Saint John SANE program Maureen Hanlon RN SANE

Saint John SANE program Maureen Hanlon RN SANE Coordinator

What is SANE? • What does SANE stand for? • Sexual • Assault • Nurse • Examiner • “Sexual Assault Nurse Examiners (SANE) are registered nurses who have completed specialized education and clinical preparation in the medical forensic care of the patient who has experienced sexual assault or abuse. ” • (www. forensicnurses. org)

History of SANE “SANE programs developed slowly beginning in the early 1970 s. Nurses saw that services to victims of sexual assault were inadequate and were not equal to the high standards of care provided to other emergency department patients. These patients had specific concerns about contracting a sexually transmitted disease or becoming pregnant. Nurses led the effort to provide better, tailored services to victims seeking care after a sexual assault. ” (https: //www. ovcttac. gov/saneguide/introduction/hist ory-and-development-of-sane-programs/)

Local SANE program development • In the past, SA patients would often be subject to lengthy wait times for examination, due to the time consuming nature of medical forensic exams. • SANE staff have received 60+ hours of intensive training in adult and pediatric SA assessment, forensic collection techniques, medical-legal documentation.

When to call SANE • SANE nurses should be called for patients of all ages who come to the ED with sexual assault or abuse related presentations. • SANE nurses should also be called for patients who have domestic violence related complaints. • Our goal is to have a SANE on call 24/7 to be available to our patients, so that delays in care minimal.

When to call SANE, continued • Our triage nurses are advised that SA patients and DV patients are a CTAS level 2 patient. • The SANE on standby will be called. • A volunteer from SART (Sexual Assault Response Team) will be called for all patients 16 yr or older. They are available as a support person during the patient exam.

Options for patient care • SANE patients are offered different options for the care they receive. • Medical care option. • Medical-forensic care with reporting to police. • Medical-forensic care with freezing of evidence

Medical care exam option • Pt must provide consent to examination and it must be documented that forensic evidence collection has been declined. • A brief medical history is taken. A focused SA history is documented. • A head to toe assessment for physical injuries is performed and documented on traumagrams.

Medical care option, continued • A speculum exam will be performed to inspect for injuries, and swabs obtained for GC, trichomonas, and urine Chlamydia specimen will be sent. A urine HCG will also be done. Baseline bloodwork is performed for HBs. Ag, HIV, HCV, and syphyllis. (per Public Health guidelines) • STI prophylaxis will be offered as per SANE order set. Emergency contraceptive is given PRN as well. (per Public Health guidelines) • https: //www. canada. ca/en/public-health/services/infectiousdiseases/sexual-health-sexually-transmitted-infections/canadianguidelines/sexually-transmitted-infections/canadian-guidelinessexually-transmitted-infections-43. html

Medical care option, continued • • Medications included in order set are: Levonogestrel 1. 5 mg PO Azithromycin 1 GM PO Cefixime 800 mg PO • In some instances, patients may require Tdap, HBIG, or HIV PEP may need to be considered.

Medical Care option, continued • Follow up testing for STI is recommended for 6, 12 and 24 weeks. • A consent is obtained for the patient to be contacted by SART for follow up counselling. (this counselling service is offered at no cost to the patient, if they have no coverage)

Medical forensic option with reporting to police • Police may be notified at any time! They are, however, not required to be present in ER during exam.

Medical forensic option with reporting to police • Consent. • Head to toe exam is performed. • Based on assault history, patient may be assessed with alternate light source, to see if any body stains fluoresce, that may require swabs for DNA evidence. We have a new ALS in our SANE cabinet. (Yay!!)

Medical forensic option with reporting to police • Forensic Kit, once opened, must have chain of evidence maintained at all times until the kit is signed over to the police. • Oral swabs, genital, anal and rectal swabs, as well as any swabs as indicated by assault history are obtained. Blood and urine samples for drug screening may be sent with kit.

Medical forensic option with reporting to police • All aspects of medical exam will be completed, (as per the wishes of the patient) including speculum/genital exam, lab testing, STI prophylaxis meds, and arrangements will be made for follow up care, testing and counselling.

Medical forensic option without reporting to police: Freezer option • There is a locked freezer located in the ED for SAE evidence kits. • Patients are made aware that kits will be held for up to 6 months and will be destroyed at that time.

Medical forensic option without reporting to police: Freezer option All medical care and forensic collection done, STI prophylaxis given and follow up care arranged. *space in the freezer at times is limited due to the size of SAE kits. Can hold approx 5 -6 kits.

Pediatric considerations • All patients under the age of 19 years less a day who present with SA are required to be reported to DSD. • “Any person who has information causing him to suspect that a child has been abandoned, deserted, physically or emotionally neglected, physically or sexually ill-treated or otherwise abused must inform this Department of the situation without delay. ” • http: //www 2. gnb. ca/content/gnb/en/services _renderer. 9355. Child_Protection. html

Pediatric considerations • The time frame for an acute assault in pediatric cases is shorter than adult cases. (2472 hrs) • Dr Mc. Kenna, Dr Sanderson and Dr Herrington are willing to be called to assist in acute and historical cases.

Pediatric considerations • Most pediatric cases that present to ED are historical, whether by disclosure from child or suspicion of parent. “Sexual abuse is not typically disclosed to or suspected by others immediately following the abuse (Mc. Elvaney, 2015)”. https: //www. justice. gov/ovw/file/846856/do wnload

Domestic violence • Patients of all ages who present with Domestic Violence can be seen by the SANE. • SANE will assess, document, report to police (if patient consents), arrange for safe discharge location, and set up follow up counselling.

Local stats • How many cases are we seeing in Saint John?

Our SANE program • We currently have 10 nurses involved with the SANE program. Most are nurses from the ER however some have different background in nursing. • If patients present with other concerns that are out of the scope of practice of SANE, the nurses are advised to ask for assistance from the ERP on duty. • Upcoming training expected in May 2018.

References • www. forensicnurses. org • https: //www. ovcttac. gov/saneguide/introduction/history-anddevelopment-of-sane-programs/ • https: //www. canada. ca/en/public-health/services/infectiousdiseases/sexual-health-sexually-transmitted-infections/canadianguidelines/sexually-transmitted-infections/canadian-guidelinessexually-transmitted-infections-43. html • http: //www 2. gnb. ca/content/gnb/en/services_renderer. 9 355. Child_Protection. html • https: //www. justice. gov/ovw/file/846856/download

Questions?