Challenges of SANE in the Clinical Setting

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Challenges of SANE in the Clinical Setting

• Connie Monahan, MPH
• New Mexico SANE Coordinator
• NM Coalition of Sexual Assault Programs
• conniem_at_swcp.com or 505-883-8020

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Objectives

• Provide overview of Sexual Assault Nurse Examiner
  (SANE) program
• Identify systems to be considered in
  developing/maintaining a SANE program, especially
  in rural and remote settings
• Identify strategies for serving Native American
  victims of sexual assault

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Profile of the Problem

• Average annual rate of rape/sexual assault among
  American Indians is 3.5 times higher than other
  races (BJS, American Indians and Crime 1999)
• At least 70 committed by persons not of the same
  race
• One in three (34) native women will be raped in
  her lifetime compared to one in five for US (DOJ
  Full Report of the Prevalence, Incidence, and
  Consequences of Violence Against Women, 2000)
• Native Americans were twice as likely to
  experience sexual assault than other races 5 per
  1000 persons age 12 and above compared to 2 per
  1000 (BJS, American Indians and Crime Profile
  1992-2002)

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Profile of the Problem

• Jurisdictional issues of tribal-state-federal
• Location of assault
• Race of victim/of offender
• Reporting laws
• Who pays for medical/forensic exam, which states
  evidence kit, which crime lab
• Historical context of sexual violence as a tool
  of conquest and oppression
• Role/responsibility of health care to violence is
  fairly new

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Resources/References
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Resources/References
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Continuum on Services

• Prevention
• Education/Awareness
• Crisis services/hotline
• Acute Medical/forensic response (SAEK for victim
  and Suspect)
• Law enforcement investigation
• Prosecution
• Victim Advocacy
• Mental health/counseling, follow-up and aftermath
  care for individual, family/friends and community
• Data, evaluation, and research

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History of acute medical response

• Sexual assault victims go to hospital ED
• Rarely a life threat, long wait, public area
• Multiple providers, reluctant/rushed to do exam,
  not trained in genitalia, photography,
  documentation, etc.
• Facilities not equipped for technology of
  evidence collection or chain of custody
• Providers or facilities not connected to
  community, advocacy, crime labs, police

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SANE Developed in Response to ED

• One-on-one, non-rushed care in a separate and
  safe environment
• Advanced training on dynamics of sexual assault,
  equipment, techniques, genitalia, documentation
• Co-response with advocacy
• Supported with coordinated community response

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Specialized Response SANE Mission

• SANE program serves sexual assault victims by
  providing prompt, objective, compassionate,
  culturally sensitive, and comprehensive medical
  treatment and forensic evaluation by
  advanced-trained nurses who work within a
  coordinated community response.

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SANE Mission Statement

• Break it down
• Prompt
• Comprehensive
• Objective-compassionate
• Medical treatment
• Forensic evaluation
• Advanced-trained nurses
• Coordinated community response

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Guiding Principles of SANE

• Ensure medical stability
• Ensure informed consent and patient
  confidentiality throughout the process
• Support the patients recovery
• Provide objective documentation
• Follow professional and state standards of care
  (nursing, legal, and forensic) including the use
  of the evidence collection kit

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Dual Role of a SANE

• SANE Medical Exam
• Assess, treat, document injuries
• Conduct detailed genital exam
• Provide medication for STI and EC
• Offer referrals and safety plan to mitigate
  trauma

• SANE Forensic Exam
• Document injuries
• Collect and secure evidence, maintaining chain of
  custody
• Participate in legal proceedings

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SANE Models Payment Source

• Law enforcement, AG or DA
• Patients filing police report to receive exam
• State Department of Health
• CVRC, VOCA, or VAWA
• Hospital
• SANEs may be paid hourly vs. case fee
• Insurance Companies
• Payment for program, services, and nurses

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SANE Models Lead agency

• Physically/financially
• Hospital or medical/health facility
• Rape crisis center
• Child Safehouse/Family Advocacy Center (one-stop
  or co-located programs)
• Stand-alone non-profit organizations
• Singular, independent/contractual nurses
• Mobile units

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SANE Variations/Consistencies

• Variations may include
• Lead agency
• Funding support
• Administrator/coordinator
• of nurses, case load, etc
• On-call vs. on-shift
• Service area/populations
• Other

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SANE Variations/Consistencies

• Consistencies may include
• Evidence collection or rape kit
• Response within standard time frame
• 24 hour coverage by gt just one nurse
• Initial SANE training and precept
• Statewide SANE task force or board
• Professional membership with IAFN
• Certification (SANE-A, SANE-P, CFN)

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References for Consistency
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SANE Initial Training

• IAFN and/or DOJ Presidents DNA Initiative
• Generally 40 hours or more
• Modeled on the multi-disciplinary team approach
  (multiple instructors)
• Certificate of completion/nursing CEs but
  initial training ? certified or certification!!
• Do not assume state reciprocity

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SANE Training

• Initial class training
• Precept
• Equipment
• Normal exams
• Shadowing being shadowed for actual cases
• Courtroom observation
• Annual competencies
• On-going professional development

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What determines development of SANE Program

• Number of patients
• Perceived need by the community
• Support by DA and Law Enforcement
• Support by the facility, including staff and MD
• Community Resources advocacy, MH
• Leadership
• Non-competitive with existing SANE

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What determines development of SANE Program

• Articulating the need
• Medical standard of care
• Alleviate burden on ED
• Consistent with hospital mission (and JCAHO!)
• Viewed as a community service/responsibility
• An opportunity for collaboration among medical
  facilities and community agencies
• Business plan expenses, payment sources, impact
  evaluation

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Leadership Who makes it happen?

• Institution
• Individual
• If you want program sustainability, Institution,
  Individual AND Community!
• Does the individual have to be nurse?

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How do you define success?

• Community awareness of sexual assault
• Number of patients served
• Number of patients who file police reports
• Type and number of services offered/used
• Does the patient leave better than arrival
• Community buy-in (participation in MDT,
  referrals, monetary or in-kind support)
• Use of medical record in legal proceedings
• Use/quality of evidence collected
• Prosecution or Conviction rates

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One Example Defining Success

• University of New Mexico (UNM) received US
  Department of Justice grant to measure the impact
  of a SANE Unit
• Compared sexual assault patients who went to UNM
  Emergency Dept (1993-1996) to sexual assault
  patients who went to the Alb. SANE Program
  (1997-2000)
• Impact Evaluation of SANE Program, DOJ Document
  203276 (Crandall, Helitzer)

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SANE Impact Evaluation

• UNM Study found SANE patients more likely than
  ED sexual assault patients to
• Receive pregnancy prophylaxis (76 vs. 43)
• Receive STD treatment (82 vs. 61)
• Receive physical exam (98 vs. 21)
• Have evidence collected (90 vs. 60)
• Receive referrals/resources (3x more likely)

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SANE Impact Evaluation

• UNM Study found, SANE patients more likely than
  ED patients to
• Spend less time (4.5 hours vs. 7.5 hours)
• File police report (72 vs. 50)
• Charges for SANE versus ED patients
• Greater number of charges filed (4.2 vs. 1.8)
• Initial and final charges more consistent (48
  vs. 36)
• Conviction rates increased slightly (not
  statistically significant)

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Systems for Rural Response

• Law enforcement
• Prosecution
• Crime lab(s)
• Will they accept and use SANE (i.e., nurse)
  medical records and evidence collected for sexual
  assault victims?
• If yes, what needs to be in place/standardized
  for investigation and prosecution

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Systems for Rural Response

• Access/transportation
• Advocates
• Aftermath care
• Follow up medical/forensic
• Mental health, counseling, safety planning
• Legal proceedings which may include criminal,
  civil, and/or family court

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Systems for Rural Response

• Existing clinical services
• Health clinics, crisis services/hotlines, EMS,
  school-based or womens health clinics
• Staffing
• Initial training, precept and on-going
• Attrition/retention of SANE nurses
• Medical Director
• Lead coordination/point person

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Medical/Forensic Response to Native Sexual
Assault Patients

• Have coherent system for referral to nearest SANE
  program
• Have advanced level providers (MD-PA-NP) conduct
  sexual assault exam
• Develop your own SANE program
• With all that is implied with sustaining a program

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Creative Strategies for Rural

• Work to improve the existing ED response
• Roll cart of supplies, in-service on rape kit
• Video for native sexual assault patients
• Promoting of Healing After Rape Among Native
  Women Girls http//etl2.library.musc.edu/crime_v
  ictims.native.wmv
• If you have/developing a SANE Program
• Use two SANEs to co-respond to patient
• Entice SANEs to work at more than one program
• Share coverage between two programs
• Mobile or portable kit

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Challenges of SANE in Clinical Setting

• Medical, forensic, AND legal response
• Pt presents ? prosecution averages 18 months
• Intensity/sustainability of specialized program
• SANE is one link in a continuum of care
• Current challenges in delivering health care
• Rural issues access, transportation, staff
• Cultural sensitivity
• Topic itself is hard work

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Thank you!