Workshop on Developing a Regional Plan for Providing SANE

Report
REGIONAL SANE
PROGRAM DEVELOPMENT
Office of the Illinois Attorney General Lisa Madigan
Scope of the Problem

Scope of sexual assault is staggering
1
in 7 women in Illinois = 670,000 women (2003)
 18.6% of Illinois women have been raped = 930,000
(2010)
 The
Illinois Coalition Against Sexual Assault Centers
helped 18,349 survivors of sexual assault in FY 2010
 But…5,316 rapes reported to Illinois law enforcement
in 2009
Why?
Current System of Care

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Emergency department environment
What happens when a sexual assault patient
presents to the emergency department?
How does the staff respond?
How does the patient respond?
Best Practice Patient Care

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Patient placed in private waiting room or designated examination room
immediately following triage*
Medical screening examination by physician or other qualified
healthcare professional
Medical-forensic examination and medications ordered by physician*
Specially trained health care provider performs medical-forensic
examination (24/7 availability of SANE)
Patient only has to disclose full account of sexual assault to one health
care provider (SANE)
One provider completes entire medical-forensic examination (SANE)
Medical-forensic examination begins in a timely fashion (within one hour
of ED arrival)
*SASETA requirements
Best Practice Patient Care
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Health care provider spends as much time as needed with patient (one-toone patient ratio)
Advocate called right away, automatically and remains with patient during
medical-forensic examination with patient consent
Informed consent*
STI testing if warranted*
STI prophylaxis medication*
HIV risk assessment*
HIV prophylaxis medication (HIV testing, CBC, serum chemistry, 3-5 days of
medication, referral to HIV specialist)*
Hepatitis B/tetanus vaccination if warranted
Pregnancy test*
ECP medication or referral for immediate ECP access*
*SASETA requirements
Best Practice Patient Care

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Evidence collection within 7 days of sexual assault*
Drug Facilitated Sexual Assault assessment and evidence collection*
Head-to-toe physical assessment*
Photography of injuries
Nuclear dye (toluidine blue dye) to assist in genital injury detection
Magnification tool to assist in genital injury detection
Strangulation assessment if warranted
Safety assessment
Detailed patient education and discharge instructions*
HFS Authorization for Payment Voucher issued
Referral to local rape crisis agency, counseling, follow-up examination and
victim’s compensation*
*SASETA requirements
Definition of SANE

A registered nurse who has been specially trained
to provide comprehensive care to the sexual assault
patient, who demonstrates competency in
conducting a medical-forensic exam and the ability
to be an expert witness
History of SANE


Evolved out of the women’s movement of the 1970’s
First SANE programs:
 Memphis
– 1974
 Minneapolis – 1977
 Amarillo – 1979
 Illinois - 1999
History of SANE in Illinois

Illinois General Assembly charges the Illinois
Criminal Justice Information Authority (ICJIA) to
conduct the SANE Pilot Program in 1999
 Findings
 Illinois’
include:
SANE Pilot Program substantially improves community
response to victims of sex crimes
 Illinois’ SANE Pilot Program improves the quality of evidence
collection
History of SANE in Illinois

Sexual Assault Survivor Emergency Treatment Act
(SASETA) defines SANE in 2002


"Sexual Assault Nurse Examiner” means a registered nurse who has
completed a sexual assault nurse examiner (SANE) training program
that meets the Forensic Sexual Assault Nurse Examiner Education
Guidelines established by the International Association of Forensic
Nurses
A sexual assault nurse examiner may conduct examinations using the
sexual assault evidence collection kits, without the presence or
participation of a physician
History of SANE in Illinois



Office of the Illinois Attorney General (OAG) Lisa Madigan
recognized that the response to sexual assault survivors was
inadequate
OAG receives grant monies to start the SANE Training Program
in 2003
Goal:


Provide free, consistent, high-quality SANE training throughout
Illinois
Improve medical-forensic services to sexual assault survivors
History of SANE in Illinois

SANE Training Program Mission:

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To increase the number of SANEs working in Illinois by
providing high quality, consistent education, and support for
registered nurses and other professionals serving sexual
assault survivors
Provides free didactic SANE training
Sets clinical training guidelines and provides assistance
with requirements
Any sexual assault survivor service provider able to
attend

Includes all healthcare providers
History of SANE in Illinois

SANE Training Program Provides:
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40-hour Adult/Adolescent (basic) SANE training
 16-hours of online content
40-hour Pediatric SANE training
16-hour Advanced SANE training
Adult/Adolescent clinical SANE training
SANE clinical guidelines
To date, over 830 individual nurses attending Attorney
General’s Office hosted SANE training
1194 total attendance
History of SANE in Illinois
OAG partnered with the Illinois Hospital
Association (IHA) to create a statewide SANE
Action Plan
 Goals:

 Double
the number of fully-practicing SANEtrained medical professionals from 75 to 150
 Establish hospital-based SANE programs in each
of the 11 trauma regions of the state

Deadline: one year
 Press
conference held October, 2011 as kick-off
Why 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
SANE Program Mission and Goals


SANE program mission: To provide compassionate, objective,
comprehensive and timely medical-forensic care to every sexual assault
patient
SANE program goals:
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To ensure that SA patient is not re-traumatized by healthcare system
To provide best practice SA patient care and medical-forensic examination,
including evidence collection, photography and thorough documentation
To evaluate risk and provide treatment to prevent STIs and pregnancy
To provide a safety assessment and crisis intervention
To refer SA patient for follow-up services, including local rape crisis agency
To enhance the ability for law enforcement to investigate and prosecution to
successfully prosecute the SA, including expert testimony if needed
SANE Program Obstacles

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Inadequate funding
Lack of investment and leadership
Lack of understanding of SANE and best-practice
SA patient care
Can a registered nurse do that? Speculum
placement!
Regional SANE Program Development

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Steps are fluid and can be completed in any order
Proceed in manner that best fits the program
Regional SANE Checklist provided with 3 sections:
 Initiating
Hospital Internal Steps
 Regional Hospital to Hospital Steps
 Community Steps

Process can take 1 to 3 years
Initiating Hospital Internal Steps

Assign a point person to work on program
development
 Need
invested staff to lead efforts
 Can be full or part time dedicated to SANE
Initiating Hospital Internal Steps

Conduct a needs assessment for hospital and region
 Needs
assessment form provided for guidance
 Try to acquire at least one year of data during the
same defined timeframe
Needs Assessment Questions

How many medical-forensic exams are performed at
the initiating hospital and other regional hospitals?
 May
need to use billing codes or how many SA kits
completed
 Reach out to surrounding hospitals for data
 Utilize local rape crisis agency
 Will
have data on medical advocacy visits to hospitals
 Contact
Illinois Hospital Association
Needs Assessment Questions

How many sexual assaults occur within local
community and region?
 Community
= city or area
 Region = county, EMS region, other
 Utilize the Illinois Coalition Against Sexual Assault
(ICASA) and local rape crisis
 Research national data
Needs Assessment Questions

How many sexual assaults are reported to law
enforcement?
 Look
at city and surrounding law enforcement agencies
 Look at county sheriff’s office
 May be able to acquire data on agency website
 Look at FBI Uniform Crime Report for Illinois
 http://www.isp.state.il.us/crime/cii2009.cfm
Needs Assessment Questions

What is the current protocol and response to sexual
assault patients and is it adequate?
 Consider:
 Is
best practice care being provided?
 Is standard of patient care equal?
 Review
response protocol approved by IDPH
 Discuss with staff
 Review patient charts
 Was
patient care consistent with response protocol and
SASETA?
 Reach
out to local rape crisis
Needs Assessment Questions

Is evidence collection completed properly?
 Consider
“typical” staff training
 Discuss with staff
 Reach out to local rape crisis
 Reach out to Illinois State Police (ISP) forensic scientists
 Find
your closest center at:
http://www.isp.state.il.us/docs/fslabareamap.pdf
 Contact ISP SA liaison Rhonda Carter at 217-782-4975
Needs Assessment Questions

Is medical-forensic documentation thorough and
helpful for the investigation and successful
prosecution?
 Consider
“typical” staff training
 Discuss with staff
 Reach out to law enforcement
 Reach out to State’s Attorney’s Office
 Chart review by SANE expert for feedback
Needs Assessment Questions

Does the presence of a sexual assault patient create
a strain on the hospital ED?
 Consider:
 Staff
comfort with conducting the exam and evidence
collection
 Average visit time
 Discuss
with staff
 Observation
 Reach out to local rape crisis
Regional Hospital to Hospital Steps

Reach out to other area hospitals

Reach out to affiliate and non-affiliate hospitals in
same city and/or region
 IHA
member hospital map provided
 Other SANE committed hospitals in your EMS region
Present findings in needs assessment
 Discuss collaboration to provide SA patient care

 May
need to explain benefits of SANE and best practice
SA patient care
 Discuss different regional SANE program models used
nationally
Regional Hospital to Hospital Steps

Determine best regional SANE program model and define
service area
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Two basic regional SANE models: one designated SANE hospital in
community vs. team of SANEs that respond to multiple hospitals in
community
Program site can be hospital-based housed within ED, hospitalbased housed in another location, community-based (clinic setting,
in rape crisis agency, etc…) or a combination of hospital and
community-based
Program can be commercial, non-profit or government-based
Service area unique to program, can be city-wide to multi-county
Regional SANE Program Models

Designated hospital:
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All other hospitals transfer sexual assault patient to “designated” SANE or sexual
assault treatment center
SANEs on-call and respond to designated hospital or on-shift 24/7 in emergency
department
Law enforcement, EMS and rape crisis agency refers or transports all medically stable
sexual assault patients to designated SANE hospital
SANEs are employees of the hospital or another agency with privileges to practice at
hospital
Medical-forensic examinations performed in a designated room within the emergency
department or another hospital space
SANE salary paid by the hospital or state reimbursement program
May have more than one hospital that participates or have a rotating hospital system
within the community
Model programs: Memphis, TN; Fort Wayne, IN; Milwaukee, WI; Tulsa, OK;
Oklahoma City, OK; Fairfax, VA; Akron, OH; Salt Lake City, UT
Regional SANE Program Models

Designated hospital pros:
 Staff,
supplies, equipment, etc… are all centrally
located
 Setting familiar and comfortable for SANEs and other
hospital staff

Designated hospital cons:
 Other
hospitals may not want to refer to another facility
 Inconvenient for SA patient
Regional SANE Program Models

Team of traveling SANEs:
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Common float-pool of SANEs that travel to hospitals within the
community
SANEs on-call and respond to hospital where patient presents
Patients are not transferred from one hospital to another
SANEs are employees of a system of hospitals or another agency
with privileges to practice at hospital
Medical-forensic examinations performed in a designated room
within the emergency department
SANE salary paid by the group of hospitals, another agency or
state reimbursement program
Model programs: South Carolina; Houston, TX; Boston, MA;
Portland, OR; West Virginia
Regional SANE Program Models

Team of traveling SANEs pros:
 Do
not have to transfer/refer patient
 More convenient for patient

Team of traveling SANEs cons:
 Not
convenient for SANEs
 Travel costs
 Need portable kit/supplies
 Decreased comfort level for SANEs and other hospital
staff
Regional Hospital to Hospital Steps

Determine SANE program location and facility
space for medical-forensic exams
 Need
SANE designated space
 Consider:
 Comfort
of the SA patient
 Access to medical support and emergency care
 Access to pharmacy and medication
 Access to laboratory testing
 Access to supplies and equipment
Regional Hospital to Hospital Steps

Develop joint policy and procedures for regional
SANE program
 This
may be step that takes the longest
 Determine standard response algorithm
 Determine response time
 Typical
is one hour, but must consider travel distance for
SANE
 Determine
 Will
how SANEs will be notified and when
need a centralized call center
 Determine
needed
if MOUs and/or transfer agreements are
Patient Access to SANE Program

How are SANE services accessed:
 SA
victim reports to law enforcement
 Law
enforcement notifies SANE of incoming patient and
transports to program
 SA
victim calls local rape crisis hotline
 Rape
crisis refers to program and notifies SANE of incoming
patient
 SA
 If
victim presents at local hospital for care
exam site, SANE notified of patient in ED
 If not exam site, patient transferred/referred to SANE and
hospital notifies SANE of incoming patient
Regional Hospital to Hospital Steps

Develop MOUs and transfer agreements between
hospitals and other community partners
 MOUs
needed for SANE privilege to practice at nonemployee hospital
 Transfer agreements needed if one hospital is
transferring to another
 Involve hospital legal and risk management
departments
 Consider EMTALA
 Examples of both provided
Regional Hospital to Hospital Steps

Submit area-wide sexual assault treatment plan to
IDPH
 Find
IDPH requirements at:
http://www.ilga.gov/commission/jcar/admincode/077
/077005450000500R.html
 Each hospital will still need to be designated as a
“treatment” or “transfer” hospital by IDPH
 Hospitals involved in area-wide program submit plan
together
Regional Hospital to Hospital Steps

Create a SANE program budget
 Budget worksheet included
 SANE model is usually more cost effective than the ED nurse/physician
approach
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Creates organized, efficient, less time-consuming response
SANEs time more cost effective
Streamlines billing process
SANE program will increase the number of SA patients seen…If you
build it, they will come
Determine a per patient cost and projected revenue figure and compare
to the current system of care
Always consider the quality of patient care that is being delivered under
the current system versus the quality utilizing the SANE model
SANE Program Budget

SANE services start-up costs to consider:
 SANE
Coordinator (full or part-time)
 SANE staff salary
 Training of SANEs
 Designated space for medical-forensic examinations,
administrative duties, etc…no ED space is more cost
effective
 Equipment (computer, printer, exam table/chair,
magnification tool, digital camera, alternative light
source, swab dryer, other)
SANE Program Budget

On-going costs to consider:
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Salary of ED staff/SANE (physician, nurse, tech, clerk, etc…)
Number of staff that interact with sexual assault patient
Average time of ED visit by sexual assault patient from check-in to
discharge
Number of sexual assault patients seen by ED
Administration
Space/examination room
Supplies
Equipment
Laboratory tests
Medications
Training and continuing education for ED staff/SANE
SANE Program Budget

On-going revenue to consider:
 Reimbursement
for patient services
 Private
insurance
 Medicaid/Medicare
 Illinois Sexual Assault Program (Medicaid reimbursement rate
for uninsured patients)
 Private/public
grants
 Donations
 Fundraising
 Other
(partner agency buy-in, etc…)
Regional Hospital to Hospital Steps

Identify SANE program funding sources
 Meet
with your internal grant and fundraising
departments for additional assistance and ideas
 Takes creativity, perseverance and hard work
 List of potential funding sources provided
 Funding sources will be unique to your community
SANE Program Funding Sources

Illinois Sexual Assault Program
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Violence Against Women Act (VAWA) and Victims of Crime Act (VOCA) grants
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Administered by the Illinois Criminal Justice information Authority (ICJIA)
Website: http://www.icjia.state.il.us/public/index.cfm
For more information: 312-793-8550 or [email protected]
Edward Byrne Memorial Justice Assistance Grant (JAG) Program

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Reimburses hospitals and other providers (i.e. ambulance, physicians) for medical-forensic services
not covered by private insurance or the Illinois Public Aid Code
Administered by the Illinois Department of Healthcare and Family Services
Requires hospital billing form to be submitted within 6 months of service
For more information, contact the Illinois Sexual Assault Program at 217-782-3303
Also administered by ICJIA; see information above
Violent Crime Victim Assistance (VCVA) Grant Program
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Administered by the Office of the Illinois Attorney General
Website: http://illinoisattorneygeneral.gov/victims/vcva.html
Per statute, must be a non-profit agency that will provide victim assistance to qualify
SANE Program Funding Sources
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Local and national grants from public and private foundations, corporations,
community organizations, or other agencies (i.e. United Way; organizations with
a focus on women, children, healthcare, or the community; local business groups;
corporation with office in community)
Community fund-raising
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Private donations
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Private donors, corporations/businesses, established pool of hospital donors
Annual or on-going hospital employee giving program

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Particularly successful for start-up costs or specific equipment
Allow employees to specify “SANE program” as an option
Other government funding (i.e. State’s Attorney’s Office, law enforcement
agencies)
Other hospitals

If regional SANE model is adapted, transfer hospitals contribute to SANE-designated
hospital
Regional Hospital to Hospital Steps

Staff SANE Program
 SANE Coordinator
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Medical Director
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Full or part-time
Usually a SANE in coordinator position
Consider reporting structure
Role = overall program operation, including call schedule and staffing,
budget, protocol development, staff training, peer review, issue management,
etc…and liaison with community agencies
Consider ED medical director or other invested physician
Role = approves protocols, peer review and on-going support
Staff SANEs

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Consider non-ED nurses and hiring specifically for SANE
Most important is motivation and assessment skills
Each hospital could tribute to SANE staff
Regional Hospital to Hospital Steps

Send SANE staff to SANE training and support and provide SANE clinical
training

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Utilize free OAG SANE Training Program
SANE training requirements:

40-hour adult/adolescent didactic SANE training

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Combination of online (16-hours) and classroom (24-hours) training
SANE clinical training includes:

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Series of activities that can be completed in 25-40 hours
The clinical training includes:

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15 female genital examinations including speculum placement
Observation at a criminal trial proceeding including the direct and cross examination of a
witness
3 out 7 available activities listed on the clinical training log (e.g. visiting a local rape crisis
center and attending a 4-hour Illinois State Police Forensic Laboratory training) OR completing
a 12-hour Virtual Practicum DVD, Sexual Assault: Forensic and Clinical Management
3 medical-forensic examinations with a preceptor
Regional Hospital to Hospital Steps

Create an on-call schedule or SANE staffing
schedule
On-call staffing vs. staff positions
 Back-up usually provided by program coordinator
 Determine length of SANE shifts
 Utilize a calendar program – Yahoo Groups, Google
calendar, other
 On-call pay?

Regional Hospital to Hospital Steps

Obtain necessary supplies and equipment


List of supplies included
Start-up equipment and supplies:
 Office equipment (computer, printer, external hard drive, CDs,
paper)
 Examination table
 Digital camera with macro lens setting (consider foot pedal or
remote)
 Tri-pod
 “L-scale” or other measuring device
 Colposcope (if funding does not permit, this is optional)
 Alternative light source (Woods Lamp)
 Swab dyer or swab rack (convenient, but optional)
SANE Supplies

On-going supplies:
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Sexual assault evidence collection kits (supplied
by the Illinois State Police)
Documentation forms
Sharps container
Speculums of various sizes
Pelvic light
Toluidine Blue Dye
Urine specimen containers
Blood draw and injection supplies
Pregnancy testing supplies
Laboratory testing supplies
Disposable towels
Drapes
Patient gowns
Paper bags
Small envelopes
Packing tape

On-going supplies:

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Lubricant
Labels
Sterile Swabs
Sterile water
Gauze
Gloves
Black sharpie markers and pens
Medications for STI treatment and pregnancy
prevention
Patient take-home packet of information (may
be supplied by rape crisis)
Extra clothing for patients to wear home
(typically supplied by rape crisis)
Regional Hospital to Hospital Steps

Develop medical-forensic exam polices and procedures

Protocol to outline medical evaluation and treatment and forensic evaluation and evidence
collection

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Triage and medical screening exam
Mandated reporting
Acute vs. non-acute timeframe

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Evidence collection = 7 days based on Illinois law
Informed consent – may need to be a separate protocol
Patient history (medical and forensic)
Head-to-assessment with injury identification
Documentation
Photography of injuries
Evidence collection
Drug Facilitated Sexual Assault (DFSA)
STI evaluation and treatment, including HIV
Pregnancy risk assessment and prevention
Follow-up medical care and referral to outside services
Discharge
SANE Protocols

Needs specific protocols to address:
 Rape crisis advocacy
 Photography

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Storage and when to release
Medical records
Unconscious/incapacitated patient
Emergency contraception
Standing medical orders if utilized
Interpreters
Support person NOT in exam room during exam
Non-reporting
Staffing policies
Other (informed consent, HIV risk assessment and prophylaxis, DFSA,
follow-up exam, etc…)
Regional Hospital to Hospital Steps

Start providing SANE services to SA patients!!!!!!
Community Steps

Identify and approach community partners for SART
 SART
members:
 Rape
crisis agency
 Law enforcement
 State’s Attorney’s Office
 Other stakeholders (military, corrections, university, forensic
scientists, etc…)
 Can
be essential to SANE program development and
on-going support
Community Steps

Develop SART and joint MOUs and mission
statement
 SART
is a multi-disciplinary team that collaborates to
provide a victim-centered response to sexual assault
survivors each time a sexual assault is reported within a
community. SARTs seek to unite three sometimes differing
sets of needs, that of the criminal justice and healthcare
systems and that of the victim, all with the ultimate goal
of decreasing the re-traumatization of the survivor and
holding the offender accountable
SART Goals

What Are the Goals of a SART?

Establish joint protocols for the team members

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Role and response of each team member
Work to decrease victim-blaming within the response system and the community
Hold the offender accountable for the violence and crime committed
Build relationships with response agencies to increase communication and conflict
resolution
Identify community resources and referrals to improve service delivery
Educate agency partners and the community about the dynamics of sexual assault,
how to prevent sexual assault and how to access the response system and other
service providers
Seek feedback from team members and survivors to enhance accessibility and
services provided throughout the criminal justice and healthcare systems
Identify team members to represent the participating agencies
Meet regularly to discuss protocols, issues, successes and other important
considerations
SANE Sustainability

Do not rush at the beginning – always think long-term

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On-going support from administration and community
On-going fund raising
Peer review and continuing education
Program evaluation

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May not be able to provide 24/7 SANE coverage
Develop an outcome measurement plan
Addressing vicarious trauma of SANE staff
Team leader and team building
Succession planning
SANE Staff Retention


This is one of the biggest program challenges
Support and recognize SANEs

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Recruit outside the ED and hospital

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Really difficult job – not for everyone
Be flexible
May not work regular hours at hospital
If SANE leaves hospital, keep them on SANE staff if possible
Utilize all nursing specialties
Coordinate and facilitate clinical training
Maintain SANE competency
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
Number of exams performed per year
Continuing education
Questions?
Shannon Liew, RN, BSN, SANE-A
SANE Coordinator
Office of the Illinois Attorney General
100 West Randolph Street, 13th Floor
Chicago, IL 60601
312-814-6267
[email protected]

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