# Presentation: 329162

## Challenges of SANE in the Clinical Setting

- Connie Monahan, MPH
- Statewide SANE Coordinator
- New Mexico Coalition of Sexual Assault Programs
- conniem@swcp.com

## 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

## Profile of the Problem

- Average annual violent crime rate among American Indians is 2.5 times the national rate (BJS, American Indians and Crime 1999)
- Nearly one-third of victims are 18-24 years
- 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)

## Profile of the Problem

- Jurisdictional issues of tribal-state-federal
- Location of assault
- Race of victim/of offender
- Reporting laws
- Agency that pays for the medical/forensic exam
- Training, protocols, agreements, coordination
- Historical context of sexual violence as a tool of conquest and/or on-going oppression
- Role/responsibility of health care to violence

- Texts...

## SANE Mission Statement

- 	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.

## SANE Mission Statement

- Break-down of the mission statement
- Prompt
- Comprehensive
- Objective-compassionate
- Medical treatment
- Forensic evaluation
- Advanced-trained nurse_**s**_
- Coordinated community response

## Guiding Principles of SANE

- Ensure medical stability
- Ensure informed consent and patient confidentiality throughout the process
- Support the patient’s recovery
- Prevent secondary illness or injury
- Provide objective documentation
- Follow professional and state standards of care – nursing, legal, and forensic

## 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
- Participate in legal proceedings

## Quick history of SANE

- Sexual assault victims go to hospital ED...
- Rarely a life threat, long wait, public area
- Multiple providers, reluctance, 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...

## SANE Development in Response to Poor ED

- One-on-one 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

## SANE Models

- Who pays influences how SANE’s operate
- Law enforcement, Attorney General or District Attorney
- Patients filing police report to receive exam
- Hospital
- SANE’s may be paid hourly vs. case fee
- State’s Department of Health
- CVRC, VOCA, or VAWA
- Victim based
- Insurance Companies

## Where are SANE’s housed?

- Physically/financially
- Hospital, medical facility, women’s or student health centers
- 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

## SANE Variations/Consistencies

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

## SANE Variations/Consistencies

- Consistencies may include
- Evidence collection or “rape kit”
- Response within standard time frame
- 24 hour coverage by > “just one nurse”
- Initial SANE training and precept
- On-going competencies, evaluation, professional development, conferences...
- Professional membership with IAFN
- Certification (SANE-A, SANE-P, CFN)

## SANE Training

- Minimum guidelines
- IAFN and/or DOJ President’s DNA Initiative
- Generally 40 hours or more
- Modeled on the multi-disciplinary team approach (multiple instructors)
- Certificate of completion/nursing CE’s but initial training ≠ *certified or certification!! *
- State reciprocity is not uniform
- State variations in evidence/crime labs, sexual assault laws, protocols, who pays, window for response

## SANE Training

- Training guidelines
- SANE is a specialized response
- Initial training only one aspect of whole
- One nurse ≠ program
- Precept requirements, competencies, chart review, evaluation
- Has to be linked to community

## What determines development of SANE Program

- Number of patients
- Perceived need by the community
- Support by DA and Law Enforcement
- Support by the facility
- Staffing: nurses, medical director, coordinator
- Community Resources – advocacy, MH
- Leadership
- Non-competitive with existing SANE

## 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
- Business plan: expenses, payment sources, impact evaluation...

## Who makes it happen?

- Institution
- Individual
- If you want program sustainability, Institution, Individual AND Community!

## 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
- Conviction rates

## 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)

## 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)

## 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)

- Breather...

## 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

## 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

## Systems for Rural Response

- Existing clinical services
- Health clinics, hospitals, crisis services, hotlines, EMS, school-based or women’s health clinics
- Staffing
- Initial training/precept
- Attrition/retention of SANE nurses
- Coordination to include scheduling, supplies, chart review, being a point person, training, competencies, outreach with community....

## 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

## Creative Strategies for Rural 

- Work to improve the existing ED response
- Introductory video for sexual assault patients
- Use two SANE’s to co-respond to patient
- Entice SANE’s to work at more than one program
- Share coverage between two programs
- Use precept Genital Skills Lab as evaluation tool or for meeting minimum competencies
- Mobile or portable kit
- On-line courses, telemedicine chart review, videos
- Participate in statewide or regional strategic planning/development

## Challenges of SANE in Clinical Setting

- Medical, forensic, AND legal response
- Moment patient presents on-through to prosecution averages 18 months
- Intensity of a 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

## Thank you!