APPENDICES FOR Making SANE work: Operations

New Mexico Coalition of Sexual Assault programs 2007

Suggested Minimal Policies for new mexico sane

Listed below are suggestions for written policies and procedures for a
program and what issues should be addressed in the policy. Each policy
should be signed and dated. At least two collections of policies should
be kept, one in a centralized area for access and review by staff and
one in safekeeping as reference. When policies are revised, old policies
should be kept to provide a history of changes.

Administrative Policies

-   Medical Director

    -   Designated unrestricted licensed physician

    -   Assurance of medical malpractice insurance

    -   Roles and responsibilities with pharmacy, quality
        assurance/record review, on-call support

-   SANE nurses and supporting staff

    -   Roles and responsibilities

    -   Minimum credentials, certification, precepting/competencies,
        insurance, and evaluation

    -   Commitment for certain amount of shifts per month

    -   Rate and method of reimbursement for sexual assault exams and
        prosecution aftermath

    -   Agreement that the individual SANE is responsible for sexual
        assault exam through prosecution and until closure

    -   Confidentiality

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-   Multi-Disciplinary Team

    -   Role and responsibilities of members

    -   Outline of methods for SANE communication and feedback loop
        between MDT and SANE program

    -   Confidentiality

    -   Coordination of co-response between SANE and advocacy and
        between SANE and police

# Medical Record Policies

-   Medical Record for Sexual Assault Exam

    -   Form for patient consent for exam

    -   HIPAA patient privacy

    -   SANE Medical Record template

    -   Use of supplemental sheets, patient satisfaction survey, etc

-   Storage and Release of Medical Record

    -   Maintenance of privacy/confidentiality of records

    -   Procedures for law enforcement, prosecution, individuals and
        relevant agencies to obtain records

    -   Form for documentation any time record is requested

    -   Process for maintaining record separate from insurance or
        hospital patient records

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-   Quality Assurance of Chart

    -   Chart review form and process of chart review

    -   Use of chart review for quality assurance and feedback process
        of review to original SANE

# Medical Response Policies

-   Medical Triage

    -   Medical priority and clearance

    -   EMS transport

-   Activation of SANE Response

    -   Criteria and method for activation of SANE, crisis advocate, and
        law enforcement

    -   Assurances for cases when law enforcement is not requested

    -   Roles and responsibilities of SANE on-call

    -   Process for scheduling exam if SANE not immediately available

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-   SANE exam

    -   Process for consent and change of consent

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    -   Description of activities within the sexual assault exam,
        including medications, photographs, evidence collection,
        referrals, discharge

    -   Exam procedures (can be adopted from SAEK)

    -   Process for responding to unconscious patients

    -   SANE safety, blood borne pathogens, HIV-high risk referrals, and
        when to call administrator and/or medical director

-   Referrals/Coordinated Community Response

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-   Pharmacy/Medications

    -   Medications to be administered during sexual assault exam,
        including STD treatment and Plan B for emergency contraception

    -   Log forms for dispensing medications

    -   Standing orders or prescription referrals

    -   Patient education/information

    -   Discharge instructions

# Law Enforcement, Evidence Transfer, and Prosecution 

-   Coordination with law enforcement

    -   Criteria and process for evidence transfer for reported and
        non-reported police cases

    -   Process for police interviewing in conjunction with SANE medical
        exam

-   Storage and Release of Evidence

    -   Designated custodian of evidence

    -   Forms and method for transferring evidence and medical records
        to law enforcement

    -   Forms and method for transferring medical records to prosecution

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-   Subpoenas

    -   Method for accepting subpoenas

    -   Method for notifying SANE of subpoena

One Page Info about New Mexico Sexual Assault Nurse Examiner (SANE)

-   Medical attention always takes priority over the sexual assault
    exam.

-   The SANE exam should be done within 5 days of the assault --
    generally, the sooner the better but the patient does have time to
    consider his/her needs.

-   SANE nurses are on-call. They are not physically on-site. To
    dispatch a SANE nurse, call your nearest SANE unit. Not all
    hospitals have SANE programs; however, hospital emergency physicians
    are qualified to do a sexual assault exam.

-   The SANE nurse needs informed consent from the sexual assault
    survivor. The patient must be able to understand, agree, and sign
    for the exam.

-   The SANE nurse would like to speak directly with the patient to
    ensure consent. If this is not possible, the SANE will ask about
    patient's medical stability, ability to give informed consent,
    special needs, and will schedule a time and place to meet the
    patient.

-   If the assault was recent, discourage the patient from eating,
    drinking, or showering -- depending upon the nature of the assault.
    Encourage the patient to bring the clothes they were wearing when
    they were assaulted.

-   SANE programs are equipped to do only one sexual assault exam at a
    time. Each exam can take 2 to 4 hours and some exams may take much
    longer.

-   SANE Programs are based on patient consent: at each step of the
    sexual assault exam, the SANE nurse allows the patient to proceed or
    not.

-   A sexual assault patient does not need to file a police report to
    receive SANE services

-   There is no cost to the sexual assault patient for services provided
    by SANE

-   Pediatric patients ages 12 and under may not need an *emergent*
    sexual exam. Law enforcement, child protective services, and the
    SANE will consult on how best to proceed with child sexual abuse
    cases.

-   The SANE response may include documentation of injuries from the
    assault, collection of forensic evidence, and medical treatment for
    emergency contraception and sexually transmitted infections -- the
    patient may choose which services he/she wants.

**Sample New Mexico SANE Job Description/Contract**

## JOB TITLE: SEXUAL ASSAULT NURSE EXAMINER (SANE)

## 

## REPOPRTS TO: SANE Program Coordinator and/or Agency of Hire

**JOB PURPOSE:**

The Sexual Assault Nurse Examiner (SANE) will provide timely,
non-judgmental, compassionate care to the sexual assault victim. This
will include a forensic exam, prophylaxis for pregnancy and sexually
transmitted diseases, photographic documentation, referrals for
appropriate medical and psychological follow-up, support and
participation in legal proceedings. The SANE is expected to follow
protocols established by the Medical Director and/or management of the
SANE Program for which the SANE is employed.

**JOB RESPONSIBILITIES:**

-   Ability to triage patient to determine if medical exam is needed
    before forensic exam.

-   Coordinate care by all agencies involved in assisting the sexual
    assault victim and coordinate referrals for appropriate medical and
    psychological follow-up as needed for each patient.

-   Perform and document sexual assault and forensic interview
    accurately.

-   Perform a complete physical and forensic evidence collection
    examination including Head-to-Toe assessment for trauma, detailed
    genital examination, forensic specimen collection and documentation,
    including photography, and assess for mandatory reporting status,
    reporting when appropriate.

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-   Document detailed injuries accurately with support of photographic
    evidence.

-   Maintain chain of custody for each sexual assault exam and adhere to
    evidence protocols

-   Maintain professional standards that do not create conflict of
    interests with employment or patient care, including patient and
    medical record confidentiality

-   Must not be under the influence of drugs or alcohol while on-call.

-   Administer appropriate prophylactic medications per protocols

-   Provide testimony as fact witness to any/all cases performed while
    with SANE and coordinate with attorneys during judicial process.

-   Responsible to maintain clinical expertise as a SANE.

A)  Maintain current New Mexico Registered Nurse Licensure or higher.

B)  Maintain malpractice insurance (1,000,000/3,000,000).

C)  Complete the initial New Mexico SANE training

D)  Complete the initial and on-going preceptor requirements as
    identified by the SANE Program

E)  Debrief as needed to maintain emotional and physical wellness.

F)  Maintain open communication with SANE Coordinator and/or management
    of SANE Program on regular basis.

G)  Maintain equipment in proper working condition and exercise fiscal
    responsibility of unit's resources.

H)  Share individual expertise with the other members of SANE

I)  Maintain competency by maintaining active performance of cases with
    no lapse of greater than six months

J)  Pass a SANE specific med-test upon initial SANE practice and every
    other year.

K)  Participate in quality assurance chart and photograph review process
    as determined by the SANE program

L)  Adhere to all administrative, clinical, and employment policies and
    procedures on file with the SANE Program or hiring agency.

M)  Commit to cover minimum number of shifts, holiday coverage, and
    other scheduling requirements as determined by the SANE program

N)  Participate in professional development as determined by the SANE
    program, including staff meetings, conferences, and in-services.

> I agree to the terms if this position as stated above. Failure to
> comply with these terms may lead to termination or resignation.
>
> Employee Signature Date

SANE Administration Date

*Optional Additions to the SANE Contract*

If the SANE program provides a stipend or monetary support for a nurse
to attend the initial New Mexico SANE Training, it is appropriate to add
a clause indicating the trainee's responsibility in returning the
up-front stipend. Sample language may be

-   Upon completion of training and preceptor requirements, the SANE
    will commit 1 year of practice to the SANE Program. If the SANE
    leaves the Program before completion of one-year independent
    practice, he/she shall reimburse the SANE Program the stipend
    received for training and preceptor.

If the SANE Program is not hospital based, it is appropriate to require
additional certification, such as Trauma Nurse Core Curriculum. Sample
language may be

-   TNCC or equivalent advanced training for non-hospital-based SANE's
    within 6 months of hire and maintained throughout employment with
    the SANE Program

**SAMPLE Sexual Assault Nurse Examiner (SANE) Interview Tool**

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1.  Why do you want to be a SANE nurse?

2.  Why do you think sexual assault happens in our society?

3.  What experience have you had with sexual assault/abuse?

    a.  What is your experience with evidence collection?

    b.  What is your experience with court testimony?

4.  Do you foresee any physical or emotional difficulties in doing the
    SANE cases or in working with sexual assault patients?

5.  Do you foresee any barriers in

    a.  administering emergency contraception medication?

    b.  language about sexuality, body parts, and/or the violence
        associated with sexual assault?

6.  Identify 3 strengths you could bring to this SANE program

7.  Identify 3 weaknesses that might interfere with your work at SANE

8.  List any relevant trainings or experiences you think will aid you in
    conducting sexual assault exam cases.

9.  Do you understand and do you have any concerns relating to your
    on-going responsibility for legal proceedings related to any SANE
    exam you do?

10. For most SANE exams, it will be you, the patient and an advocate --
    can you speak to your ability to problem solve, autonomy and
    decision-making skills?

11. In addition to the initial SANE training, you will be required to
    complete a series of clinical competencies and obtain on-going
    professional development (such as monthly meetings, participation in
    the SART, attending conferences, learning new equipment as it is
    acquired, etc) -- do you foresee any barriers in taking on these
    extra duties?

12. Discuss a job that you have had that were detail oriented -- what
    challenges did you have with those tasks

13. Discuss your definition of control; what strategies would you use to
    encourage patients gaining control after a sexual assault.

**SAMPLE CASE SCENARIOS**

1.  Explain how you would handle this situation: You find the client
    > sitting in the waiting area. On interview she reports being
    > beaten. You see no obvious bruising. Vital signs are normal, she
    > is A&O x 3, color is good skin W&D. She is in no apparent distress
    > at present. She states she had an episode of LOC for unknown time!
    > What would you do **first**?

2.  Explain how you would handle an angry parent of a 14-year-old female
    > that can legally sign for her own exam and only wants medications
    > and no exam. The parent insists that you do a SANE exam on the
    > daughter. How would you negotiate solving this dispute?

3.  A 15-year-old sexual assault victim arrives at the unit while you
    > are in the middle of doing a full exam on another patient. She is
    > clearly distraught and has no family with her. How do you handle
    > this situation?

4.  You have just completed an exhausting 7-hour SANE exam on an elderly
    > patient that was brutal and that has affected you personally and
    > emotionally. What strategies and resources would you use to help
    > you process the event?

CORE COMPONENTS OF THE NEW MEXICO

SANE MEDICAL RECORD

New Mexico has a standardized Sexual Assault Evidence Kit (SAEK) that
provides for the acute medical response, injury documentation, and
forensic collection of sexual assault patients. The New Mexico SAEK is
to be used within 5 days for adolescents/adults and 72 hours for
pediatrics.

As independent units, New Mexico SANE Programs have the autonomy to
create, implement and modify their own documentation of the medical and
sexual assault exam. To support consistency among the SANE programs,
however, the New Mexico Coalition of Sexual Assault Programs -- in
coordination with the Statewide SANE Task Force -- has outlined the
following minimum core components that should be addressed in a SANE
medical record. The following components are recommended, not required,
and are based on national and state best-practices.

**OVERARCHING PRINCIPLES OF SANE DOCUMENTATION**

Any recommendation of core components to be addressed in a SANE medical
record must address overarching, guiding principles of patient care,
nursing competencies and forensic documentation. Specifically,

-   The SANE exam and treatment are based on patient consent and choice.

-   Each sexual assault is unique: SANE documentation needs to reflect
    the situational aspects of different patients and different types of
    assaults.

-   Nurses are mandated reporters of suspected child sexual abuse and
    SANE documentation includes questions to assist the nurse's role in
    state reporting requirements.

-   Nurses provide holistic care of the patient, including safe
    discharge and appropriate referrals, and SANE documentation includes
    questions to assist the nurse's determination of a safety plan for
    the patient, exposure risk for infectious diseases, and referrals
    for aftermath care.

-   The SANE documentation is primarily a medical record that includes
    forensic documentation; however, the SANE medical record is not an
    investigatory tool.

-   Some data on a SANE Medical Record are required to fulfill
    grant/funding obligations for statewide data collection and
    reporting.

-   During the SANE exam, a patient may spontaneously disclose personal
    information or excited utterances which may or may not be pertinent
    to the sexual assault. It is recommended that the specially trained
    and objective SANE nurse exercise professional judgment in
    determining the type and level of patient information disclosed in
    the SANE Medical Record.

[The SANE Medical Record will comprehensively address **Patient
Consent**, including:]{.underline}

-   Differences between a Full and Limited SANE exam, including the
    option to not collect evidence

-   Consent to release evidence to law enforcement whether or not a
    police report is filed

-   Notification that basic information about the sexual
    assault/information on the police report may be disclosed to
    inquiring sources

-   Consent to release patient's name and telephone number for follow-up
    services

-   Consent to receive or decline Emergency Contraception

-   Information about HIPPA Regulations

-   Information Crime Victims Reparation Commission (CVRC) Compensation

[The SANE Medical Record will include basic **Patient Demographics**,
such as]{.underline}

-   Patient Name

-   Patient Age

-   Patient Gender

-   Patient Home or Contact Address and Telephone Number

-   Patient Ethnicity

-   Referral source (as identified by patient: who told/encouraged them
    to seek SANE services)

[The SANE Medical Record should document basic and relevant **Patient
Medical History**, to include:]{.underline}

-   Medications, status of vaccines, and known allergies

-   Medical/surgical history

-   Vital signs to include temperature, blood pressure, pulse,
    respirations, pain scale, etc.

-   Disabilities

-   Primary Care Provider

-   Pre-existing injuries or symptoms of the genitalia and whether the
    patient has had consensual intercourse within the previous 5 days
    and to which orifice

[The SANE Medical Record should document, in a check-off format for
consistency, **Patient Demeanor**, to include:]{.underline}

-   Specific, observable behavior, such as tearful, sobbing, smiling,
    flat, dazed, tense, calm, angry, responsiveness to questions,
    fidgeting, trembling, agitated, anxious, quiet, eye contact, etc.

-   Abnormal appearance or dress, such as disheveled, clothes torn,
    clothes on backward, etc.

# The SANE Medical Record will identify whether a Police Report was Filed at Time of Exam and to Which Agency

# The SANE Medical Record will include Victim Drug/Alcohol Information

-   Any drug or alcohol use within the previous 48 hours with amount and
    time of ingestion

[The SANE Medical Record will address basic and relevant patient
**Assault History** to include:]{.underline}

-   Date, time, and location of assault

-   Any recent loss of consciousness/loss of memory to suspect drug
    facilitated sexual assault

-   Actual and attempted penetration of specific orifices

-   Ejaculation and/or presence/absence of condom

-   If the sexual assault was related to domestic violence to determine
    need for safety plan

-   Type and level of coercion and force

-   Patient narrative of event

# The SANE Medical Record will clearly indicate any Additional Personnel Present for the interview and exam

-   First names of individuals present, with identification of the
    persons' role or relationship, such as rape crisis advocate,
    staff-in-training, translator, guardian, parole officer, family
    members, etc., with indication of personnel present for initial
    interview and/or for exam

# The SANE Medical Record will detail victim Post-Assault Hygiene Activity, in a check-off format for consistency

-   Specific behavior to include relevant activities such as urinated,
    defecated, genital wash/wipe, clothing changed, showered, bathed,
    douched, removed/inserted tampon, diaphragm, condom, chewed gum,
    brushed teeth, gargled/mouthwash, vomited, smoked, ate, drank, etc.

# 

# The SANE Medical Record will include minimal information on the Offender, such as

-   Number of offender/s

-   Relationship of offender/s

-   Age of offender/s

-   Offender/s gender

# The SANE Medical Record will list all Evidence Collected

-   SAEK

-   Clothing, which may include description and identification of color,
    photographs taken, and identification of how clothes were brought to
    the SANE unit (i.e., carried, worn, etc)

-   Urine

-   Photographs, including type (digital, 35 mm) and an estimated number
    of photos taken

-   Miscellaneous evidence, such as environmental debris, fingernail
    scrapings, etc.

# The SANE Medical Record will detail the type of Medical Services provided to the sexual assault patient

-   Emergency contraception

-   Prophylaxis for sexually transmitted infections

-   Vaccines (Tetanus, Hepatitis B)

-   Other medications (Phenergan, Tylenol, Ibuprofen, Colace, Tucks)

# 

# The SANE Medical Record will document the visual Assessment of the patient, including description of injuries using the TEARS acronym

-   Full body

-   Genital

-   Identification of the patient position during the genital exam

-   Use of visualization adjuncts such as, filters, Toluidine Blue dye,
    magnification of colposcope, and number of photographs

# 

# The SANE Medical Record will include a copy of the Discharge Instructions that were given to the patient, including

-   Synopsis of services rendered

-   Medications administered

-   Follow-up/referral services

-   Safety planning discussed with patient

For state reporting purposes, the SANE documentation includes questions
for the annual *Sex Crimes in New Mexico* report, funded by the New
Mexico Department of Health Office of Injury Prevention and the New
Mexico Crimes Victim Reparation Commission Violence Against Women Act
Grants Office. For a full list of data fields abstracted from the SANE
medical record for reporting purposes, contact the New Mexico Coalition
of Sexual Assault Programs.

Given the variability among sexual assault patients, SANE programs may
decide to incorporate additional information or create supplemental
sheets in addition to the medical record. The Coalition recommends
supplemental sheets for cases where patient age, gender, or specific
patient complaints dictate the need for additional information, such as

-   Separate pediatric chart or supplemental pediatric body maps

-   Supplemental Tanner reference

-   Supplemental male sheet

-   Supplemental mouth sheet

-   Supplemental hands/feet sheet

-   Supplemental drug facilitated assault sheet

-   Supplemental strangulation sheet

-   Supplemental suicide assessment tool

-   Supplemental for patients with physical disability

-   Patient satisfaction/feedback survey

-   Progress note for the SANE to explain, describe and summarize the
    SANE exam from start to finish

**Cost Analysis of Creating and Maintaining a SANE Program**

**New Mexico Coalition of Sexual Assault Programs (NMCSAP)**

> During the 2003 Legislative Session, the Governor's Office requested a
> cost analysis of establishing and maintaining a SANE program. Listed
> below is the information provided to the Governor's Office in 2003.
> Please recognize that the costs are estimates and are subject to price
> changes.

In outlining a SANE Program, certain assumptions need to be clarified:

-   A community needs more than just one SANE nurse to have a
    comprehensive response. One SANE nurse will not last long. We
    recommend at least three SANE nurses for 24/7 coverage and to
    decrease burnout, promote collaborative learning, and
    institutionalize the program within the community. We also recommend
    salary for a part-time administrator.

-   A SANE program is required to be hospital or community-based to
    receive patient reimbursement funds from the New Mexico Department
    of Health - Behavioral Health Services Division (NMDOH-BHSD), paid
    through the New Mexico Coalition of Sexual Assault Programs. The
    state does not allow the Coalition to reimburse independent SANE
    contractors due to liability and professional standards.

-   The NMDOH-BHSD established a Sexual Assault Examiner Service
    Provider Agreement to reimburse the specially trained SANE nurses
    who request sexual assault exam medical reimbursement. This
    agreement is required if *nurses* conduct the sexual assault exam
    and is not required if a hospital chooses to have their physicians
    conduct the sexual assault exam.

# Training: \$2,700 x 3 nurse minimum = \$8,100 start up/first year with \$2,700 thereafter 

# Initial SANE training (6 day training held twice a year, usually in Albuquerque or Las Cruces). Per person costs include: hotel/per diem costs, travel to/from training site, and registration (\$50), approximately \$1,000 per nurse. 

-   Preceptor or clinical training (two to three weekends during the
    first three months, mentoring with an existing SANE program and/or
    participation in the SANE Genital Skills Lab sponsored by the
    NMCSAP) at approximately \$500 per nurse. (Covers mileage and
    hotel).

-   Annual on-going training and/or conferences to maintain skills and
    competencies. \$1,200 per nurse. To support this component, the
    NMCSAP sponsors annual Advanced SANE Conference in Albuquerque and
    limited stipends for attendance at national conferences.

-   Programs need to expect attrition of SANE nurses. We recommend at
    least one new SANE nurse is added to the program every/every other
    year.

# Equipment: \$10,000 to \$25,000 start up cost with occasional replacements or upgrades. 

# Variation in equipment cost due to donations, existing equipment within the facility, and purchase of Colposcope. If a Colposcope is not initially purchased, alternative and less costly techniques can be used for visualization/documentation of genital injuries.

-   Per site: colposcope (\$15,000), gynecology table (\$4000),
    gynecology lamp (\$300), roll-cart for supplies (\$250, digital
    camera (\$2000) and/or 35 mm/flash (\$1,800), alternative light
    source (\$350), swab dryer (\$400), pressure-cuffs/stethoscope
    (\$100), locked-file cabinet for records (\$500), copier (\$400),
    fax (\$200), computer (\$1,200), and printer (\$250).

-   Depending on support of law enforcement and number of law
    enforcement agencies, additional equipment may include lockers and
    locked refrigerator for storage of evidence.

# 

# Supplies \$7,000 annually

-   Office and evidence supplies: heavy duty staplers, evidence tape
    sealers, evidence rulers, sharpie markers, pens, clips, stickers,
    labels, paper for medical records, film for 35 mm photos, ink
    cartridges, folders, and batteries for cameras, pagers, flashes.
    (\$250 per month)

-   Medical supplies include speculum, rubber gloves, pregnancy tests,
    specific-gravity dipsticks, press- cuffs, band-aids, gauze, soap,
    cleaning supplies, syringes, needles, saline solution, tourniquets,
    swabs, foleys, tongue depressants, bio-hazard sharp containers, etc.
    (\$250 per month)

-   Victim supplies: coffee/tea equipment and supplies, microwave,
    snacks, juice, and clothes for when patients' clothes are taken for
    evidence. Some of this may be donated by local sources, although
    this is considerably more difficult in rural areas. Approximately
    \$1,000 first year, \$600 each year following.

# Overhead \$7,200 annually (plus room/office rental if not covered by the hospital)

-   Dedicated space including exam and interview/office room. Some of
    this might be donated by the hospital.

-   Communications: telephone, fax, internet, dispatch service, pagers
    for each nurse, cell phone for supervisor and/or medical director.
    (\$600 month per site)

# Personnel \$12,000 to \$30,000 annually 

-   Part-time coordinator (\$10,000 to \$25,000, depending on hours) to
    oversee program, schedule nurses, coordinate evidence, maintain
    clinical competencies of staff, respond to requests for records and
    subpoenas, maintain records, exam room and equipment, develop
    policies and protocols, trouble-shoot system breakdowns, conduct
    public outreach/education on how to access program, coordinate with
    community programs, evidence, apply for grants, recruit donations,
    etc. Based on New Mexico experiences, SANE programs without an
    administrative coordinator do not exist for long.

-   Medical Director (annual stipend of \$2000 to \$5000, optional) for
    medical oversight, establish and maintain pharmacy licensure,
    oversee clinical operations and coordinate with Emergency Department

# 

# Licensures/Regulations: dependent upon what the facility covers

-   Pharmacy license (\$150) and/or pharmacy consultant oversight

-   General insurance: property, theft, fire/damage, workmen's
    compensation, etc

-   Individual liability insurance for each SANE nurse
    (1,000,000/3,000,000)

-   Liability insurance medical director

**Rough Estimated Totals for SANE Program in New Mexico**

Start up/1^st^ year costs: \$45,000 to \$90,000 +

Annual costs thereafter: \$34,000 to \$50,000 +

**SANE National Resources**

[www.acep.org](http://www.acep.org/). The American College of Emergency
Physicians published recommendations to standardize the evaluation,
treatment, and management of sexual assault patients.

<http://www.ama.assn.org/ama1/pub/upload/mm/386/sexualassault.pdf>. The
American Medical Association in 1995 published its Strategies for the
Treatment and Prevention of Sexual Assault to guide physicians in their
response to sexual assault patients.

[www.civicresearchinstitute.com](http://www.civicresearchinstitute.com/).
Lists books and periodicals published by the Civic Research Institute
for ordering. Produces the hardcopy newsletter, Sexual Assault Report,
which brings together experts from criminal and civil law, nursing and
medicine, law enforcement, counseling, and social services.

[www.forensictrak.com](http://www.forensictrak.com/). American Forensic
Nurses is an organization providing medical forensic services to law
enforcement agencies and medical providers to highlight forensic
sciences. The website sells training tools, curricula, references, and
manuals as well as sponsors conferences and trainings in sexual assault.

[www.iafn.org](http://www.iafn.org/). The International Association of
Forensic Nursing is the professional organization for forensic nurses.
The website provides information for forensic careers, conferences and
trainings related to SANE, recent articles, a quarterly newsletter and
sponsors several list-serve and chat rooms for members only. Based on
self-report, the website lists SANE programs in the United States.

[http://medlineplus.gov](http://medlineplus.gov/). Medline is the
National Library of Medicine's and National Institutes of Health
database of biomedical journals. Provides links to federal agencies,
research articles, and public health programs that work with sexual
assault in a user-friendly format for individuals and professionals.

[www.nsvrc.org](http://www.nsvrc.org/). Supported by the CDC, the
National Sexual Violence Resource Center provides descriptions of state
sexual assault reports, state's statistics, research abstracts and
technical support on development of sexual assault prevention and
intervention activities.

[www.ojp.usdoj.gov](http://www.ojp.usdoj.gov/).

Under the Violence Against Women Act of 2000, the Attorney General is
required to develop sexual assault training standards for licensed
health care professionals and develop a national protocol for conducting
sexual assault exams -- both are available through this website. OVC
also has the SANE Development and Operation Guide on-line; this manual
has been a sentinel product for new SANE programs since 1996.

[www.rainn.org](http://www.rainn.org/). Rape, Abuse, and Incest National
Network carries out programs to prevent sexual assault, help victims,
and ensure that rapists are brought to justice. The network offers
statistics, counseling resources, prevention tips, and news.
Specifically geared for survivors and youth.

[www.sane-sart.com](http://www.sane-sart.com/). Supported by the Sexual
Assault Resource Center, US Department of Justice and US Department of
Commerce, the website provides a forum for SANE list-serves, a list of
SANE programs in the United States, conference and training
opportunities, and links to recent events and news coverage about sexual
assault.

[www.vaw.umn.edu](http://www.vaw.umn.edu/). The University of Minnesota
operates a Violence Against Women On-Line Resources, cooperating with
the Office on Violence Against Women, the Office of Justice Programs, US
Department of Justice and the Minnesota Center Against Violence and
Abuse. Of note, the website has Linda Ledray's sentinel report on the
Evidence Collection and Care of the Sexual Assault Survivor, which
outlines the recommended components of a SART.

[www.vawnet.org](http://www.vawnet.org/). VAWnet, a project of the
National Resource Center on Domestic Violence and funded by the CDC
National Center on Injury Control, provides a collection of resources,
including Applied Research Papers, Program Development Materials, Fact
Sheets, and more.

<http://whqlibdoc.who.int/publications/2004/924154628X.pdf>. The World
Health Organization published guidelines for the international
medical-legal response to sexual assault victims.

OVERVIEW OF GENITAL SKILLS LAB for NEW MEXICO SANE PRECEPT

**Purpose**

The purpose of the Genital Skills Lab is to provide hands-on training
for new SANE Student nurses who have already received the didactic
portion of the State SANE Training. This lab will allow the SANE Student
to obtain twelve (12) experiences relating to different aspects of the
genital exam with live patients. This will be accomplished within a
one-day concentrated timeframe and with active guidance and supervision
by an experienced SANE Proctor. Specifically, by the end of the day, the
new SANE Student will be able to:

-   Explain the genital exam, normalizing speaking and listening skills
    -- for females, the explanation will be focused on speculum
    insertion/removal and visualization techniques (foley catheter,
    Q-tip and Toluidine Blue Dye) and for males, the explanation will be
    focused on purpose, positioning, traction, and taking wet-dry swabs.

-   Identify normal anatomy and variants of the anatomy of the
    genitalia, including the anus

-   Use multiple visualization techniques (Q-Tip, foley catheter,
    Toluidine Blue, and traction)

-   Use a Colposcope and camera

-   Gain confidence in the process of a genital exam

**Process**

The learning process will be actively supported by immediate guidance
from experienced Proctors and active feedback from the Standardized
Patients. The attached Skills/Learning Objectives Check-Off list will
guide the process.

**Patients will immediately communicate to the new SANE nurse if
anything hurts.**

**Proctors will immediately stop any procedure that is being done wrong
or can cause harm.**

**Any problems with equipment or supplies, contact the Coordinator as
soon as possible.**

**Process: Manual Skills**

For each station, skills will be increased in number, level of
difficulty and expectation of independent performance. In other words,

-   The first or second time the SANE student conducts a skill, the
    Proctor will give **active guidance** and help -- offering technical
    assistance, hands-on showing, and/or specific verbal directions.

-   The second or third time the SANE student conducts a skill, the
    Proctor will give **some guidance** -- interrupting the process if a
    bad habit or weak technique is being used, responding to specific
    questions from the new SANE Student, and/or asking gentle questions
    as prompters to remind the new SANE Student of newly learned skills.

-   The fourth time the SANE student conducts a skill, the Proctor will
    give **no guidance** unless specifically asked. If the SANE student
    asks for help, the Proctor will answer the questions. These stations
    are meant to be a positive learning experience, and we recognize
    that some SANE students may learn at a slower rate, may be nervous,
    and may temporarily forget content.

-   Each of the nine exercises will include additional skills and the
    proctor will notify the SANE student of the new skill the first time
    it is being addressed.

-   It is appropriate for the Proctor to prompt the SANE Student to keep
    on track. In other words, the Proctor may say: proceed to speculum
    insertion, or proceed to identifying the cervix, etc.

**Process: Communication Skills**

-   For the first two exams, the Proctors should actively guide the SANE
    student in how to explain procedures to the patient, what to say to
    help the patient relax, the purpose of the speculum, etc. For the
    subsequent exams, the Proctors can offer help in
    patient-communication skills if asked or if something is said in
    error.

-   For the first two exams, the Standardized Patients will provide
    comments to the SANE student on how speculum insertion felt. For
    subsequent exams, the Standardized Patient may answer the SANE
    Student if asked or at completion of the exam, when prompted by the
    Proctor.

-   For the last three stations, the SANE Student should explain to the
    Standardized patient in laymen's terms the photos of the body parts.
    If the Standardized Patient does not understand the explanation, it
    is appropriate to ask for clarification.

-   NOTE: the primary purpose of this exercise is for the SANE student
    to obtain hands-on skills in conducting a genital exam. A secondary
    objective is for the SANE students to gain confidence in explaining
    procedures and how to talk through a genital exam; however, let
    questions/sample responses supplement and not distract from the
    hands on practice of conducting the genital exam.

-   NOTE: at any time, if any of the actions by the SANE student causes
    discomfort, the Standardized Patient should communicate clearly and
    immediately!

**Proctors**

It is the responsibility of the Proctor to

-   **Immediately stop any procedure that is being done wrong or can
    cause harm.**

```{=html}
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```
-   Complete the Skills/Learning Objectives Check-Off list. The Proctor
    may use the Check-Off list to prompt the SANE student to keep moving
    and on track.

-   Complete the SANE Student Evaluation after each genital exam

-   Notify the SANE Student at the start of the station of the new skill
    being learned.

-   Prompt the Standardized patient to describe "how speculum
    insertion/removal felt" at the end of the station if the
    Standardized Patient has not already done so (for the first two
    stations) and if the SANE student has not already asked (for the
    remaining stations).

-   The Coordinator will knock on the door with a five minute and two
    minute notification of station completion. At the two minute knock,
    whatever isn't done -- is not done! Just note on the Check-Off list
    and proceed to speculum removal.

-   Clarification of note: The Proctors evaluate/measure observable
    behavior of the SANE student while the Standardized Patients
    describe how they as patients felt during the process.

**SANE Students**

It is the responsibility of the SANE Student to

-   Review the student packet prior to starting the day's exercises.

-   Feel comfortable and prepared for the learning objectives: it is
    okay to have a blank copy of learning objectives with you on the
    genital skills lab day

-   Complete the Evaluation upon completion of all nine stations.

-   Ask questions when clarification or help is needed.

-   Recognize that the four Proctors may have different styles in
    teaching and in practice. While every attempt has been made to
    minimize the influence of these differences on your leaning skills,
    we ask that you incorporate the different styles as part of the
    learning process.

**Standardized Patients**

It is the responsibility of the Standardized Patient to

-   **Immediately communicate to the new SANE nurse if anything hurts.**

-   **If you are allergic to latex, tell this to both the Proctor and
    SANE student -- there are non-latex gloves available.** For the
    Foley exercise, we have purchased non-latex equipment.

-   Complete the SANE Student Evaluation after each genital exam.

-   For the first two exams, the Standardized Patients will provide
    comments to the SANE student on how speculum insertion felt. For all
    subsequent exams, the Standardized Patient may answer the SANE
    Student if asked during the exam. If not asked during the normal
    course of the exam, the Standardized Patient should coordinate with
    the Proctor in providing feedback on how speculum insertion/removal
    felt.

-   At any of the stations, if the SANE Student speaks to you as a live
    patient, please respond accordingly but briefly. For example, if the
    SANE student asks "are you doing okay?"- answer!

-   For the last three stations, the SANE Student should explain to the
    Standardized patient in laymen's terms the photos of the body parts.
    If the Standardized Patient does not understand the explanation, it
    is appropriate to ask for clarification until you do understand.

-   Coordinate with the SANE Proctor to ensure a positive learning
    environment.

**Coordinator and Assistant**

The two Coordinators will be in the hallway to assist with

-   Keeping track of time, including knocking on the door with the
    "five" and "two" minute warnings

-   Collecting evaluations as needed.

-   Directing SANE Students to the next station

-   The coordinator will be entering rooms to check the process and
    answer questions.

-   Coordinating lunch and refreshments

-   Replenishing supplies as needed and trouble shooting equipment as
    needed

**Timelines**

-   Note the times -- not all skills labs are the same length of time!
    The later skills labs are longer because of added and more complex
    skills

-   There will be breaks scheduled during the day for bathroom break
    and/or stretch, completing evaluations/paperwork, and for exchanging
    Standardized Patients when scheduled.

-   Lunch will be provided and will be kept to 25 minutes

**Supplies**

-   Swabs, Texas swabs, Gloves (both latex, small and medium, and
    non-latex), Foley and syringe for air, Specula, small and medium,
    Chux and drapes for patients, Dixie cups and distilled water,
    genital wipes, Toluidine Blue supplies, gyne light,

-   Evaluations and learning objectives for Students, Proctor and
    Standardized Patients, patient consent forms

-   Cleaning supplies and paper towels for clinic area, trash bags

-   Four clinic rooms with gyne tables, three with Colposcope and one
    for males/Toluidine Blue skills

-   Power strips, extension cords, three-prong adaptors

-   Food for snacks and lunch

Critical Elements and Agency Leadership for Sexual Assault Response --
MDT/SART Assessment and Review

> The purpose of this inventory is to encourage the multi-disciplinary
> sexual assault response team to discuss and review what services are
> offered, by which agency(s), if duplication/overlap of services is
> potential source for problem, and to identify what services are not
> being offered.

+---------------------------------+---+---+---+---+---+---+-----+----+
| **Critical Elements of Sexual   | * | * | * | * | * | * | **  | *  |
| Assault Response**              | * | * | * | * | * | * | Cou | *A |
|                                 | R | S | L | D | V | C | rts | re |
|                                 | a | A | a | A | i | r | an  | as |
|                                 | p | N | w | * | c | i | d** | f  |
|                                 | e | E | * | * | t | m |     | or |
|                                 | * | * | * |   | i | e | **C | A  |
|                                 | * | * |   |   | m | * | orr | tt |
|                                 |   |   | * |   | * | * | ect | en |
|                                 | * |   | * |   | * |   | ion | ti |
|                                 | * |   | E |   |   | * | s** | on |
|                                 | C |   | n |   | * | * |     | ** |
|                                 | r |   | f |   | * | L |     |    |
|                                 | i |   | . |   | A | a |     |    |
|                                 | s |   | * |   | d | b |     |    |
|                                 | i |   | * |   | v | * |     |    |
|                                 | s |   |   |   | . | * |     |    |
|                                 | * |   |   |   | * |   |     |    |
|                                 | * |   |   |   | * |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Receive report of victim sexual |   |   |   |   |   |   |     |    |
| assault                         |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Activate other services on      |   |   |   |   |   |   |     |    |
| behalf of sexual assault victim |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Ensure initial safety for       |   |   |   |   |   |   |     |    |
| victim                          |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Offer info/options to victim    |   |   |   |   |   |   |     |    |
| about services, decisions,      |   |   |   |   |   |   |     |    |
| costs                           |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine need/consent for      |   |   |   |   |   |   |     |    |
| medical care                    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Arrange transportation to/from  |   |   |   |   |   |   |     |    |
| medical care                    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Advise victim of evidence       |   |   |   |   |   |   |     |    |
| preservation steps              |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Work with secondary victims     |   |   |   |   |   |   |     |    |
| (family, friends, witnesses)    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Record victim's                 |   |   |   |   |   |   |     |    |
| statements/condition            |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine extent of medical     |   |   |   |   |   |   |     |    |
| attention and emergency care    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Identify need and refer victim  |   |   |   |   |   |   |     |    |
| for emergency medical care      |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Inform victim of evidence       |   |   |   |   |   |   |     |    |
| collection/receive              |   |   |   |   |   |   |     |    |
| authorization                   |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine if victim wants       |   |   |   |   |   |   |     |    |
| advocate support during medical |   |   |   |   |   |   |     |    |
| and/or forensic exam            |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine need and provide      |   |   |   |   |   |   |     |    |
| interpreters for victim         |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine need for mandated     |   |   |   |   |   |   |     |    |
| reporting requirements          |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine need and activate     |   |   |   |   |   |   |     |    |
| legal guardianship              |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Conduct forensic examination    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Collect and preserve evidence   |   |   |   |   |   |   |     |    |
| from the victim                 |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Provide clothing/amenities for  |   |   |   |   |   |   |     |    |
| victim                          |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Test for pregnancy/provide      |   |   |   |   |   |   |     |    |
| treatment for STD/EC            |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Obtain victim standards         |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Risk assessment/referral for    |   |   |   |   |   |   |     |    |
| suicide risk                    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Arrange for transportation home |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Inform victim of follow-up care |   |   |   |   |   |   |     |    |
| resources                       |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Provide follow-up/aftermath     |   |   |   |   |   |   |     |    |
| services                        |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+

+---------------------------------+---+---+---+---+---+---+-----+----+
| **Critical Elements of Sexual   | * | * | * | * | * | * | **  | *  |
| Assault Response, continued**   | * | * | * | * | * | * | Cou | *A |
|                                 | R | S | L | D | V | C | rts | re |
|                                 | a | A | a | A | i | r | an  | as |
|                                 | p | N | w | * | c | i | d** | f  |
|                                 | e | E | * | * | t | m |     | or |
|                                 | * | * | * |   | i | e | **C | A  |
|                                 | * | * |   |   | m | * | orr | tt |
|                                 |   |   | * |   | * | * | ect | en |
|                                 | * |   | * |   | * |   | ion | ti |
|                                 | * |   | E |   |   | * | s** | on |
|                                 | C |   | n |   | * | * |     | ** |
|                                 | r |   | f |   | * | L |     |    |
|                                 | i |   | . |   | A | a |     |    |
|                                 | s |   | * |   | d | b |     |    |
|                                 | i |   | * |   | v | * |     |    |
|                                 | s |   |   |   | . | * |     |    |
|                                 | * |   |   |   | * |   |     |    |
|                                 | * |   |   |   | * |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine location of scene     |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine need for crime scene  |   |   |   |   |   |   |     |    |
| activation/resources            |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Determine if assailant is still |   |   |   |   |   |   |     |    |
| nearby                          |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Investigation of crime scene,   |   |   |   |   |   |   |     |    |
| trace evidence, photos, etc     |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Search warrants                 |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Collect suspect/assailant       |   |   |   |   |   |   |     |    |
| standards                       |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Inform/assist victim with CVRC  |   |   |   |   |   |   |     |    |
| reimbursement claim             |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Inform victim of law            |   |   |   |   |   |   |     |    |
| enforcement investigation       |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Keep victim informed of case    |   |   |   |   |   |   |     |    |
| status                          |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Inform victim of pre-trial      |   |   |   |   |   |   |     |    |
| hearings and motions            |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Accompany victim through legal  |   |   |   |   |   |   |     |    |
| proceedings                     |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Consider needs/rights of victim |   |   |   |   |   |   |     |    |
| in scheduling proceedings       |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Inform victims of reasons to    |   |   |   |   |   |   |     |    |
| consider a negotiated plea      |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Describe optional courses of    |   |   |   |   |   |   |     |    |
| action for victim               |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Ensure opportunity for victim   |   |   |   |   |   |   |     |    |
| impact statement as part of     |   |   |   |   |   |   |     |    |
| sentence considerations         |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Include victim needs as part of |   |   |   |   |   |   |     |    |
| sentence, such as restitution   |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Notify victim about changes in  |   |   |   |   |   |   |     |    |
| offender status                 |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Notify victim of scheduled      |   |   |   |   |   |   |     |    |
| parole hearings                 |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Provide opportunity for victim  |   |   |   |   |   |   |     |    |
| testimony at parole hearings    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Notify victim of release and    |   |   |   |   |   |   |     |    |
| status of release               |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Train/educate co-responding     |   |   |   |   |   |   |     |    |
| agencies of what each program   |   |   |   |   |   |   |     |    |
| does and what services are      |   |   |   |   |   |   |     |    |
| provided by each agency         |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Develop materials and outreach  |   |   |   |   |   |   |     |    |
| for public about services       |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Target hard-to-reach or at-risk |   |   |   |   |   |   |     |    |
| populations about services      |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Review sexual assault cases to  |   |   |   |   |   |   |     |    |
| improve interagency response    |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+
| Share/compare data, trends, and |   |   |   |   |   |   |     |    |
| timelines of how sexual assault |   |   |   |   |   |   |     |    |
| cases move between systems      |   |   |   |   |   |   |     |    |
+---------------------------------+---+---+---+---+---+---+-----+----+