Regional Sexual Assault Nurse Examiner (SANE) Models

1. Regional Sexual Assault Nurse Examiner (SANE) Models September 6, 2012

2. IHA-OAG Joint Goals on SANES • Double the number of fully-practicing SANES • Establish a hospital-based SANE program in each of Illinois’ eleven EMS regions • 33 more nurses and 2 hospitals still needed to fulfill these goals by this fall! • Hospitals looking at options for regional SANE programs

3. 9/6 Webinar and 10/4 Workshop Provided by ICAHN Grant Funding for this program is provided through the Medicare Rural Hospital Flexibility Grant program and supported by the Illinois Critical Access Hospital Network (ICAHN). • Grant-funded program requires “pre-survey”

4. Pre-program Survey •  Are you currently a sexual assault transfer or a treatment hospital under the SASETA law? ANSWERS:  A.   Transfer hospital B.   Treatment hospital • How many practicing SANES do you currently have? ANSWERS:   A. None B. 1-2 C. 3 or more • Are low volumes of victims presenting at your facility a concern for SANES to maintain skills? Answers: A.  Yes           B.  No C.  N/A as we are a transfer hospital • Have you done any work on developing a regional plan for SANE services? Answers: A.  Yes           B.   No

5. Regional SANE Models • Shannon Liew, SANE Coordinator, Office of Attorney General Lisa Madigan • Dr. Pat Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN, will discuss the SANE model in Memphis • Connie Monahan, MPH, will describe New Mexico’s unique infrastructure for providing SANE services • Marlena Clary, BSN, RNC, SANE-A, SANE-P, will discuss the Columbia, SC program

6. SANE Program Models Overview Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN Associate Professor and Public Health Nursing Option Coordinator, College of Nursing University of Tennessee Health Science Center

7. Objective The goal of this presentation is to introduce the learner to • The evidence for different models of SANE programs nationally, including possible IL models • The Memphis Model for Forensic Nursing care of sexual assault victims (c. 1973)

8. Three Types of Programs (CDC, 1997) • Commercial • May be private, for profit • Held to same regulations • Not-for-profit • Must make a profit to remain in business • Government • Increases program activity with policy/funding • Decreases program activity with policy/funding

9. Commercial SANE Programs • Characteristics • Obviously, need to make profit • Contract with hospitals or governments to provide forensic nursing care to the DV or SA community • Located in states where BON/Rules and Regulations allow • Will send SANEs to the hospital • Uses hospital resources • May carry luggage with necessary equipment, kits, chart, and cameras • Will leave consultant documentation for hospital • Pre SANE service negotiations mandatory

10. Not-For-Profit SANE Programs • Characteristics • 501 c 3 paperwork • May be hospital, clinic or agency outside health care arena, e.g., CAC model • Contract with hospitals or governments to provide forensic nursing care to the DV or SA community • Pre SANE service negotiations mandatory • Will leave consultant documentation for hospital • Will send SANEs to the hospital in addition to seeing patient in the community • When present, will use hospital resources • May carry luggage with necessary equipment, kits, chart, and cameras • Located in states where BON/Rules and Regulations allow contractor relationships • Must also make a profit

11. Government SANE Programs • Characteristics • Locations variable • Usually funded with tax dollars • Memorandum of Understandingswith NFP or Commercial hospitals to provide forensic nursing care to the DV or SA community • Located in states where BON/Rules and Regulations allow • Must make a profit (or at least be budget neutral)

12. Memphis Rape Crisis CenterFormerly, Memphis Sexual Assault Resource Center • Government • Community-based • Funded by government grant • Initially HHS grant • After funding, City Council funded and agency folded into community and family services • After funding slashed, taken over by county health department; currently under County Victim’s Assistance • Most patients seen in community clinic by APNs • RNs must have supervision of practice in community • Public Health Department relationship continues 40 years • SART members respond together, remain present throughout evaluation, and leave together

13. Memphis Rape Crisis CenterFormerly, Memphis Sexual Assault Resource Center • 2009 – Model program split after financial crisis into child and adult • Children – local hospital and CAC • Adolescents and Adults - Memphis Rape Crisis • Remained in the community • Continues to serve surrounding counties (80 miles diameter = possible 3 hour drive with law enforcement) • SART meets at hospital when medical condition warrants • Memorandum of Understanding • Privileges for all nurses associated with program - MOU • Consultant Notes left in hospital chart • Treatment recommendations • Medical Forensic chart remains with SANE

14. Illinois program variations • Legislated funding directed toward hospitals • Hospital sponsored • Hospital affiliated clinics • Institutional designated areas • Satellite clinics • Hospital based • Emergency departments • Available rooms • Designated rooms • Areas away from emergency departments • Use hospital affiliated buildings close to the ED • Have even seen trailers in the ED parking lot in California!

15. SANE Program Evolution - Questions?

16. New Mexico SANE and Rural Hospitals Connie Monahan, MPH Statewide SANE Coordinator New Mexico Coalition of Sexual Assault Programs conniem@swcp.com 505-883-8020

17. Who am I – Connie Monahan • Public health education and experience in NM for 20+ years • Worked on a NIJ funded research project evaluating the effectiveness of our state’s first SANE program • Executive Director of Albuquerque SANE (4 years) • State Coordinator for the SANE Programs at NM Coalition of Sexual Assault Programs since 2004 • I am not a nurse

18. New Mexico Medical-Forensic Response • New Mexico Sexual Assault Evidence Kit (SAEK) • NM has system for paying for medical/forensic exam funded by NM Human Services Dept and administered by our Coalition • Patient does NOT have to file police report for the exam • Time window is 5 days/120 hours for adults/adolescents and 3 days/72 hours for pediatrics 12 and under, with specialized response for non-acute pediatric exams • Accepted by both crime labs – State DPS and APD Metro; also accepted by FBI/Indian Country • Used by both hospitals and SANE Programs in NM

19. New Mexico SANE Programs SANE Program Satellite SANE Delayed Pediatric Communities with interest

20. New Mexico SANE Programs Albuquerque, 1996 400 Santa Fe, 1998 150 Las Cruces, 1999 100 Roswell , 2000 50 SAS of Northwest, 2003 130 Arise SAS/Eastern NM, 2004 120 Carlsbad, 2004 <10 Otero/Lincoln County, 2005 50 Grants/Cibola County, 2006 <10 Taos, 2010 <10 Silver City, 2011 <20 Hospitals without SANEs <60 (annual averages)

21. Sexual Assault ExamOptions for Rural Hospitals • Hospitals can perform the exam by a MD-PA-NP (i.e., advanced level provider) who may be “teamed” with a RN but not separated duties OR • Develop their own Sexual Assault Nurse Examiner (SANE) Program OR • Refer to nearby SANE Program or develop into a Satellite SANE

22. Rural Hospital Response – MD, PA, or NP(default response) Challenges • The average sexual assault exam can take 2 to 4 hours - burden on hosp. staffing esp with team response • Expected expertise with techniques/equipment is intimidating first time(s) • Expectation of legal proceedings is daunting Advantages • Helps hospital meet other standards • Incredible service to the community, professionals • Directions are in the SAEK • Sample “crash cart” list of needed supplies • Connection to advocacy

23. Rural HospitalDeveloping their own SANE What the hospital is expected to do… • Lots of up-front and on-going work and costs • Takes about 8 to 15 months of preparation • Formal application indicating LE-DA-Advocacy support, hospital commitment, medical directorship, data, site visits • A team of at least three nurses and one medical director • Expectation of 15 to 20 adult/adolescent patients a year to ensure nurse competencies • “if you build it, they will come”

24. Rural Hospitals Developing their own SANE What our Coalition and I can do to help • SANE specific technical assistance/support, policies, training, miscellaneous forensic supplies… • Link the hospital with existing SANE Program with comparable hospital structure or community • The New Mexico Coalition of Sexual Assault Programs offers trainings/in-services for law enforcement, conference stipends for prosecutors, prevention materials, CSA prevention program for schools, sexual assault county data

25. Rural Hospitals and Referral/Satellite • Referral • Informal process, not systemic • Transportation is predictable barrier • Advocacy becomes the critical piece in ensuring victim centered care (county mental health program, DA’s victim advocate) • Satellite • Formal MOU with another SANE Program/$ involved • Portable SANE kit ($3500), SANE can come to the hospital or patient can go to the nearby SANE Program • Community Sexual Assault Response Team (SART)

26. Rural Hospitals and Referral/Satellite • For Referral/Satellite, either Coalition or SANE Program coordinates in-service and materials to the hospital • Timeframe for response, consent, other parameters • How to activate, what to do while waiting • How to explain the SANE exam, what might happen • What to say to empower the victim, how victims might be responding/feeling • What are the local resources and co-responders

27. What NM has learned… • Most rural/small hospitals do an informal referral, in crisis mode – generally works but co-responders aren’t satisfied with process. • We assumed that hospitals that signed up for the Satellite SANE would eventually take ownership of their own SANE program: that is not happening and it seems to be the hospital that stops the growth, not the community. • We have several communities where Law Enforcement and DA’s want a SANE Program and the hospital outright refuses; SANE Programs do not have to be hospital based but starting a SANE in a non-hospital setting is intimidating and doesn’t happen often

28. Regional Forensic Nurse Examiner Program How we respond to victims of sexual assault Marlena Clary, BSN, RNC, SANE-A, SANE-P

29. Where we came from……….. The Sexual Assault Nurse Examiner (SANE) Program • 1998-First SANE course offered in SC • 1999-Started as an ED based program at Palmetto Health Richland • SANE trained ED nurse’s performed exams (if working/available) • 1999-SART formed

30. 2005 • Full time SANE coordinator • Private exam, interview and admin offices

31. 2006 • Began seeing Pediatric patients • Expanded program to include sister hospital

32. Sexual Assault Victims 2006-2009

33. 2010 Regional Forensic Nurse Examiner Program • A mobile forensic unit providing services to 7 area hospitals within a 6 county region • 2 Judicial Circuits • 3,633 square miles • Population of 765,685

34. Sexual Assault Victims Seen in 2010

35. Sexual Assault Victims Seen in 2011

36. Program details • 6 full time trained forensic nurse examiners, 1 full time coordinator • Memorandums of agreements with outside hospitals (5) • Contract employees at these hospitals • All patients 12 and younger seen at our pmain hospital • All documentation computerized, done contemporaneously in a web based database • Forensic record and photographs maintained by RFNE Program

37. Mobilizing the FNE When a patient presents: • Hospital contacts a centralized communication center • Communication center calls FNE on call • FNE triages call to determine: • If it meets criteria for a forensic exam • Prioritize which patient needs to be seen first if more than one patient and/or at more than one facility • FNE ensures facility has contacted local rape crisis counselor and law enforcement if applicable • FNE travels to that particular location to perform the forensic exam (response time 1 hr*)

38. How it’s done • Each nurse is outfitted with her own mobile cart equipped with a: laptop, digital camera, UV light, battery operated speculum light and all the other supplies needed to perform the exam.

39. Each hospital also has a locked medical equipment cart containing exam supplies and items specific to that particular hospital

40. Patient Care • Report from primary RN • Plan of care discussed with treating physician • Forensic evaluation, exam and evidence collection performed as indicated • Based on evaluation and exam findings provide medication and lab work recommendations to ED physician • Medications administered (by ED RN at outside hospitals) • Lab work processed (obtained by FNE during exam and submitted via ED RN at outside hospitals) • Discharge instructions and follow up recommendations provided (specific ED discharge instructions provided by ED RN in addition at outside hospitals)

41. Additional Responsibilities • Serve as a resource to other SANE programs throughout the state • Serve as a referral site for patients who live in areas without any trained forensic nurses • Provide education and training for: • Law enforcement agencies • Hospitals/medical staff • Community agencies involved in caring for victims of sexual assault • Solicitor’s office/judicial agencies • Active members of SART’s in all counties we serve • Collaborate with community agencies/organizations in prevention and education efforts

42. Palmetto Health Richland Regional Forensic Nurse Examiner Program 5 Medical Park Drive Columbia, SC 29201 Marlena Clary, BSN, RNC, SANE-A, SANE-P Forensic Nurse Examiner 803-331-6720 (cell) marlena.clary@palmettohealth.org

43. QUESTIONS • Register for follow-up workshop on October 4 in Springfield or Naperville: http://www.ihatoday.org/education-and-events/events2.aspx • If further questions, contact Barb Haller at IHA: bhaller@ihastaff.org or 630-276-5474 or Shannon Liew at OAG: Sliew@atg.state.il.us