Purpose of the MA Adult/Adolescent SANE Protocol
This protocol provides guidance to Adult/Adolescent SANEs and Emergency Department clinicians regarding best-practice guidelines for sexual assault patients 12 years of age and older. In addition, this document provides an overview of the scope and role of the SANE as well as other responders who provide service for sexual assault patients. Such responders include, but are not limited to medical providers, rape crisis advocates, law enforcement agents, and other social service, and legal professionals who work to support patient healing, recovery, and access to justice.
Introduction
The Massachusetts Sexual Assault Nurse Examiner (SANE) Program has evolved from a Massachusetts Department of Public Health (MDPH) training initiative established in 1995 into a statewide service delivery system for patients of all ages who have been sexually assaulted.
SANE mission
The mission of the SANE Program is to deliver time-sensitive, compassionate, coordinated, expert forensic nursing care to sexual assault patients, across the lifespan in Massachusetts.
The SANE Program is a coordinated, compassionate, and comprehensive service delivery model:
- Compassionate: The SANE Program provides a unique forensic nursing approach to patient care that empowers and cares for the patient without judgment, while maintaining dignity, respect and compassion.
- Coordinated: The SANE Program provides care to sexual assault victims in tandem with other multi-disciplinary team members, who may interface with the victim.
- Comprehensive: The SANE Program provides a full array of forensic nursing care to victims of sexual assault including forensic physical examination and evidence collection, documentation of assault history and physical findings, medication management, crisis intervention, discharge planning and referrals. MA SANEs may also work collaboratively with law enforcement and provide testimony in for cases that move forward to prosecution.
MA SANE statute
In 2005, MGL Chapter 111, Section 220 was passed codifying the MA SANE Program and the MA SANE Advisory Board. The Massachusetts SANE Program holds the national distinction of being the only centralized statewide SANE program for patients of all ages. The SANE Program has a strong leadership team that oversees quality service delivery and collaborates with other agencies to improve systems of care and response for sexual assault victims. The Program also draws on the expertise of other statewide and national experts to inform evidence-based practices for patients who have been sexually assaulted. This SANE Program Protocol was developed through the combined efforts of these experts and other SANE Advisory Board members.
Program history
The Massachusetts SANE began in 1995 as a training initiative for nurses to help ensure best practice standards for victims of sexual assault ages 12 and over. At that time, there were approximately 2,300 sexual assault patients entering emergency departments across the state. A study conducted by the Massachusetts Department of Public Health (MDPH) revealed a host of medical, criminal justice, and victim service problems with the response to sexual assault victims at hospitals. Many patients were cared for by multiple providers who were inadequately trained and unsure of the protocols for collecting forensic evidence and performing a post-sexual assault exam. Results of this study showed that evidence was not collected in 38% of cases where it was indicated, and that 39% of collected evidence was done incompletely. In addition, many patients were kept waiting up to eight hours after coming to the emergency department which resulted in many patients leaving the ED before receiving medical care or a forensic exam and evidence collection.
During this same time, District Attorneys were reporting that clinicians who performed evidence collection were often unavailable to testify at the time of trial, may have collected poor quality evidence, and were often untrained in providing testimony. The study indicated that training alone would not be sufficient to address these deficiencies. In response to these findings, the MDPH SANE Program launched, and an in-person SANE emergency response was piloted in Lawrence and Boston (in 1997 and 1998 respectively). The program gradually expanded to 27 hospital sites by 2008. In 2005, MGL Chapter 111, Section 220 was passed codifying the SANE Program and MA SANE Advisory Board. In 2015, three additional hospitals were added making a total of 30 hospitals currently receiving in-person SANE services. TeleSANE services were piloted in 2016 (see below). As of January 2022, the TeleSANE arm of the program is providing expert clinical guidance and consultation to 10 additional hospitals, for a total of 40 MA hospitals (63%) receiving an in-person SANE or TeleSANE response.
Pediatric SANE Program
Soon after the commencement of the Adult/Adolescent SANE Program, it became clear that similar services were needed for children. Emergency department clinicians were not well versed in the care of children who had been sexually abused, and many used the MA Sexual Assault Evidence Collection Kit (MSAECK), intended for use with for adult/adolescent patients, for child sexual abuse examinations. There were anecdotal accounts of children being restrained or sedated for forensic evidence collection, along with the use of speculum exams for pre-pubertal children. In 2000, the MA SANE Program convened a multi-disciplinary Pediatric SANE Working Group (PSWG) to address these issues. The group adopted a “do no harm” philosophy of care and worked to develop Pediatric SANE Protocols for children 11 years and younger that did not re-traumatize or cause pain/discomfort. These protocols were shared with hospitals statewide.
In 2002, the PSWG utilized Byrne Memorial Justice Assistance Grant funding to create the first Pediatric Sexual Assault Evidence Collection Kit (MA PEDI Kit) in the U.S. The MA PEDI Kit incorporates the “do no harm’ principles”, and provides a developmentally appropriate, user-friendly tool for pediatric evidence collection. The MA PEDI Kit was first manufactured and released for use in 2005. The MA PEDI Kit has since been replicated by the state of Alaska and has been reviewed by other locations including Puerto Rico and Japan. In 2017, a multi-disciplinary MA PEDI Kit Working Group was convened to further refine/update the MA PEDI Kit so that ED practitioners will be able to use it with more confidence and yield improved evidence collection. The SANE Program also developed a MA PEDI Kit training DVD that was shared with emergency department providers statewide.
In 2004, the SANE Program conducted its first MA Pediatric SANE Training Course for 25 Registered Nurses and Nurse Practitioners. In 2005, with an increase to the SANE Program line item, six Nurse Practitioner Pediatric SANEs were hired to work as part of a Multi-Disciplinary Team (MDT) providing services to children within six Children’s Advocacy Centers (CACs): Barnstable, Berkshire, Essex, Norfolk, Plymouth, and Suffolk Counties. In 2007, a Pediatric SANE was hired for the newly established Bristol County CAC, and a Pediatric SANE became part of the MDT in the Middlesex County CAC in 2017. In FY’21 a shared Pediatric SANE position was created for CACs in Franklin and Hampshire Counties. In addition to providing expert forensic nursing care focused to the child’s health and well-being, the Pediatric SANEs provide critical education to MDT members and are consulted as medical experts by other community pediatricians and medical providers. Individualized training is provided for all new Pediatric SANEs by a Pediatric Clinical Coordinator who oversees the quality of clinical practice for all Pediatric SANEs. As of January 2022, Pediatric SANEs are part of MDTs in ten of the state’s twelve CACs.
Cross-Training in Use of MA PEDI Kit
In 2005, Adult/Adolescent SANEs at Lawrence General Hospital (LGH), who attended the 2004 Pedi SANE Certification Training, began to use the MA PEDI Kit to respond to LGH for children (11 years and younger) with acute disclosures of sexual abuse. This SANE response for pediatric patients expanded to Lowell General Hospital when that hospital became a MDPH-designation SANE site in 2016. In 2015, Adult/Adolescent SANE from the Cape and Islands were also cross-trained to use the MA PEDI Kit for children <11 years of age, and currently respond to Cape Cod Hospital and Falmouth Hospital, to care for children in addition to adult/adolescent patients.
TeleSANE Program - MA Department of Public Health’s National TeleNursing Center (NTC)
From 2012 – 2018 the MDPH SANE Program was awarded funding by the U.S. Department of Justice, Office for Victims of Crime (OVC) to pilot the development of a National TeleNursing Center (NTC). The goal of the NTC was to pilot the use of telemedicine technology to “export” MA SANE expertise to communities with little or no access to SANE services, or to assist SANE programs with low volume and few resources. During the project’s tenure, expert MA teleSANEs, working in donated space at Newton Wellesley Hospital, provided care to almost 300 patients in 6 diverse settings (tribal, military, rural and community) in 3 states (MA, AZ, CA), and provided over 100 trainings to remote site clinicians. The NTC project team developed a NTC TeleSANE Practice Model, based on Joanne Duffy’s Quality Caring Model™, that also reflects the MA SANE Program’s commitment to trauma-informed care for diverse populations. This model is presently lauded by OVC as a preferred TeleSANE practice model. Due to the pilot’s high patient acceptance rates, and success in extending MA SANE expertise to underserved communities, in 2019 the Baker Administration provided funding to expand MA TeleSANE care to 8 additional MA hospitals, for a total of 10 sites (National TeleNursing Center). The NTC extents its expertise by participating as a Technical Assistance (TA) Partner with the International Association of Forensic Nurses (IAFN), on a grant funded by the OVC, to expand TeleSANE practice to additional states (Alaska, Arkansas, South Dakota, Texas) nationwide.
About the program
Adult/Adolescent SANE Certification
Certification Requirements
To be certified as a Massachusetts SANE, candidates - including nurses, nurse practitioners, certified nurse midwives, and physicians—must successfully complete the 40+ hour MDPH SANE Certification Training Program, pass a written examination, adhere to quality performance standards when conducting “mock exams” and direct patient care overseen by an expert preceptor, and participate in on-going education and training. Prior to MA SANE Certification Training, SANE candidates are required to have at least three years of prior nursing/medical practice participate in a candidate interview with SANE program staff, and provide three professional references. Upon acceptance into the program and throughout their subsequent training, candidates must demonstrate relevant experience, compassion, critical thinking, and a commitment toward fulfilling their obligations as MA SANEs.
MA SANE Personal and Professional Comportment
- MA SANEs must practice to the highest of ethical standards including maintaining patient privacy and confidentiality.
- MA SANEs may be compelled to provide court testimony regarding their patient care, and must understand that their personal and professional character may be at issue.
- MA SANEs must immediately notify MDPH is there is a change in their licensure status, or if their license is under review for any reason.
- MA SANEs must be aware that their use of social media should not include any information that could negatively reflect on their personal integrity or question their neutrality as a witness in a sexual assault prosecution.
Re-Certification Requirements
MA SANEs must fulfill annual re-certification requirements. Re-certification requires effective performance as a SANE which includes meeting established minimum on-call coverage, satisfactory achievement of quality assurance monitoring activities, regular attendance at monthly SANE meetings, and attendance at the annual MA SANE Program Recertification/Update Training.
MA SANE Adult/Adolescent Training Course Curriculum
- Is multidisciplinary and prepares the SANE candidate for the delivery of compassionate, trauma-informed patient care.
- Emphasizes the importance of the patient retaining their fundamental right to choose the course of their care.
- Emphasizes the importance of privacy, confidentiality, and the need for patient consent when reporting and disclosing details of the reported assault.
- Prepares the SANE candidate to provide a forensically-sound post-assault examination that includes a forensic exam with forensic evidence collection, written and photo-documentation, and effective courtroom testimony.
- Discusses the role of the Boston and State Police crime laboratories, the forensic evidence collection process, the critical importance of maintaining chain of custody of the evidence, and the processes for police reporting (if the patient chooses), medical follow-up, and victim compensation.
- Provides opportunities for SANE candidates to have hands-on experience in completing limited pelvic examinations on Standardized Patient Models (SPM) and conducting forensic examinations and evidence collection using the MA Sexual Assault Evidence Collection Kit (MSAECK).
Adult/Adolescent Service Delivery Model
Upon successful completion of the MDPH SANE Training Course, MDPH contracts with MA SANEs to provide on-call services within one of six designated service regions (see Appendix 1: SANE Services Map). MA SANEs respond to MDPH-designated SANE hospitals when paged by the hospital that a patient, 12 years and older, has presented within 5 days (120 hours) of a sexual assault. While the MA SANE coordinates the care for the sexual assault patient, they act in a consultant role. Therefore, each patient must also have a physician and primary nurse assigned whose roles include overall patient monitoring, ordering & administering any medications, and laboratory testing. Rape Crisis Advocates from community Rape Crisis Centers (RCCs) respond in tandem with MA SANEs to support the patient during the forensic examination and provide resources for patient aftercare services (Refer to Section II Roles and Responsibilities (PDF) | (DOCX)).
MDPH-Designated SANE Sites
The MA Department of Public Health (MDPH) designates hospitals throughout MA as SANE sites. MDPH, enters into a Memorandum of Understanding (MOU) with those hospitals and the MOU outlines the expectations for both parties to ensure that sexual assault patients receive quality post-assault care. Over the past 20 years, the MA SANE Program has expanded SANE coverage by increasing the number of MDPH-designated SANE sites. Expansion has been thoughtfully planned based on available program funding, resources, and regional need. As of January 2022, MA Adult/Adolescent SANEs provide an in-person response to 30 MDPH-designated SANE sites, and expert TeleSANE utilize telehealth technology to provide clinical guidance and consultation to patients and their clinicians in 10 MDPH-designated TeleSANE sites.
Currently, 70% of forensic evidence kits submitted to the Boston and State Police Crime labs are completed by SANE nurses; as such, the goal of targeting high volume hospitals has been met. The SANE Program continues to explore other avenues, such as the option of teleSANE services, to expand SANE expertise to lower volume hospitals. In addition, the program is committed to helping all Massachusetts hospitals maintain the highest quality standard of care regarding sexual assault patients. The program meets this goal by offering over 100 trainings per year, many hospital personnel regarding the trauma-informed approach to care, and the provision of a forensic examination and forensic evidence collection using the MA Sexual Assault Evidence Collection Kit (MSAECK). In 2021, the Program established a virtual training platform for hospital clinicians, regarding the care of sexual assault patients. The training is offered on a quarterly basis and has been well attended and received.
Adult/Adolescent SANE Regional Coordinators
Massachusetts is divided into six regions (Western, Central, Northeast, Boston, Southeast and Cape/Islands) for the purpose of SANE service delivery. MDPH employs an expert MA SANE to act as the Regional Coordinator (RC) for each designated area. The RCs are managed by the Adult/Adolescent SANE Associate Director. The RC’s role is to coordinate a regional on-call schedule with the goal of ensuring 24/7, 365-day SANE coverage. The RCs also work closely with a designated “SANE Site Liaison” at each hospital to ensure that appropriate equipment and supplies are available for sexual assault patients, and that standards of care for sexual assault patients, as outlined in a Memorandum of Understanding (MOU) with MDPH, are met. RCs complete quality assurance monitoring of SANE documentation and conduct monthly meetings for SANEs during which on-going education, case review, and peer support is provided.
SANE Program Training and Outreach
The SANE Program also has a robust training arm consisting of the Adult/Adolescent SANE Training and Outreach Coordinator, Pediatric Clinical Coordinator, TeleSANE Educator, and the Administrative Coordinator for Training. Together with Regional Coordinators and Pediatric SANEs, this team works to improve the standard of care for all sexual assault patients across Massachusetts. To meet this goal, the program provides on-going trainings to clinicians at both SANE and non-SANE hospitals. Trainings are intended to teach clinicians how to provide trauma-informed care for sexual assault patients, and to gain competency and confidence in the use of the MA Sexual Assault Evidence Collection Kit (MSAECK) and the MA Pediatric Sexual Assault Evidence Collection Kit (MA PEDI Kit). In addition, the program provides outreach and training to SANE community partners such as crime labs, police (state/local), correctional officers, District Attorneys’ Offices (prosecutors and victim witness advocates), local Rape Crisis Centers, schools, colleges and universities, and other state agencies (e.g., Department of Children and Families, Disabled Persons Protection Commission). Experienced MA SANEs are welcome to participate in these community trainings as determined by their Regional Coordinator.
SANE Program Administration
The SANE Program is centrally managed at the Massachusetts Department of Public Health with a senior leadership team consisting of a Program Director, Adult/Adolescent Associate Director, TeleSANE Associate Director, Pediatric Associate Director and Operations Manager, and supported by an administrative staff. Since the commencement of SANE services in 1997, MA SANEs have cared for over 30,500 sexual assault patients. The success of the MA SANE Program is based on its unwavering commitment to providing compassionate services and helping to ensure the health and well-being of patients, as well as providing expert forensic care and time-sensitive forensic evidence collection. Court testimony provided by MA SANEs plays a critical role in criminal prosecutions and public safety.
Acknowledgements
SANE Advisory Board to assist with the creation of the MA SANE Program, and the development of uniform standards and protocols for use by MA SANEs. The Board includes the following statutory member agencies: the Executive Office of Public Safety and Security, MA District Attorney’s Association, Office of Attorney General, MA Department of Children and Families, MA Medical Society, the Massachusetts Health & Hospital Association, the Massachusetts Nurses Association, the MA Emergency Nurses Association, MA College of Emergency Physicians, MA Children’s Alliance, Jane Doe Inc., MA Disabled Persons Protection Commission, MA Office for Victim Assistance, Boston Crime Lab and Massachusetts State Police Crime Lab and the MA Chapter of the American Academy of Pediatrics. Additional state and community stakeholders are included as SANE Board Members based on their expertise in critical role in service-delivery systems for sexual assault patients.
MDPH staff from the Sexual and Reproductive Health Unit, State Laboratory STD Division, Office of AIDS/HIV, and the Division of Sexual and Domestic Violence Prevention and Services provided and reviewed relevant information contained in this Protocol.