1. Saint John SANE program
Maureen Hanlon RN
SANE Coordinator

2. 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.” (

3. History of SANE
“SANE programs developed slowly beginning in the early 1970s. 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.” (

4. 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.
SJ SANE- In 2006, Saint John formed a SANE program, under the direction of Hiadee Goldie, providing access to 1:1 care for our patients, in a timely manner, without impacting nursing or physician staffing within the ER. Nurses are available on standby, not during scheduled work hours

5. 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 are minimal.

6. 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 16yr or older. They are available as a support person during the patient exam.
If it is felt that the patient requires medical care above what the SANE is covered to perform, the patient should be first referred to the ERP or NP for assessment. ie- possible fractures, lacerations that may require suturing, strangulation injuries with stridor, etc.

7. 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
Forensic kits should ideally be done within 72hrs of assault, but may be done up to 96 hours. Considerations- timing, drinking, eating, bathing, showering, voiding, defecating may impact evidence.

8. 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.
Consent (We have consent forms specific to our program)
Documentation- We have a new SANE Record of Examination form that is similar to documentation found in the SAE kit, that is used for patients who chose Medical Care only.

9. 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 HBsAg, 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)

10. Medical care option, continued
Medications included in order set are:
Levonogestrel 1.5mg PO
Azithromycin 1GM PO
Cefixime 800mg PO
In some instances, patients may require Tdap, HBIG, or HIV PEP may need to be considered.
Consultation with ERP or ID may be required on a case by case basis. Ie- allergies to meds, ID concerns, etc.

11. 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)
Follow up testing- The SANE on call will fill out a referral to family MD, or if the patient is uncomfortable to do so, may be followed up by NP Shelley Gautreau, at Community Health Centre.

12. 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.
Reporting- Patients may report to police prior to presenting to ED. It is important to try and keep the SANE exam as private as possible. In these instances, it has been agreed that the police are not obligated to stay in the ED during the exam, as long as chain of evidence is maintained by the SANE with SAE kit, clothing, or any other evidence collected. Police may be called to return to sign over SAE kit, etc, at the end of the exam.

13. 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!!)
Consent is obtained for exam, evidence collection and reporting to police.
Seizure of clothing and personal items-At times, articles of clothing are submitted as evidence. SART makes regular donations of clothing and personal care items that can be given to the patient if this is the case.

14. 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.
Documentation -SAE kit contains forms to be filled out by SANE: Sexual Assault history form, record of examination, and evidence collection form.
***It is important to remember- The patient may decline any part of the exam at any time!***

15. 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.

16. 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.
CONSENT obtained for exam, evidence collection, and storage.
Chain of custody documentation will be signed and witnessed by a second staff when kits locked in freezer.
If/when a patient decides to report to police, the kit will be signed over by the coordinator. (within 6 month period)

17. 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.

18. 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.”
DSD- Every patient under the age of 19 who presents with sexual abuse or sexual assault is to be reported. DSD will “triage” the patients accordingly, if they have a safe discharge plan.
Patients over 12 years old or post menarchal will receive the same care as adult/adolescents for the purposes of SANE.
Consider the developmental age of the patient. Use appropriate terms, to be understood by the patient.
Age of consent for intercourse varies depending on age of victim, assailant, assailant in position of authority, etc.

19. Pediatric considerations
The time frame for an acute assault in pediatric cases is shorter than adult cases. (24-72hrs)
Dr McKenna, Dr Sanderson and Dr Herrington are willing to be called to assist in acute and historical cases.
Pediatric patients will be seen in ED if presenting with acute case of sexual assault or abuse. In this age group, <24-72 hours is considered acute. SANE nurse will be called. SART volunteers do not respond to these calls at this time.
Any historical cases, >24-72 hours, patient may be booked through SANE to follow up at a time that is convenient to the patient/family and staff. (in the event that the family or patient is in distress, they may be seen by SANE and pediatrician on a case by case basis)
Dr Marianne McKenna, Dr Susan Sanderson and Dr Katharine Herrington are willing to be called for acute cases, and would also like to be called for coordinated follow up visits.

20. 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 (McElvaney, 2015)”.
Forensic interviews are only conducted by trained CPS staff. (Be cautious not to ask any leading questions if the child has not made any disclosure of abuse)
Most exams are medical care only. Very rarely are speculum exams performed in this age group. Forensic samples in this age group may include external or internal vaginal swabs. Conducting the exam should be minimally invasive as possible to avoid re-traumatizing the child.

21. 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.
The SANE will assess for injuries, document, (traumagrams are available in SANE cabinet) report to police (as per patient wishes) and if necessary can look into
a safe discharge location. (list of shelters is available)
Follow up counselling through SART is available to DV patients as well, at no cost.
Clothing and personal care items donated by SART may be given to DV patients who are not being discharged to their home.

22. Local stats How many cases are we seeing in Saint John?
This year SANE has seen 54 patients so far. (April 2017-present)
We have seen 49 SA patients and 5 DV patients. (we have started taking calls for DV patients more recently)
The majority of patients are female, however we do also see male patients. (2 Adult male and 2 pediatric male cases)
Of the 49 SA patients, 14 cases have been under the age of 16.

23. 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.

24. References www.forensicnurses.org

25. Questions?