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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-to-one 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 include:
Illinois’ 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
SANE-trained 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, hospital-based 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 how SANEs will be notified and when Will need a centralized call center
Determine if MOUs and/or transfer agreements are needed
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 victim presents at local hospital for care If 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 non-employee 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 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 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 [email protected]
Edward Byrne Memorial Justice Assistance Grant (JAG) Program 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 Particularly successful for start-up costs or specific equipment
Private donations Private donors, corporations/businesses, established pool of
hospital donors Annual or on-going hospital employee giving program
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
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
Medical Director 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 May not be able to provide 24/7 SANE coverage
On-going support from administration and community
On-going fund raising Peer review and continuing education Program evaluation
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
Really difficult job – not for everyone Be flexible May not work regular hours at hospital
Recruit outside the ED and 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-ASANE Coordinator
Office of the Illinois Attorney General100 West Randolph Street, 13th Floor
Chicago, IL 60601312-814-6267
