1. TREATMENT OF SEXUAL ASSAULT SURVIVORS IN ILLINOIS – TRANSFER HOSPITALS Office of the Illinois Attorney General Lisa Madigan Illinois Hospital Association

2. Objectives  Discuss the SASETA mandates for transfer hospitals  Discuss how best to meet the immediate needs of the sexual assault patient  Discuss the best practice for preserving evidence  Discuss the role of law enforcement in the transfer process  Discuss special considerations for Critical Access Hospitals 2

3. Scope of Sexual Assault  Scope of sexual assault is staggering  1 in 7 women in Illinois = 670,000 women  5,620 rapes reported to Illinois law enforcement in 2008  The Illinois Coalition Against Sexual Assault Centers helped 9,991 survivors of sexual assault in FY 2009 Served an additional 8,442 anonymously on 24-hour rape crisis hotlines 3

4. SASETA  Sexual Assault Survivors Emergency Treatment Act (SASETA)  Passed in 1975 (called the Rape Victims Emergency Treatment Act)  Mandates emergency and forensic services to sexual assault survivors of ALL ages – overseen by the Illinois Department of Health (IDPH)  Establishes the statewide evidence collection program – overseen by the Illinois State Police (ISP)  Provides for reimbursement of costs for emergency and forensic services and follow-up care – overseen by the Illinois Department of Healthcare and Family Services (HFS) 4

5. SASETA Designation  SASETA administrative rules through IDPH  Requires hospitals to submit a transfer or treatment plan every 3 years  Transfer services  Defined as “the appropriate medical screening examination and necessary stabilizing treatment prior to the transfer of a sexual assault survivor to a hospital that provides hospital emergency services and forensic services to sexual assault survivors pursuant to a sexual assault treatment plan or area-wide sexual assault treatment plan” 410 ILCS 70/1a  ~24 transfer hospitals in Illinois per IDPH website 5

6. SASETA Requirements  All transfers must comply with the federal Emergency Medical Treatment and Active Labor Act (EMTALA)  Medical screening examination needed All unauthorized personnel (including law enforcement) shall remain outside the examination room  Must be stable prior to transfer Use your trauma patient protocol as a guide  First attempt to transfer to designated treatment hospital 6

7. SASETA Requirements  Sexual assault patient shall be given an appropriate explanation concerning the reason for the transfer to another hospital for treatment  Emergency department staff of the transfer hospital shall notify the receiving hospital of the transfer of a sexual assault patient  Patient must consent to transfer  Transfer hospital shall offer to call a friend, family member or rape crisis advocate to accompany the patient 7

8. SASETA Requirements  Receiving hospital shall  Have available space and staff for the treatment of a sexual assault patient  Agree to accept the transfer and to provide the appropriate treatment of a sexual assault patient  Must respond within minutes to ensure the privacy, shall refer to the patient by code to avoid embarrassment, and shall offer a private room 8

9. SASETA Requirements  Transfer hospital shall send a copy of the ED record  Shall not reflect any conclusions regarding whether a crime occurred  Records shall include Complete ED admission form Clinical findings Nurses’ notes Any person present during the MSE Any treatment provided Test results 9

10. SASETA Requirements  Transfer hospital shall maintain chain-of-custody  Handle the sexual assault patient and her/his clothing minimally If removal of clothing is necessary, attempt to remove without cutting, tearing or shaking garments  Shall not attempt to obtain any evidence specimens Nothing that would be collected with the SA evidence kit (hair combings, swabs, blood)  If any clothing or other loose possessions must be collected as evidence Left to dry if possible Placed in separate paper bags – can be placed in a larger bag for convenience after properly sealed/labeled Bag(s) shall be transported with the patient 10

11. SASETA Requirements  If the patient does not have any life-threatening conditions, may be transported to receiving hospital by police or friend/family member  Consent of patient needed  If not medically stable, must be transferred by ambulance, in accordance with EMTATLA requirements 11

12. When to Transfer  Anytime a patient states that (s)he has been sexually assaulted within 7 days and consents to a medical- forensic examination  SASETA rules mandate evidence collection up to 7 days following sexual assault  It is not the healthcare professional’s role to determine if the report of sexual assault is “valid” or to investigate  If after 7 days  Refer for medical examination  Do not need to transfer unless a medical emergency exists or injury is noted 12

13. How to Transfer  Triage patient  Perform a medical screening examination  Do not need entire patient history of the sexual assault Need general information only – enough to facilitate transfer Who, what, when, where  Do not conduct a genital examination unless medically necessary  Do not collect evidence unless necessary  Do not provide medication unless necessary 13

14. How to Transfer  Call receiving hospital for transfer acceptance  Provide physician and nurse report to receiving hospital  Provide patient with a copy of ED record and transfer paperwork  Written patient consent needed  If medically stable, allow patient to be transported by law enforcement or friend/family member  Must follow all mandated reporting requirements 14

15. Emergency Department Record  Shall not include any conclusions  Discourage the use of “Alleged Sexual Assault”  Use these as possible diagnosis Sexual Assault Sexual Assault Examination Sexual Assault by History Evaluation of Sexual Assault Patient states… 15

16. How to Communicate  Assume that rape occurred  Use open ended questions  Poor question: “So, you think you were raped?”  Good question: “Please, tell me what happened.”  Avoid leading questions or questions that could indicate blame  Do not start a question with “Why?”  If clarification needed, reflect patient’s own words back to them  Allow time for answer 16

17. Convey  You are safe here  I’m sorry this happened to you  You did not deserve to be hurt  You did not ask to be hurt  The person who did this is the only one responsible  You did everything right  You are very brave  Thank you for coming to see me  I’m glad I got to meet you  We are going to get you to the right place for the best treatment 17

18. Explain Process  Provide an explanation of why transfer is necessary  Provide an explanation of the transfer process  Provide an explanation for what to expect at the receiving hospital  Medical advocate  SANE 18

19. Explain the Medical-Forensic Examination  Six main steps of the SANE exam: 1.Obtain consent 2.History 3. Head – to – toe assessment 4.Detailed genital assessment Only exception would be if no genital contact reported by patient for adolescent/adult population 5.Evidence collection 6. Medication administration and discharge instructions 19

20. Evidence Preservation  Do not collect evidence unless necessary  What about allowing the patient to urinate or have a drink?  What if clothing must be collected?  How to properly seal Evidence bags sealed with clear tape Examiner labels with date and initials – on and off the tape Label outside of bag with patient name, date, time of collection, examiner name and contents of bag Can place individually sealed bags in one large bag  Give to patient or law enforcement 20

21. Role of Law Enforcement  Mandated reporting requirements  Respond to transfer hospital  Facilitate transfer and provide transportation 21

22. Critical Access Hospitals  Staffing – Would it make sense for a Critical Access Transfer Hospital to have a SANE on staff, as a resource for the MDs and other nurses? How could the SANE keep up skills?  Weather – If weather is bad and transferring the patient may be dangerous, what should the CAH do?  Other concerns? 22

23. Billing  Illinois Department of Healthcare and Family Services (HFS) oversees billing  Patients with private insurance – transfer hospital must bill private insurance  Any monies normally covered by patient – bill the Illinois Sexual Assault Program (co-pay, deductible, co-insurance, etc.)  Patients with Medicaid/Medicare – bill Medicaid/Medicare  Others patients – transfer hospital can utilize the Illinois Sexual Assault Program for payment  For billing questions  Kathy Prunty at kathleen.prunty@illinois.gov or 217-782-3303kathleen.prunty@illinois.gov 23

24. References/Resources  SASETA (Act)  http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1531 &ChapAct=410%26nbsp%3BILCS%26nbsp%3B70%2F&C hapterID=35&ChapterName=PUBLIC+HEALTH&ActName= Sexual+Assault+Survivors+Emergency+Treatment+Act%2E http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1531 &ChapAct=410%26nbsp%3BILCS%26nbsp%3B70%2F&C hapterID=35&ChapterName=PUBLIC+HEALTH&ActName= Sexual+Assault+Survivors+Emergency+Treatment+Act%2E  SASETA (Administrative Rules)  http://www.ilga.gov/commission/jcar/admincode/077/07 700545sections.html http://www.ilga.gov/commission/jcar/admincode/077/07 700545sections.html  To view a listing of treatment/transfer hospitals  http://www.idph.state.il.us/healthcarefacilities/SASETA/ind ex.htm http://www.idph.state.il.us/healthcarefacilities/SASETA/ind ex.htm 24

25. Questions? 25  Shannon Liew, RN, BSN, SANE-A SANE Coordinator Office of the Illinois Attorney General 100 West Randolph Street, 13 th Floor Chicago, IL 60601 312-814-6267 sliew@atg.state.il.us  Barbara E. Haller Illinois Hospital Association Director, Health Policy & Regulation 1151 E. Warrenville Road Naperville, IL 60566 630.276.5474 bhaller@ihastaff.org  Karen Senger, RN, BSN Supervisor of Central Office Operations Division of Health Care Facilities and Programs 525 West Jefferson Street, 4th Floor Springfield, IL 62761 217-782-0381 karen.senger@illinois.gov