The Role of the Sexual Assault Nurse Examiner in the Investigation of Reported Sexual Assaults Valerie Krasneski-Schreiber, RN, BSN, MS, SANE-A Unit Director, UPMC Mercy Dept. of Emergency Medicine Debra Shane, MSN, RN, SANE-A Clinician, UPMC Mercy Dept. of Emergency Medicine

Factors Affecting Delay of Care/Reporting Ingestion of drugs/alcohol Amnesia Doubt Self Blame Afraid parents will find out After disclosure to family/friend

Sexual Assault Nurse Examiners (SANE) SANE-Sexual Assault Nurse Examiner RN specially trained in evidence collection and care of victims of sexual assault 40 plus hours of training plus clinical Evidence collected by a SANE is more like ly to be useful

Sexual Assault Nurse Examiners (SANE) Forensic Nurses play an integral role in bridging the gap between law and medicine. They should be in each and every emergency room” Joseph Biden, Vice President, United States from Forensic Nursing: a Handbook for Practice

We Can’t Do This Alone

Collaborate with Health Care Team Medical Screening Exam Physician performs Notification of Advocate/Law Enforcement Who can do this? When does it get done?

Advocates Hospital personnel will initiate the call to Pittsburgh Action Against Rape (PAAR) or the Center for Victims (CV) upon patient arrival They offers emotional support and accurate factual information to victims of sexual assault both during the initial crisis and for as long after as the victim wishes Insures victims are treated with dignity Communication with advocate is privileged

The Law We will call law enforcement in the jurisdiction in which the incident occurred. Reporting does not obligate or penalize the victim who may later not want to press charges. Acute and past incidents are reportable. Statute of limitations (adult S.A.) is 7 years.

In the Emergency Department Not all ED’s have SANE’s Importance of a SANE collecting the evidence

In the Emergency Department Life threatening emergencies are always the priority

PCCD FRE Claim Form

“Am I OK?” The medical forensic exam is health care focused and patient centered Address immediate concerns Avoid revictimization Assess for safety including after discharge Provide reassurance Identify emergent conditions Relieve physical pain Identify injuries Collect evidence Provide prophylaxis for STIs Provide pregnancy prophylaxis Have a follow up plan

Safety Where is the assailant? Is this also Domestic Violence? Is the patient suicidal? Who is actually in the room with the patient? Where will the patient go when the exam is completed?

Informed Consent Risks Benefits Alternatives Consequence if treatment or procedure is not performed

Crime Victim Consideration Patient who has been a crime victim is experiencing: Loss of control Invasion of body It is best to allow the patient to consent to each item of collection to regain that control

Assumed Consent In a medical emergency, consent is assumed for medical intervention Forensic consent goes beyond medical consent and should be obtained when possible Facility policy & procedure as well as legal counsel will determine appropriate course of action on case by case basis

Patient Says “Maybe” In accordance with the Violence Against Women Act (2013), Patients may have evidence collected and not report the crime- UPMC policy is to hold the kit for 365 days Patients may also request exam and medical treatment (including prophylaxis) with no evidence collection Patients may have a portion of the exam and decline other portions

“Waiting it Out” If a patient appears intoxicated, consider blood alcohol level Not usually completed in ED unless SA is a possibility. While it may delay care, it ensures that our patient is sober enough to consent to the forensic exam and/or release of evidence It is also a more concrete way of assessing sobriety, as opposed to opinion

Patient Says “No” If a patient presents and declines to have evidence collected, we should not collect* Hospital should still perform MSE to comply with EMTALA and ensure that patient has capacity for consent/ refusal EC and prophylaxis and advocacy should still be offered If a patient changes his/her mind during evidence collection, STOP Allow the patient time with the advocate to decide what they want to do

What we ask- Interviewing Date and time of sexual assault Pertinent Patient Medical History Recent Consensual Sexual Activity Post-assault Activities of Patents Assault-related Patient History Suspect Information Nature of the Physical Assault Narrative of Assault Description of the Sexual Acts Strangulation assessment First 8 pages of documentation

Forensic Photography Documentation

Forensic Photography Documentation

Injury description and documentation Forensic documentation should include: L=location A=appearance S=shape T=type S=size   Locator # Type Photo # Description 1 CT 4-6 3mm x4mm oval area, purple and red 2 AB 7-9 2cm red linear area with dried blood

Alternate Light Source Examination

Evidence Collection Clothing Oral Swabs and Smears Buccal Swabs Fingernail Evidence Dried Secretions Genital evidence Miscellaneous Evidence

Drying and Packaging the Evidence Minimum Drying time 1 hour on all swabs Clothing may take longer Specific documentation on all items Packaging the kit and clothing separately

What Happens Now? FEARS: STI, HIV, Pregnancy, How will I pay for this?

After the Exam Medications nPEP Education Follow Up Shower/fresh Clothing Safe Place to Stay Transportation

Testifying in Court Educated on testimony Beneficial to victim

Patient Education Video

Questions?