1. 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

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

3. 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

4. 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

5. We Can’t Do This Alone

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

7. 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

8. 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.

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

10. In the Emergency Department
Life threatening emergencies are always the priority

11. PCCD FRE Claim Form

12. “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

13. 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?

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

15. 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

16. 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

17. 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

18. “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

19. 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

20. 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

21. Forensic Photography Documentation

22. Forensic Photography Documentation

23. 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

24. Alternate Light Source Examination

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

26. 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

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

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

29. Testifying in Court
Educated on testimony
Beneficial to victim

30. Patient Education Video

31. Questions?