Sexual Assault Nurse Examiner Best Practices - Washington State Department of Commerce

Chapter 88, Laws of 2018 required the Office of Crime Victims Advocacy of Washington State’s Department of Commerce to:  

Develop best practices that local communities may use on a voluntary basis to create more access to sexual assault nurse examiners, including, but not limited to, partnerships to serve multiple facilities, mobile sexual assault nurse examiner teams, and multidisciplinary teams to serve sexual assault survivors in local communities…

[And] develop strategies to make sexual assault nurse examiner training available to nurses in all regions of the state without requiring the nurses to travel unreasonable distances or incur unreasonable expenses…

To meet the intent of Chapter 88, Laws of 2018, this document proposes best practices that local communities may use on a voluntary basis to create more access to sexual assault nurse examiners and quality sexual assault responses for adult and adolescent victims. These best practices are informed by statewide interviews, surveys, and national literature reviews. Local communities are encouraged to adopt, tailor and add to them as they best see fit.

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1. Sexual assault patients need to be triaged a high priority for care and escorted to a safe, private room upon arrival at an emergency care facility.
2. A sexual assault advocate needs to be contacted immediately upon the patient’s arrival at an emergency care facility and the patient told that an advocate is on his or her way, will comprehensively explain the patient’s options, and that the patient may consent or refuse to speak with the advocate.
3. Patients need to be able to receive medical care and forensic evidence collection and medically appropriate sexually transmitted disease prophylaxis and emergency contraception, if they so choose, from a SANE, defined as someone who has undergone formal SANE training.
4. Each hospital should have procedures in place for maintaining chain of custody of evidence, providing patients reporting options, and holding evidence or transferring it to law enforcement for testing.
5. SANEs need to receive continuing education and evaluation and be up-to-date on changes to best practices in forensic evidence collection and trauma-informed care.
6. If requested, SANEs should receive a temporary break following an exam to recompose, before being sent onto another task.
7. SANEs need to be compensated on-call wages and per case. If on-call pay does not make sense in low-population density communities, SANEs should be compensated at a premium per case.
8. Hospitals should assist their local communities by developing, sustaining, and improving their SANE programs and supporting their community’s SART.
9. Hospitals unable to support their own SANE program should establish policies and procedures, as well as partnerships with other facilities, to ensure that when a sexual assault patient presents, a SANE is available to assist the patient in a timely manner or have the patient transferred to another hospital with the assistance of an advocate. The patient should be seen within an hour of arriving at a SANE staffed hospital.
10. Hospitals should have established partnerships with a community health agency or physician group that receives trauma informed care training and specialized training in the care of survivors of sexual assault. Patients should be referred there for follow-up care.
11. Preferably, SANE staffed hospitals should have a safe, private room designated for sexual assault patients. If not, a hospital should have an accessible mobile cart—outfitted with the tools necessary for a medical forensic exam—that can be easily moved from one room to another for examinations.
12. Stakeholders and community members should continue to seek ways to provide a better response for their local community.
13. Address the potential for vicarious trauma by building a pro-active environment that provides team-based mechanisms that can be individually tailored to decrease the risk of vicarious trauma, such as established support networks with regular check-ins to debrief and discuss coping mechanisms.

Do not:

1. Do not automatically call law enforcement to the hospital for adult victims.
2. Do not require adult victims to report to law enforcement as a condition for receiving an exam.
3. Do not bill the patient or patient’s insurance for an exam.

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1. Pediatric patients need to be triaged a high priority for care and escorted to a safe, private room upon arrival at an emergency care facility.
2. The patient and non-offending parents and caregivers should be given access to an advocate upon a patient presenting.
3. Patients need to be seen by a medical staff trained to conduct pediatric patients [that is, a pediatric SANE (P-SANE)], preferably at a child friendly environment, such as a Child Advocacy Center (CAC).
4. A P-SANE needs to “screen and assess all acute and non-acute concerns or disclosures of sexual abuse, neglect, or suspected abuse, making proper jurisdictionally mandated reports, referrals, and transfers based on the need for time-sensitive exams or follow-up.”[1]
5. A P-SANE needs to remain vigilant about non-disclosed child abuse when there are other children living in the same household as the victim. Local authorities should be notified if any concerns about non-disclosed abuse arise.
6. Each hospital or CAC should have procedures in place for maintaining chain of custody of evidence, storing evidence, and transferring it to law enforcement for testing.
7. P-SANEs need to receive continuing education and evaluation and be up-to-date on changes to best practices in forensic evidence collection and trauma-informed care.
8. If requested, P-SANEs need to be given time following an exam to recompose, before being sent to another task. 
9. P-SANEs need to be compensated on-call wages and per case. If on-call pay does not make sense in low-population density communities, P-SANEs should be compensated at a premium per case.
10. Hospitals should have policies regarding patient and staff safety when “the person accompanying the child victim is the suspected offender, is suspected to be in collusion with the offender, or is otherwise believed to be contributing to the abuse.”[2]
11. Law enforcement and hospitals should know where the nearest CACs are, and hospitals should have established transfer arrangements with their local CAC, if the CAC is P-SANE staffed.
12. Hospitals or CACs unable to support their own P-SANE programs should establish partnerships with other facilities to ensure that when a sexual assault patient presents, they may be seen or referred to a P-SANE in as expeditious of a manner as possible. If a patient needs to be transferred to a hospital or CAC, it should be done with the assistance of an advocate and hospital staff.
13. Before transferring the patient to another facility, hospital staff should confirm the availability of P-SANEs at the receiving hospital, if that receiving hospital does not offer 24/7 services.
14. Stakeholders and community members should continue to seek ways to provide better service for their community.
15. All medical and legal staff should regularly update and follow their county’s sexual abuse protocol when it comes to pediatric patients.
16. Address the potential for vicarious trauma by building a pro-active environment that provides team-based mechanisms that can be individually tailored to decrease the risk of vicarious trauma, such as established support networks with regular check-ins to debrief and discuss coping mechanisms.

[1] U.S. Department of Justice, A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric: https://www.justice.gov/ovw/file/846856/download

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1. Form a multi-stakeholder planning team of representatives, which may include local law enforcement, sexual assault victim advocates, sexual assault nurse examiners, prosecutors, child protective services, therapists, crime lab specialists, medical administrators, tribal officials, child advocacy center administrators, and other concerned stakeholders, such as victims.
2. Identify an executive leadership team and coordinator to facilitate the development of the SART or MDT.
3. Define the SART’s or MDT’s jurisdiction.
4. Identify local resources and barriers to access to emergency and long-term care for victims of sexual assault.
5. Identify ways to overcome these barriers.
6. Write a mission statement.
7. Establish protocols that delineate cross-disciplinary roles and responsibilities for each member of the SART or MDT and how they function to promote the best response possible given local circumstances.
8. Ensure all members understand and are aware of their responsibilities for compliance with the federal Health Insurance Portability and Accountability Act (HIPAA) and state confidentiality, privilege, and privacy laws.
9. Establish regularly scheduled SART or MDT meetings to elicit feedback from members, review and track cases, and promote constant learning.
10. Establish mechanisms for communicating with SART or MDT members and other key stakeholders outside of SART or MDT meetings.
11. Ensure that underserved populations are meaningfully included and pro-actively listened to.
12. Identify and establish mechanisms to increase professional and public awareness of and support for SART or MDT services.
13. Work with the local Children’s Advocacy Center, Community Sexual Assault Programs, and other stakeholders to avoid the duplication of work between SARTs, MDTs, and others.
14. Establish mechanisms to incorporate team member and patient feedback to evaluate and improve the SART or MDT process.
15. Address the potential for vicarious trauma by building a pro-active environment that provides team-based mechanisms that can be individually tailored to decrease the risk of vicarious trauma, such as established support networks with regular check-ins to debrief and discuss coping mechanisms.

American College of Emergency Physicians, Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient (PDF)

Emergency Nurses Association and the International Association of Forensic Nurses, Care of Prepubescent Pediatric Sexual Abuse Patients in the Emergency Care Setting (WEB)

Emergency Nurses Association and the International Association of Forensic Nurses, Adult and Adolescent Sexual Assault Patients in the Emergency Care Setting (WEB)

National Institute of Justice, National Best Practices for Sexual Assault Kits: A Multidisciplinary Approach (WEB)

National Sexual Violence Center, Sexual Assault Response Team Toolkit (WEB)

Office for Victims of Crime, SANE Program and Operation Guide (WEB)

Oregon Sexual Assault Forensic Taskforce, Sexual Assault Response Team Handbook (PDF)

U.S. Department of Justice, A National Protocol for Sexual Abuse Medical Forensic Examinations Adults/adolescents (PDF)

U.S. Department of Justice, A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric (PDF)

Washington State, Sexual Assault Emergency Medical Evaluation Recommended Guidelines Adults and Adolescents 2017 (PDF)

Washington State, Sexual Assault Emergency Medical Evaluation Recommendation Guidelines Child 12 Years or Younger 2017 (PDF)

Link to PDF

Introduction

These best practices are intended for use by local communities to increase access to forensic nurse examiners (FNEs) in cases of nonfatal strangulation assault. Strangulation involves external compression of the victim’s airway and blood vessels, causing reduced air and blood flow to the brain. Victims may show no or minimal external signs of injury despite having life-threatening internal injuries including traumatic brain injury. In addition, strangulation or suffocation are often associated with sexual assault and domestic violence and are second-degree assaults and Class B felonies. Therefore, it is essential to increase access to health care providers with forensic nurse training so that victims of nonfatal strangulation assault can receive care, access resources, and have forensic information available for prosecution.

The Office of Crime Victims Advocacy (OCVA) acknowledges that every community’s resources, needs, and existing programs are different. If your community does not already have a Sexual Assault Response Team (SART) or other team to address sexual assault or domestic violence, OCVA recommends that these best practices be used as a starting point to for a FNERT. If your community already has a SART or other team, these best practices can help to build on existing systems, add relevant processes and entities, or to start a new team that works alongside existing systems. Local communities are encouraged to adopt, tailor and add to these best practices as they see fit.

Best Practices

1. Form a multi-stakeholder planning team of representatives, which may include representatives of the following groups: local law enforcement, domestic violence advocates, sexual assault advocates, forensic nurse examiners, other nurses or health care providers with forensic examination training, other health care providers, hospital administrators, prosecutors, child protective services, therapists, crime lab specialists, medical administrators, tribal officials, tribal health care providers, child advocacy centers, representatives of underserved populations, representatives of culturally specific programs serving domestic violence and sexual assault survivors in traditionally underserved communities (such as BIPOC, immigrant, and LGBTQ+ populations), and other concerned stakeholders, such as victims and survivors.

• Commerce recognizes that some of these representatives may not be present or available in every community, and understands that each planning team may differ in their composition depending on the needs and resources of the community.

1. Establish and help to maintain a communicative connection between local law enforcement and forensic nurses (or other health care providers that conduct forensic examinations).
2. This connection is essential to enable law enforcement to promptly refer victims to forensic nurses for medical care and evaluation.
3. Identify an executive leadership team and coordinator to facilitate the development of the FNERT.
4. Define the FNERT’s jurisdiction.
5. Identify local resources and barriers to access to the following: emergency care, follow-up care, local advocates and local healthcare providers who are able and willing to partner with the FNERT to provide long term care for victims of non-fatal strangulation.
6. Identify ways to overcome these barriers.
7. Ensure that practices and protocols incorporate safety planning and prioritize survivors’ autonomy and self-determination at every point, including decisions about reporting to law enforcement and prosecutors.
8. Ensure that underserved populations are meaningfully represented and proactively listened to. Identify populations in your own community that are underserved, and develop and enact a plan to include them. Use an equity assessment tool to evaluate the process and resulting practices.
9. Write a mission statement and guiding principles.
10. Establish protocols that delineate cross-disciplinary roles and responsibilities for each member of the FNERT, including state and federal confidentiality protections specific to domestic violence and sexual assault service providers, and how they function to promote the best response possible given local circumstances. Ensure that these protocols address survivors’ unique confidentiality and privacy needs.
11. Ensure all members understand and are aware of their responsibilities for compliance with the federal Health Insurance Portability and Accountability Act (HIPAA) and state and federal confidentiality, privilege, and privacy laws and funding requirements.
12. Establish regularly scheduled FNERT meetings to elicit feedback from members, review and track cases, and promote constant learning.
13. Establish mechanisms for communicating with FNERT members and other key stakeholders outside of FNERT meetings.
14. Develop a set of values to guide practitioners on how to debrief and talk about cases and victims, including naming how to address conflict and disagreement, victim-blaming, and misconceptions/myths that arise related to dynamics of DV/SA.
15. Identify populations within your community that may have different laws than local or state, such as tribes, military, schools, and work with these populations to understand the laws, appropriate response, and intersection with forensic nurse examination for nonfatal strangulation.
16. Develop protocols to connect survivors with community based domestic violence and sexual assault advocates for comprehensive safety planning and legal advocacy.
17. Identify and establish mechanisms to increase professional and public awareness of and support for FNERT services.
18. Work with expert entities, such as the Harborview Abuse and Trauma Center, and other local experts to coordinate trainings for community nurses to initiate and continue forensic examination learning.
19. Work with the local children’s advocacy center, community domestic violence programs, sexual assault response teams (SARTs), sexual assault programs and other stakeholders to avoid the duplication of work, collaborate when appropriate, and learn from one another’s’ successes and challenges.
20. Establish mechanisms to incorporate team member and client feedback to evaluate and improve the FNERT process.
21. Work with LNI to understand reimbursement eligibility, get reimbursed for examination services, and educate other local healthcare professionals about reimbursement services.
22. Work with other councils that are caring for victims of known or suspected sexual assault, intimate partner violence, elder abuse as well as child maltreatment to encourage routine screening for strangulation and understanding the laws for reporting.
23. Address the potential for vicarious trauma by using a trauma-informed approach to decrease the risk of vicarious trauma, such as established support networks with regular check-ins to debrief and discuss coping mechanisms.
24. Take inventory of health care providers in and near the community that have forensic examination training and that can perform this examination when FNERT resources are limited.

Increasing Access to Forensic Nurse Examiner Training (PDF)