Section II: Roles and responsibilities

MA protocol for adult/adolescent SANEs

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Hospital clinicians

The MA SANE provides forensic care to sexual assault patients in collaboration with other medical providers and works with law enforcement agencies as appropriate.

Triage nurse/ED staff

1. Give Patient Priority Attention and Expedited Triage
   1. After the patient has been triaged, the patient should be brought immediately back to a patient exam room.
   2. If the patient does not speak English, ensure that a hospital translator is available per MGL c.111, s.25J (see Appendix 2: Hospital Interpreter Services for more information).
2. Initiate Paper Work/Triage Note
   1. Obtain vital signs. Document medical history, current medical conditions, current medications and any known allergies. Assess patient for any pain or discomfort resulting from reported sexual assault.
   2. Write a brief triage note. For example: “Reported Sexual Assault, patient reports approximately 4 hours prior to ED presentation.”
   3. Avoid using phrases such as "in no acute distress" or similar terms which may be appropriate for medical patients, but may be misunderstood regarding sexual assault patients as negating any psychological trauma.
   4. Do not interview the patient about the assault or related events. Do not take a statement or otherwise elicit or document details of the assault.
   5. If patient meets SANE eligibility criteria below, discuss SANE option with patient, and obtain patient consent before paging SANE (See eligibility criteria and paging process below).
3. Assign clinical Staff
   1. Assign primary nurse and medical provider to care for patient according to hospital protocol.
4. Escort the patient to the designated examination room for sexual assault patient
   1. The area or room should be private, but should not be in a secluded area of the hospital. At designated SANE sites, ensure that the SANE cart is on-hand. And if the patient is female, a pelvic stretcher must be provided. If possible, the registration interview should be conducted in the privacy of the patient’s room. Please be sure to offer the patient support and facilitate calling friends and family if requested by the patient.
5. Determine the Patient's Eligibility for SANE Program Services
   1. For patients 12 years of age and older, a full evidentiary exam can be performed up to five days (or 120 hours) after a sexual assault has occurred. Carefully calculate an accurate determination of the passage of time based on known or estimated date and time of the assault, and the present date and time.
   2. When a patient presents to the ED more than five days (or 120 hours) after the assault, the ED staff should evaluate the patient’s needs regarding sexually transmitted infection testing and treatment, documentation and photography of injuries. Completion of a forensic evidence collection kit is not indicated more than five days after an assault.
   3. ED staff should always call the community Rape Crisis Center, who is available to respond to the hospital whether or not forensic evidence collection is indicated. Hospital staff should likewise determine the need for additional hospital or community referrals.
   4. ED staff may consult with the SANE by telephone as needed regarding the appropriate treatment and referral of a patient who seeks treatment five or more days after a sexual assault.
6. Initiate the Paging System for the SANE Program
   1. When calling the SANE regional pager, hospital staff should enter the 10-digit phone number for a return call by the SANE. The SANE will call the hospital back and ask to speak with patient’s primary nurse or medical provider. The SANE will confirm the patient meets criteria for a SANE response (outlined below). The SANE should also confirm that the hospital has paged the local RCC and request that they do so if not already done.
   2. If all criteria are met, the SANE will provide an estimated time of arrival to the Emergency Department.
7. If there is no response to SANE page
   1. If the SANE has not returned the page after 15 minutes, hospital staff should page again, re-entering the complete 10-digit call-back phone number. If there is no response from the SANE within 15 minutes of second page, the SANE is unavailable and per hospital/MDPH Memorandum of Understanding (MOU) hospital staff must offer and complete a forensic exam/evidence collection for the patient without further delay.
   2. Notify Community Rape Crisis Center (RCC)
   3. The local Rape Crisis Center should be contacted via hotline or pager at the time the SANE is paged.
8. Avoid Loss of Evidence
   1. Whenever possible, patients should not be asked to undress before the arrival of the SANE. If medical care necessitates that clothing be removed, place each item of clothing in a separate bag and if possible, place all bags into one larger bag. Label each bag with the patient’s name and transfer to the SANE upon arrival.
   2. If possible, do not wipe blood, other fluids or stains off of the patient. Do not remove any foreign material from the patient's clothing or body. Advise the patient not to wash until the SANE arrives.
   3. While it is ideal for the patient to not have food or drink/water until after evidence collection, the patient’s’ physical and emotional needs should always be considered. If possible, refrain from administering oral medications prior to SANE evidence collection. However, if a patient needs medication prior to SANE arrival, for example anti-anxiety or pain medication, please do not delay this administration.
   4. If the patient must urinate, provide them with a specimen container and ask them not to wipe.
      • A portion of the specimen should be used to obtain a urine pregnancy test and STI testing.
      • The remaining specimen should then be labeled with the patient’s name, signed, dated and locked in evidence refrigerator until the SANE arrives.
9. Police
   1. Note: Police contact should be facilitated by hospital upon Patient Request Only!
   2. If the patient was accompanied by police upon arrival at the ED, ask the officer(s) to remain in the ED until the SANE arrives, so that they can give the SANE as much information about the assault as possible. This is particularly important when it is difficult for the patient to describe the circumstances of the assault, but the police may have previously ascertained such information.
   3. If the officer is unable to remain at the hospital, document the officer's name, badge number and police station telephone number so that the officer can be contacted later, if necessary.
10. Direct Billing to Victim’s Compensation
    1. As of March 2016, MA hospitals may bill all Emergency Department (ED) expenses for sexual assault patients, including a forensic exam and administration of a MA Sexual Assault Evidence Collection Kit (MSAECK), directly to the Attorney General’s Office Victim Compensation Assistance Division (VCAD). Each hospital must have a process in place to facilitate such billing. Patients should be informed that their bill will be sent directly to Victim’s Compensation versus to their insurance carrier.
    2. The Attachment B form (located in the envelope attached to the MSAECK) must be completed and provided to the ED billing staff to ensure that billing is directed to the VCAD. The SANE should provide the Primary Nurse with the date and location of the assault and the MSAECK Kit# to facilitate direct billing. The Primary Nurse must provide this information directly to the registration clerk for direct billing paperwork purposes.

Criteria for MA SANE services

The following criteria should be met before paging the SANE:

1. The patient is 12 years of age or older,
2. The assault occurred within 5 days/120 hours,
3. The patient is able to consent to the exam, and he/she has consented to SANE services:
   • If the patient is under the influence of alcohol or drugs: A drug/ETOH level is not needed for screening purposes. However, the primary nurse/ED clinician should determine that the patient is awake, coherent and able to consent to and understand a SANE exam.
   • Explain to patient what a forensic exam entails and obtain verbal consent from the patient for SANE care prior to paging SANE. Use the MA SANE Program Script brochure to re-familiarize yourself with the process, and to provide verbal and written guidance to the patient.
4. The patient has been seen by an ED Physician or mid-level provider and is medically cleared (see “Physician Responsibilities” below).

Once the patient meets these criteria or if the staff has questions about the patient’s status, SANE should be paged.

ED physician or mid-level practitioner

1. Assess the Patient for Injuries or Medical Problems
   1. Conduct a medical clearance evaluation.
2. Treat Emergency Medical and/or Surgical Problems
   1. The ED Physician/Mid-level Practitioner is responsible for assessing the patient for any serious injuries or medical issues requiring intervention before a forensic examination is conducted. The clinician should assess the patient for strangulation, cervical spine injury, head trauma, altered level of consciousness and abdominal pain. In addition, he/she should order appropriate imaging and lab testing, and ensure that specialist referrals are made to ensure that the patient’s medical/surgical needs are addressed before the SANE is paged. All imaging and other medical procedures should be completed before the SANE is paged.
   2. Patients with significant mental health issues such as psychosis or suicidal ideation should receive careful assessment prior to SANE notification. Such issues do not negate a forensic exam, but the clinician must assess that the patient has the ability to understand and consent to SANE services.
   3. Once the patient is medically cleared and the SANE arrives, the physician/mid-level practitioner is responsible to work in collaboration with the SANE to meet the patient’s on-going needs such as ordering STI testing, and medications for pregnancy and STI/HIV prophylaxis. The ED Physician will be available to the SANE for consultation regarding all medical issues, and to perform the speculum exam in specific circumstances outlined below.
   4. If a patient’s condition changes, before the SANE arrives, the SANE should be re-paged and informed that the SANE exam will be delayed.
3. The ED Physician/Mid-level Practitioner is responsible for:
   1. Evaluating existing medical problems which may have been exacerbated by the assault;
   2. Providing consultation to the SANE for the evaluation and treatment of any trauma;
   3. Determining the need for and performing a speculum exam on patient who is exhibiting acute or suspected signs of internal injury or trauma;
   4. Performing a speculum examination if there is concern for internal injuries;
   5. Performing a speculum examination if the patient is pregnant;
   6. Documenting a brief patient history;
   7. Performing a medical and mental health assessment and ordering appropriate treatment for the patient;
   8. Ordering necessary lab/screening tests, including pregnancy and Sexual Transmitted Infection (STI) testing when indicated (refer to Section VIII: Sexually Transmitted Infections).
   9. Ordering prophylaxis medications for pregnancy, STI/ HIV as appropriate and with patient consent.
   10. Establishing appropriate medical follow-up
   11. Discharging the patient from the ED.
4. The ED Physician is encouraged to participate in the SANE exam, and to be available to answer questions the patient may have regarding their Emergency Department visit.
5. Briefly Document in the Hospital ED Record
   1. Include an abbreviated medical history and physical (per COBRA/EMTALA requirements).
   2. If the patient presents with injuries or other medical conditions related to the assault, documentation on the MD note should relate to such treatment. Note SANE Program involvement, brief discussion of SANE exam findings, treatment and follow-up plans, and the MA Sexual Assault Evidence Collection Kit (MSAECK) number. The ED Physician is not responsible for documenting a detailed history of the assault. The detailed history of the patient’s assault should be obtained one time only by the SANE and is documented by the SANE on MSAECK Form 3.

Primary nurse

1. Act as ED Liaison for the SANE. Assist and collaborate with the SANE as requested. Specifically:
   1. Advise the SANE of hospital procedures;
   2. Ensure OB/GYN stretcher is available and locate necessary equipment;
   3. Assist with patient transfers and positioning if patient has mobility challenges;
   4. Administer ordered medications as needed;
   5. Arrange for lab testing, draw blood or have blood drawn as per hospital protocol;
   6. Arrange for consultations and X-rays that are ordered by MD;
   7. Provide continued observation of the patient and respond to any medical, safety concerns SANE may recognize during exam;
   8. Provide hospital discharge instruction to include information regarding administered medications.

SANE

1. Upon arrival to the Emergency Department, the SANE will introduce themselves to the patient’s Primary Nurse and Medical Provider.
2. Establish Rapport with the Patient:
   1. Introduce self to patient and rape crisis advocate, if present;
   2. Ascertain patient’s name and preferred pronouns;
   3. If necessary, escort the patient to the exam room;
   4. Explain the SANE role and what can be offered to the patient; explain what she/he can expect in ED;
   5. Ask if the patient has decided whether to make a police report;
   6. Determine, privately, if the patient would like others to remain in the room during the examination. If not, have them wait close by;
   7. Do not assume the sexual orientation of the patient or the assailant;
   8. Consider known cultural, psycho-social and medical factors (e.g. ethnicity, primary language, age, sexual orientation, physical or cognitive disabilities, living arrangements, etc.) when providing care and treatment to the patient.
3. Evidence Collection and Exam
   1. Document consent from the patient for all aspects of interview and exam utilizing consent Form 1.
   2. Provide education and anticipatory guidance to the patient throughout the examination process;
   3. Conduct a trauma-informed interview and document the patient’s account of the assault.
   4. Assess pregnancy risk and make recommends to medical provider for pregnancy testing and emergency contraception based on SANE Protocol;
   5. Assess STI/HIV risk on a timely basis, and share recommendations for STI/HIV testing and prophylaxis with medical provider to facilitate timely medication administration;
   6. Complete a full head to toe exam including full external genital and limited speculum exam, if indicated, and document findings on Form 4 and Form 5A
   7. Collect, document, preserve, maintain custody of, and transfer forensic evidence to law enforcement authorities
   8. Consult with the ED Physician regarding the provision of medical treatment, medication orders, and readiness for discharge;
   9. Develop an individualized discharge plan for patient, complete SANE discharge Form 6, review with patient and have patient sign forms to indicate understanding;
   10. Provide services in the ED, OR and ICU with appropriate hospital staff and equipment to meet SANE standards of care
   11. With patient consent facilitate police contact and share appropriate information.
   12. Complete mandatory reporting forms for patients who are minors (<18 years), elders or living with disabilities.
4. Advise the Patient of the Limits of Confidentiality
   1. Carefully explain the potential for release of the SANE findings and other information.
   2. Indicate which entities (e.g. courts) may be able to gain access to certain information.
   3. Advise the patient of what information will be recorded, since it is possible that documentation (e.g. previous counseling or psychiatric issues and related treatment) may be subpoenaed during court proceedings. MA General Law Chapter 258B s.3(h): Rights of Victims and Witnesses of Crime provides victims the right to request confidentiality in the criminal justice system. The court may enter orders to limit disclosure of information to protect the privacy and safety of victims.
5. Discuss Reporting the Assault to Police
   1. Explain that reporting an assault is not the same as prosecuting an assailant, but is the first step in the process.
   2. Advise the patient that an immediate report will be more useful during court proceedings, but that they have the option to report the assault to police at a later date.
   3. Advise the patient that they have no legal duty to report to police to have SANE services and evidence collected.
   4. Advise the patient that once reported to the police, it is the discretion of the police and District Attorney’s office to decide to move forward with the case. If a case moves forward to trial, the patient may be subpoenaed to testify.
   5. Advise the patient that reporting to the police is not required; however, if applicable, mandatory reporting laws (re) still apply which may result in law enforcement involvement.

Multi-Disciplinary Team (MDT)

Pre-hospital/Emergency Medical Services (EMS) personnel

1. Use Trauma Informed Approach/Assessment
   1. Believe the patient; show this in your care.
   2. Make the patient feel safe.
   3. Make the patient feel they are believed.
   4. Explain what you are doing and why.
   5. Offer to transport the patient to a SANE site for care. (As of 3.24.16 the MDPH Emergency Medical Services (EMS) Statewide Point of Entry Plan includes a provision for EMS to by-pass the closest hospital to transport a patient to a MDPH-designated SANE site: if the patient’s needs would be best addressed, and additional transport is no more than 20 miles).
   6. The patient will be sensitive to how you react and may not continue with further care if they feel unsupported or not believed.
2. Avoid Loss of Evidence Prior to Hospital Visit
   1. Use paper bags, if possible, to transport any potential evidentiary items.
   2. If possible, transport patient in clothing worn during the assault and request that patient bring a change of clothes to the hospital.
   3. Ambulance stretcher sheet may contain evidence and should be provided to ED staff. Carefully fold sheet to retain any possible debris/evidence.
   4. Chain of Custody: document transfer of any evidence to hospital staff or police on EMS record.
3. Alert ED Triage Nurse to the Patient’s Report of Assault
   1. If using EMS radio system to announce patient’s arrival, use code word such as “Trauma X” or other such term to protect patient’s confidentiality.
   2. If possible, escort the patient directly to the treatment room.

Law enforcement

1. Use Trauma Informed Approach/Assessment
   1. Believe the patient and make the patient feel that they are believed during your encounters.
   2. Make the patient feel safe.
   3. Explain what you are doing and why.
   4. Recommend transporting the patient to a SANE site for care.
   5. The patient will be sensitive to how you react and may not continue with further care if they feel unsupported or not believed.
2. Police Report
   1. If the patient wishes to report the assault to the police at the time of the exam and the patient requests that the SANE help facilitate police reporting, the police may respond to the hospital to obtain a statement directly from the patient, as long as the process does not interrupt direct patient care.
   2. If patient consents, and it does not delay evidence collection, the police detective and the SANE may interview in tandem so the patient does not have to repeat the account of the assault.
3. Work Collaboratively with the SANE
   1. Police should share any specifics of the assault that have implications for treatment or evidence collection with the SANE. The SANE may share information about the patient’s assault history and exam findings with police only if verbal and written consent is obtained from the patient and documented on Form 1.
4. Maintain Chain of Evidence and Transport MSAECK (see Section IX: Chain of Custody Procedures for more information).
   1. In accordance with the Executive Office of Public Safety and Security (EOPSS) MSAECK Transport Protocol, police in the city or town where the assault occurred are responsible for accepting custody of completed MSAECKs from hospitals and transporting evidentiary MSAECKs (assaults reported to police) in a timely manner to the appropriate crime laboratory. As per Crime Justice Bill H4011 enacted in April 2018, “non-investigatory kits shall be safely stored by law enforcement in a manner that preserves evidence for the duration of the statute of limitations for all sexual assault and rape cases.”
   2. Police should never open kits since as this could result in the loss of valuable evidence.
   3. The responding officer will sign the appropriate chain of custody sections on the MSAECK box, clothing bag and toxicology kit (as appropriate). They will also be asked to provide their name and badge number to be recorded in the Evidence Log Book, kept by the hospital.

Community rape crisis advocate

1. Rape Crisis Advocates respond in tandem with MA SANEs at MDPH-designated SANE sites and will work together to meet a range of needs for the sexual assault patient. Rape Crisis Advocates who are trained and supervised by Rape Crisis Centers are granted unique confidentiality privileges under Massachusetts General Law, Chapter 233 Sec. 20J.¹ Community Rape Crisis Advocates work with ED staff and SANEs to ensure that the patient is treated with sensitivity and provided with all the information and support needed to make the best informed decisions regarding their in-hospital and follow-up care. These services should be offered to every sexual assault patient that presents to the ED. Ideally, the hospital should contact the Rape Crisis Center directly to request an advocate’s assistance at the hospital, at the same time the SANE is paged. The SANE should ask if the RCC has been called when first responding to the hospital page. If the RCC has not yet been called, the SANE should request a call be made. The RCC advocate will respond to describe and offer their services to the patient. A Rape Crisis Counselor is available to meet with a patient and patient’s accompanying family or friends at the hospital, anytime day or night.
2. NOTE: To protect the patient’s privacy, Rape Crisis Advocates do not write in the patient’s hospital record or on the MSAECK documentation forms. Likewise, the advocate’s name should not be written in the hospital record or on MSAECK forms.
3. The patient will be provided an opportunity to identify who (if anyone) he/she would like in the room with them throughout the exam. In some cases the patient will choose to have the advocate to remain in the room during the entire exam, and in other circumstances may prefer that the advocate assist the patient's family/significant others/friends who have accompanied the patient to the hospital. The patient's choices should be respected at all times. The Rape Crisis Advocate will explain their role to the patient in the ED setting, and provide referrals for other aftercare support services.

¹ Massachusetts General Laws, Chapter 233 Sec 20J states: "…A sexual assault counselor shall not disclose such confidential communication, without the prior written consent of the victim; provided, however, that nothing in this chapter shall be construed to limit the defendant’s right of cross-examination of such counselor in a civil or criminal proceeding if such counselor testifies with such written consent. Such confidential communications shall not be subject to discovery and shall be inadmissible in any criminal or civil proceeding without the prior written consent of the victim to whom the report, record, working paper or memorandum relates."