequate funding
Lack of investment and leadership
Lack of understanding of SANE and best-practice
SA patient care
Can a registered nurse do that? Speculum
placement!
Regional SANE Program Development
Steps are fluid and can be completed in any order
Proceed in manner that best fits the program
Regional SANE Checklist provided with 3 sections:
Initiating
Hospital Internal Steps
Regional Hospital to Hospital Steps
Community Steps
Process can take 1 to 3 years
Initiating Hospital Internal Steps
Assign a point person to work on program
development
Need
invested staff to lead efforts
Can be full or part time dedicated to SANE
Initiating Hospital Internal Steps
Conduct a needs assessment for hospital and region
Needs
assessment form provided for guidance
Try to acquire at least one year of data during the
same defined timeframe
Needs Assessment Questions
How many medical-forensic exams are performed at
the initiating hospital and other regional hospitals?
May
need to use billing codes or how many SA kits
completed
Reach out to surrounding hospitals for data
Utilize local rape crisis agency
Will
have data on medical advocacy visits to hospitals
Contact
Illinois Hospital Association
Needs Assessment Questions
How many sexual assaults occur within local
community and region?
Community
= city or area
Region = county, EMS region, other
Utilize the Illinois Coalition Against Sexual Assault
(ICASA) and local rape crisis
Research national data
Needs Assessment Questions
How many sexual assaults are reported to law
enforcement?
Look
at city and surrounding law enforcement agencies
Look at county sheriff’s office
May be able to acquire data on agency website
Look at FBI Uniform Crime Report for Illinois
http://www.isp.state.il.us/crime/cii2009.cfm
Needs Assessment Questions
What is the current protocol and response to sexual
assault patients and is it adequate?
Consider:
Is
best practice care being provided?
Is standard of patient care equal?
Review
response protocol approved by IDPH
Discuss with staff
Review patient charts
Was
patient care consistent with response protocol and
SASETA?
Reach
out to local rape crisis
Needs Assessment Questions
Is evidence collection completed properly?
Consider
“typical” staff training
Discuss with staff
Reach out to local rape crisis
Reach out to Illinois State Police (ISP) forensic scientists
Find
your closest center at:
http://www.isp.state.il.us/docs/fslabareamap.pdf
Contact ISP SA liaison Rhonda Carter at 217-782-4975
Needs Assessment Questions
Is medical-forensic documentation thorough and
helpful for the investigation and successful
prosecution?
Consider
“typical” staff training
Discuss with staff
Reach out to law enforcement
Reach out to State’s Attorney’s Office
Chart review by SANE expert for feedback
Needs Assessment Questions
Does the presence of a sexual assault patient create
a strain on the hospital ED?
Consider:
Staff
comfort with conducting the exam and evidence
collection
Average visit time
Discuss
with staff
Observation
Reach out to local rape crisis
Regional Hospital to Hospital Steps
Reach out to other area hospitals
Reach out to affiliate and non-affiliate hospitals in
same city and/or region
IHA
member hospital map provided
Other SANE committed hospitals in your EMS region
Present findings in needs assessment
Discuss collaboration to provide SA patient care
May
need to explain benefits of SANE and best practice
SA patient care
Discuss different regional SANE program models used
nationally
Regional Hospital to Hospital Steps
Determine best regional SANE program model and define
service area
Two basic regional SANE models: one designated SANE hospital in
community vs. team of SANEs that respond to multiple hospitals in
community
Program site can be hospital-based housed within ED, hospitalbased housed in another location, community-based (clinic setting,
in rape crisis agency, etc…) or a combination of hospital and
community-based
Program can be commercial, non-profit or government-based
Service area unique to program, can be city-wide to multi-county
Regional SANE Program Models
Designated hospital:
All other hospitals transfer sexual assault patient to “designated” SANE or sexual
assault treatment center
SANEs on-call and respond to designated hospital or on-shift 24/7 in emergency
department
Law enforcement, EMS and rape crisis agency refers or transports all medically stable
sexual assault patients to designated SANE hospital
SANEs are employees of the hospital or another agency with privileges to practice at
hospital
Medical-forensic examinations performed in a designated room within the emergency
department or another hospital space
SANE salary paid by the hospital or state reimbursement program
May have more than one hospital that participates or have a rotating hospital system
within the community
Model programs: Memphis, TN; Fort Wayne, IN; Milwaukee, WI; Tulsa, OK;
Oklahoma City, OK; Fairfax, VA; Akron, OH; Salt Lake City, UT
Regional SANE Program Models
Designated hospital pros:
Staff,
supplies, equipment, etc… are all centrally
located
Setting familiar and comfortable for SANEs and other
hospital staff
Designated hospital cons:
Other
hospitals may not want to refer to another facility
Inconvenient for SA patient
Regional SANE Program Models
Team of traveling SANEs:
Common float-pool of SANEs that travel to hospitals within the
community
SANEs on-call and respond to hospital where patient presents
Patients are not transferred from one hospital to another
SANEs are employees of a system of hospitals or another agency
with privileges to practice at hospital
Medical-forensic examinations performed in a designated room
within the emergency department
SANE salary paid by the group of hospitals, another agency or
state reimbursement program
Model programs: South Carolina; Houston, TX; Boston, MA;
Portland, OR; West Virginia
Regional SANE Program Models
Team of traveling SANEs pros:
Do
not have to transfer/refer patient
More convenient for patient
Team of traveling SANEs cons:
Not
convenient for SANEs
Travel costs
Need portable kit/supplies
Decreased comfort level for SANEs and other hospital
staff
Regional Hospital to Hospital Steps
Determine SANE program location and facility
space for medical-forensic exams
Need
SANE designated space
Consider:
Comfort
of the SA patient
Access to medical support and emergency care
Access to pharmacy and medication
Access to laboratory testing
Access to supplies and equipment
Regional Hospital to Hospital Steps
Develop joint policy and procedures for regional
SANE program
This
may be step that takes the longest
Determine standard response algorithm
Determine response time
Typical
is one hour, but must consider travel distance for
SANE
Determine
Will
how SANEs will be notified and when
need a centralized call center
Determine
needed
if MOUs and/or transfer agreements are
Patient Access to SANE Program
How are SANE services accessed:
SA
victim reports to law enforcement
Law
enforcement notifies SANE of incoming patient and
transports to program
SA
victim calls local rape crisis hotline
Rape
crisis refers to program and notifies SANE of incoming
patient
SA
If
victim presents at local hospital for care
exam site, SANE notified of patient in ED
If not exam site, patient transferred/referred to SANE and
hospital notifies SANE of incoming patient
Regional Hospital to Hospital Steps
Develop MOUs and transfer agreements between
hospitals and other community partners
MOUs
needed for SANE privilege to practice at nonemployee hospital
Transfer agreements needed if one hospital is
transferring to another
Involve hospital legal and risk management
departments
Consider EMTALA
Examples of both provided
Regional Hospital to Hospital Steps
Submit area-wide sexual assault treatment plan to
IDPH
Find
IDPH requirements at:
http://www.ilga.gov/commission/jcar/admincode/077
/077005450000500R.html
Each hospital will still need to be designated as a
“treatment” or “transfer” hospital by IDPH
Hospitals involved in area-wide program submit plan
together
Regional Hospital to Hospital Steps
Create a SANE program budget
Budget worksheet included
SANE model is usually more cost effective than the ED nurse/physician
approach
Creates organized, efficient, less time-consuming response
SANEs time more cost effective
Streamlines billing process
SANE program will increase the number of SA patients seen…If you
build it, they will come
Determine a per patient cost and projected revenue figure and compare
to the current system of care
Always consider the quality of patient care that is being delivered under
the current system versus the quality utilizing the SANE model
SANE Program Budget
SANE services start-up costs to consider:
SANE
Coordinator (full or part-time)
SANE staff salary
Training of SANEs
Designated space for medical-forensic examinations,
administrative duties, etc…no ED space is more cost
effective
Equipment (computer, printer, exam table/chair,
magnification tool, digital camera, alternative light
source, swab dryer, other)
SANE Program Budget
On-going costs to consider:
Salary of ED staff/SANE (physician, nurse, tech, clerk, etc…)
Number of staff that interact with sexual assault patient
Average time of ED visit by sexual assault patient from check-in to
discharge
Number of sexual assault patients seen by ED
Administration
Space/examination room
Supplies
Equipment
Laboratory tests
Medications
Training and continuing education for ED staff/SANE
SANE Program Budget
On-going revenue to consider:
Reimbursement
for patient services
Private
insurance
Medicaid/Medicare
Illinois Sexual Assault Program (Medicaid reimbursement rate
for uninsured patients)
Private/public
grants
Donations
Fundraising
Other
(partner agency buy-in, etc…)
Regional Hospital to Hospital Steps
Identify SANE program funding sources
Meet
with your internal grant and fundraising
departments for additional assistance and ideas
Takes creativity, perseverance and hard work
List of potential funding sources provided
Funding sources will be unique to your community
SANE Program Funding Sources
Illinois Sexual Assault Program
Violence Against Women Act (VAWA) and Victims of Crime Act (VOCA) grants
Administered by the Illinois Criminal Justice information Authority (ICJIA)
Website: http://www.icjia.state.il.us/public/index.cfm
For more information: 312-793-8550 or cja.grantsunit@illinois.gov
Edward Byrne Memorial Justice Assistance Grant (JAG) Program
Reimburses hospitals and other providers (i.e. ambulance, physicians) for medical-forensic services
not covered by private insurance or the Illinois Public Aid Code
Administered by the Illinois Department of Healthcare and Family Services
Requires hospital billing form to be submitted within 6 months of service
For more information, contact the Illinois Sexual Assault Program at 217-782-3303
Also administered by ICJIA; see information above
Violent Crime Victim Assistance (VCVA) Grant Program
Administered by the Office of the Illinois Attorney General
Website: http://illinoisattorneygeneral.gov/victims/vcva.html
Per statute, must be a non-profit agency that will provide victim assistance to qualify
SANE Program Funding Sources
Local and national grants from public and private foundations, corporations,
community organizations, or other agencies (i.e. United Way; organizations with
a focus on women, children, healthcare, or the community; local business groups;
corporation with office in community)
Community fund-raising
Private donations
Private donors, corporations/businesses, established pool of hospital donors
Annual or on-going hospital employee giving program
Particularly successful for start-up costs or specific equipment
Allow employees to specify “SANE program” as an option
Other government funding (i.e. State’s Attorney’s Office, law enforcement
agencies)
Other hospitals
If regional SANE model is adapted, transfer hospitals contribute to SANE-designated
hospital
Regional Hospital to Hospital Steps
Staff SANE Program
SANE Coordinator
Medical Director
Full or part-time
Usually a SANE in coordinator position
Consider reporting structure
Role = overall program operation, including call schedule and staffing,
budget, protocol development, staff training, peer review, issue management,
etc…and liaison with community agencies
Consider ED medical director or other invested physician
Role = approves protocols, peer review and on-going support
Staff SANEs
Consider non-ED nurses and hiring specifically for SANE
Most important is motivation and assessment skills
Each hospital could tribute to SANE staff
Regional Hospital to Hospital Steps
Send SANE staff to SANE training and support and provide SANE clinical
training
Utilize free OAG SANE Training Program
SANE training requirements:
40-hour adult/adolescent didactic SANE training
Combination of online (16-hours) and classroom (24-hours) training
SANE clinical training includes:
Series of activities that can be completed in 25-40 hours
The clinical training includes:
15 female genital examinations including speculum placement
Observation at a criminal trial proceeding including the direct and cross examination of a
witness
3 out 7 available activities listed on the clinical training log (e.g. visiting a local rape crisis
center and attending a 4-hour Illinois State Police Forensic Laboratory training) OR completing
a 12-hour Virtual Practicum DVD, Sexual Assault: Forensic and Clinical Management
3 medical-forensic examinations with a preceptor
Regional Hospital to Hospital Steps
Create an on-call schedule or SANE staffing
schedule
On-call staffing vs. staff positions
Back-up usually provided by program coordinator
Determine length of SANE shifts
Utilize a calendar program – Yahoo Groups, Google
calendar, other
On-call pay?
Regional Hospital to Hospital Steps
Obtain necessary supplies and equipment
List of supplies included
Start-up equipment and supplies:
Office equipment (computer, printer, external hard drive, CDs,
paper)
Examination table
Digital camera with macro lens setting (consider foot pedal or
remote)
Tri-pod
“L-scale” or other measuring device
Colposcope (if funding does not permit, this is optional)
Alternative light source (Woods Lamp)
Swab dyer or swab rack (convenient, but optional)
SANE Supplies
On-going supplies:
Sexual assault evidence collection kits (supplied
by the Illinois State Police)
Documentation forms
Sharps container
Speculums of various sizes
Pelvic light
Toluidine Blue Dye
Urine specimen containers
Blood draw and injection supplies
Pregnancy testing supplies
Laboratory testing supplies
Disposable towels
Drapes
Patient gowns
Paper bags
Small envelopes
Packing tape
On-going supplies:
Lubricant
Labels
Sterile Swabs
Sterile water
Gauze
Gloves
Black sharpie markers and pens
Medications for STI treatment and pregnancy
prevention
Patient take-home packet of information (may
be supplied by rape crisis)
Extra clothing for patients to wear home
(typically supplied by rape crisis)
Regional Hospital to Hospital Steps
Develop medical-forensic exam polices and procedures
Protocol to outline medical evaluation and treatment and forensic evaluation and evidence
collection
Triage and medical screening exam
Mandated reporting
Acute vs. non-acute timeframe
Evidence collection = 7 days based on Illinois law
Informed consent – may need to be a separate protocol
Patient history (medical and forensic)
Head-to-assessment with injury identification
Documentation
Photography of injuries
Evidence collection
Drug Facilitated Sexual Assault (DFSA)
STI evaluation and treatment, including HIV
Pregnancy risk assessment and prevention
Follow-up medical care and referral to outside services
Discharge
SANE Protocols
Needs specific protocols to address:
Rape crisis advocacy
Photography
Storage and when to release
Medical records
Unconscious/incapacitated patient
Emergency contraception
Standing medical orders if utilized
Interpreters
Support person NOT in exam room during exam
Non-reporting
Staffing policies
Other (informed consent, HIV risk assessment and prophylaxis, DFSA,
follow-up exam, etc…)
Regional Hospital to Hospital Steps
Start providing SANE services to SA patients!!!!!!
Community Steps
Identify and approach community partners for SART
SART
members:
Rape
crisis agency
Law enforcement
State’s Attorney’s Office
Other stakeholders (military, corrections, university, forensic
scientists, etc…)
Can
be essential to SANE program development and
on-going support
Community Steps
Develop SART and joint MOUs and mission
statement
SART
is a multi-disciplinary team that collaborates to
provide a victim-centered response to sexual assault
survivors each time a sexual assault is reported within a
community. SARTs seek to unite three sometimes differing
sets of needs, that of the criminal justice and healthcare
systems and that of the victim, all with the ultimate goal
of decreasing the re-traumatization of the survivor and
holding the offender accountable
SART Goals
What Are the Goals of a SART?
Establish joint protocols for the team members
Role and response of each team member
Work to decrease victim-blaming within the response system and the community
Hold the offender accountable for the violence and crime committed
Build relationships with response agencies to increase communication and conflict
resolution
Identify community resources and referrals to improve service delivery
Educate agency partners and the community about the dynamics of sexual assault,
how to prevent sexual assault and how to access the response system and other
service providers
Seek feedback from team members and survivors to enhance accessibility and
services provided throughout the criminal justice and healthcare systems
Identify team members to represent the participating agencies
Meet regularly to discuss protocols, issues, successes and other important
considerations
SANE Sustainability
Do not rush at the beginning – always think long-term
On-going support from administration and community
On-going fund raising
Peer review and continuing education
Program evaluation
May not be able to provide 24/7 SANE coverage
Develop an outcome measurement plan
Addressing vicarious trauma of SANE staff
Team leader and team building
Succession planning
SANE Staff Retention
This is one of the biggest program challenges
Support and recognize SANEs
Recruit outside the ED and hospital
Really difficult job – not for everyone
Be flexible
May not work regular hours at hospital
If SANE leaves hospital, keep them on SANE staff if possible
Utilize all nursing specialties
Coordinate and facilitate clinical training
Maintain SANE competency
Number of exams performed per year
Continuing education
Questions?
Shannon Liew, RN, BSN, SANE-A
SANE Coordinator
Office of the Illinois Attorney General
100 West Randolph Street, 13th Floor
Chicago, IL 60601
312-814-6267
sliew@atg.state.il.us
