After Sexual Assault - Illinois Hospital Association

Report
TREATMENT OF SEXUAL ASSAULT
SURVIVORS IN ILLINOIS –
TREATMENT HOSPITALS
Office of the Illinois Attorney General Lisa Madigan
Illinois Hospital Association
Objectives
2
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Discuss the SASETA mandates for treatment
hospitals
Discuss best practice treatment of the sexual assault
patient
Discuss the best practice for collecting and
preserving evidence
Discuss the role of the Sexual Assault Nurse
Examiner (SANE)
Discuss special considerations for Critical Access
Hospitals
Scope of Sexual Assault
3

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
Treatment of Sexual Assault Survivors
in Illinois
4

Patel, Panchal, Piotrowski, & Patel (2008) surveyed
156 Illinois hospitals
 Comprehensive
Medical Care Management (CMCM) =
10 elements of best practice care
 Only 9.6% of the 156 hospitals provided all ten
elements of CMCM
SASETA
5

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)

SASETA Designation
6
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SASETA administrative rules through IDPH


Requires hospitals to submit a transfer or treatment plan every 3 years
Hospital emergency services

Defined as “healthcare delivered to outpatients within or under the care
and supervision of personnel working in a designated emergency
department of a hospital, including, but not limited to, care ordered by
such personnel for a sexual assault survivor” 410 ILCS 70/1a

Forensic services

Defined as “the collection of evidence pursuant to a statewide sexual
assault evidence collection program administered by the Department of
State Police, using the Illinois State Police Sexual Assault Evidence
Collection Kit” 410 ILCS 70/1a
IDPH has the authority to conduct site reviews of hospitals

SASETA Requirements
7
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SASETA and administrative rules impose minimum
requirements for hospitals to provide hospital
emergency and forensic services
All hospitals must comply with the federal
Emergency Medical Treatment and Active Labor Act
(EMTALA)
Services ordered by a physician, advanced practice
nurse or physician assistant
Consent of sexual assault patient required
SASETA Requirements
8
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Evaluation and treatment
 Provide appropriate medical examinations and
laboratory tests required to ensure the health, safety
and welfare of patient, or which may be used as
evidence against a criminal defendant
 At minimum the examination must include
General physical examination
 Evaluation and/or treatment of sexually transmitted
infections in accordance with Centers for Disease Control
(CDC) or American College of Emergency Physicians (ACEP)
guidelines
 Evaluation and possible treatment for HIV exposure in
accordance with CDC or ACEP guidelines

SASETA Requirements
9
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At minimum the examination must include
 When
HIV prophylaxis is deemed appropriate, provide
an initial dose or doses of HIV prophylaxis
 Provide an amount of medication for treatment at the
hospital and after discharge as deemed appropriate
 Pregnancy test for females of childbearing age
SASETA Requirements
10
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Explain and distribute information
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Provide appropriate oral and written information concerning the
possibility of infection, sexually transmitted disease and
pregnancy
Provide medically and factually accurate written and oral
information about emergency contraception; the indications and
counter-indications and risks associated with the use of
emergency contraception; and a description of how and when
the survivor may be provided emergency contraception
Provide appropriate oral and written information concerning the
accepted medical procedures, medication and possible
contraindications of such medication available for the prevention
or treatment of infection or disease resulting from sexual assault
SASETA Requirements
11
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Explain and distribute information
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Provide written and oral instructions indicating the importance of timely
follow-up healthcare related to HIV treatment and testing
Provide written and oral instructions indicating the need for follow-up
examinations and laboratory tests 1-2 weeks after the sexual assault to
determine the presence or absence of sexually transmitted disease
Provide brochure After Sexual Assault published by the Illinois Coalition
Against Sexual Assault and the Illinois Department of Health, and written
information prepared by the Illinois Attorney General about the Crime
Victim Compensation Program*

This is now a FAQ titled, Crime Victim Compensation - Frequently Asked
Questions by Sexual Assault Victims
SASETA Requirements
12

Explain and distribute information
 Provide
information on drug-facilitated sexual assault
testing, including an explanation of the comprehensive
scope of a drug screen and the limited time frame
within which evidence can be collected
 Contact
Rhonda Carter at the Illinois State Police for original
copies of the information sheet and consent form at 217782-4975 or [email protected]
 Provide
information regarding evidence collection, and
the process and use of evidence in criminal
investigation/cases
SASETA Requirements
13
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Refer to appropriate resources

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Provide referral to a physician for follow-up health care
and/or monitoring of medication given or prescribed at the
time of the initial hospital emergency visit as may be deemed
appropriate
Provide referral by hospital personnel for appropriate
counseling; the initial referral should be to a communitybased rape crisis center, if such a center is available, or
referral to other counseling
SASETA Requirements
14
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Medical records requirements
 Hospital
must develop a uniform documentation system
and preserve the records in a way that maintains
survivor confidentiality
 Medical records should not reflect any conclusions
regarding whether a crime occurred
 All medical records for sexual assault survivors shall be
maintained through a filing system that allows for
immediate accessibility during Department surveys. This
filing system may be maintained electronically
SASETA Requirements
15
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The hospital record must
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Indicate if the patient changed clothes, bathed or douched, defecated,
urinated, ate, smoked or performed oral hygiene between the time of
the sexual assault and the time of the examination
Indicate the presence of all trauma, major or minor, that may be used in
a criminal proceeding
Contain photographs of injuries, clothing, etc. when taken with the
victim’s consent
Contain a medical history that includes brief, general information
concerning possible injury and drug allergies, and for female patients, a
detailed gynecological history must be obtained including: menstrual
history (last menstrual period), whether the patient knows or believes
that she is pregnant, history of prior gynecological surgery such as
hysterectomy or tubal ligation, history of contraceptive use, history of
cancer and any prior genital injury or trauma
SASETA Requirements
16
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The hospital record must
Indicate the presence of any and all persons during the
examination process
 Document compliance with each of the hospital’s procedures
to ensure the welfare and privacy of the survivor
 Indicate whether a report was filed with the Department of
Children and Family Services, or whether the Department on
Aging or the Department of Public Health was contacted
 Include a completed emergency department record

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Indicate whether an evidence collection kit was completed
17
Best Practice Medical Record Chief
Complaint

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…
SASETA Requirements
18

Patient consent required
 “Any
person who is a sexual assault survivor who seeks
emergency hospital services and forensic services or
follow-up healthcare under the Act shall be provided
such services without the consent of any parent,
guardian, custodian, surrogate, or agent” 410 ILCS
70/5b
 The hospital shall take all reasonable steps to secure
the patient’s written informed consent to or refusal of
the examination and treatment
SASETA Requirements
19

A sexual assault evidence collection kit may not be released by a hospital
without the written consent of the sexual assault survivor

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In the case of a survivor who is a minor 13 years of age or older, evidence and
information concerning the sexual assault may be released at the written request
of the minor.
If the survivor is a minor under 13 years of age, evidence and information
concerning the sexual assault may be released at the written request of the
parent, guardian, investigating law enforcement officer, or Department of
Children and Family Services.
If the survivor is an adult who has a guardian of the person, a healthcare
surrogate, or an agent acting under the health care power of attorney, then
consent of the guardian, surrogate, or agent is not required to release the
evidence and information concerning the sexual assault. If the adult is unable to
provide consent for the release of evidence and information and a guardian,
surrogate, or agent under a health care power of attorney is unavailable or
unwilling to release the information, then an investigating law enforcement
officer may authorize the release.
SASETA Requirements
20
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Privacy and emotional support
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A member of the health care team shall respond within minutes to
move the survivor to a closed environment to ensure privacy and
shall refer to survivors by code in order to avoid embarrassment
If, for any reason, the survivor is incapable of receiving oral and
written information, the information shall be given to the
caregiver/guardian
All unauthorized personnel, including law enforcement personnel,
must remain outside the examination room during the medical
examination
Hospital shall offer to call a friend or family member and a rape
crisis advocate, where available, to accompany the survivor
SASETA Requirements
21

Sexual assault evidence collection kit program
The Illinois State Police Sexual Assault Evidence Collection
Kit shall be used in the manner prescribed by the
information contained in the Evidence Collection Kit
 With the survivor’s consent, the Evidence Collection Kit shall
be completed if the survivor presents himself/herself within
7 days after the sexual assault
 If the Evidence Collection Kit is not collected by law
enforcement promptly after completion, or law enforcement
has not yet obtained the survivor’s consent to release the
Evidence Collection Kit, hospital staff shall store it in a
safe location for at least 2 weeks
 Defines SANE (located with Act)

Evidence Collection Kit Testing
22

Sexual Assault Evidence Submission Act
If the evidence is released to law enforcement after
September 1, 2010, the Sexual Assault Evidence Submission
Act mandates that law enforcement submit the evidence to
the crime lab within 10 business days of receipt
 The crime lab must analyze the evidence within 6 months of
receipt if sufficient staffing and resources are available.
 The law requires law enforcement to submit to the Illinois
State Police an inventory of all untested sexual assault
evidence collected previously
 The Illinois State Police must submit a plan for testing all of
the inventoried evidence

SASETA Requirements
23

Follow-up healthcare
 Defined
as “healthcare services related to a sexual
assault, rendered within 90 days of the initial visit for
hospital emergency services” 410 ILCS/70 1a
 The services include, but are not limited to
A
physical examination
 Laboratory tests to determine the presence or absence of
sexually transmitted disease
 Appropriate medications, including HIV prophylaxis.
 Follow-up
healthcare may be provided by the hospital
or other professionals or facilities licensed to provide
these services
SASETA Requirements
24

Reimbursement through the Illinois Sexual Assault Emergency
Treatment Program

When any ambulance provider furnishes transportation, hospital
provides hospital emergency services and forensic services, hospital or
health care professional or laboratory provides follow-up healthcare, or
pharmacy dispenses prescribed medications to any sexual assault
survivor, who is neither eligible to receive such services under the Illinois
Public Aid Code nor covered as to such services by a policy of insurance,
the ambulance provider, hospital, health care professional, or laboratory
shall furnish such services to that person without charge and shall
be entitled to be reimbursed for its billed charges in providing such
services by the Illinois Sexual Assault Emergency Treatment Program
under the Department of Healthcare and Family Services. Pharmacies
shall dispense prescribed medications without charge to the survivor and
shall be reimbursed at the Department of Healthcare and Family
Services' Medicaid allowable rates
Patient Care Billing
25
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
Illinois Department of Healthcare and Family Services (HFS)
oversees billing
Patients with private insurance – transfer hospital must bill
private insurance
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Any monies normally covered by patient – bill the Illinois Sexual
Assault Program
Patients with Medicaid/Medicare – bill Medicaid/Medicare
Others patients – hospital and/or follow-up provider can
utilize the Illinois Sexual Assault Program for payment
For billing questions

Kathy Prunty at [email protected] or 217-782-3303
Authorization for Payment Voucher
26
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In 2008, HFS implemented a new registration system to improve
patient access to follow-up services
Hospitals, after providing the initial treatment, are able to register
the sexual assault patient with HFS and provide the patient with an
“Illinois HFS Sexual Assault Emergency Treatment Program
AUTHORIZATION FOR PAYMENT VOUCHER”
With the voucher, the sexual assault survivor will be able to receive
unlimited follow-up services for up to 90 days at the community
provider of their choice
The 90 day limit is following the initial hospital visit
The follow-up service provider can then directly bill the Illinois
Sexual Assault Program
Mandated Reporting
27
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Injury

The Criminal Identification Act requires any person conducting or operating a medical facility, or any physician or nurse
to notify the local law enforcement agency of the treatment of a person who is not accompanied by a law enforcement
officer, when it reasonably appears that the person requesting treatment has received either (1) any injury resulting from
the discharge of a firearm, or (2) any injury sustained in the commission of or as a victim of a criminal offense

Notification must be made as soon as treatment permits
Department of Children and Family Services

If you have reasonable cause to believe that a child has been physically or sexually abused and/or neglected, you must
immediately make a report to the Department of Children and Family Services (DCFS) on the toll-free hotline: 1-800-25ABUSE; 1-800-358-5117 (TTY)

Reports must also be confirmed in writing and submitted to the Department within 48 hours. The form can be obtained
from the local DCFS office or online at the DCFS website
Department on Aging

The professional must make a report to the Department on Aging’s Elder Abuse and Neglect Program within 24 hours of
forming the belief that the older person has been abused, neglected or financially exploited

The report should be made by calling the 24-hour, toll–free Elder Abuse Hotline: 1-866-800-1409, 1-888-206-1327
(TTY)

The Department on Aging encourages a reporter who is unsure whether an older person is able to self-report, but
suspects that the person is being abuse or neglected, to voluntarily report the situation to the Elder Abuse and Neglect
Program
Evidence Collection and Preservation
28

Evidence collection highlights
 Follow
Evidence Collection Kit instructions
 All seals must be covered with clear tape, initialed and
dated
 Maintain chain-of-custody
 Cannot

leave evidence once collected
Cannot leave Evidence Collection Kit once opened
 Collect
the patient’s clothing that was worn at the time
of the sexual assault
 Contact Shannon Liew or Rhonda Carter with specific
questions
Drug Facilitated Sexual Assault
29


Evidence collection based on the patient narrative
Patient signs and symptoms
 Confusion
 Dizziness
 Impaired
judgment
 Impaired memory or retrograde memory loss
 Lack of muscle control
 Loss of consciousness
 Nausea/vomiting
 Reduced inhibition
Drug Facilitated Sexual Assault
30

Examples of scenarios:
If a patient recalls having a drink but cannot recall what
happened for a period of time afterwards
 If a patient suspects someone had sex with them but cannot
remember any or all of the incident
 If a patient feels more intoxicated than their usual response
to the same quantity of alcohol
 If a patient wakes up feeling hung over, experiences
memory loss, or can’t account for a period of time
 If a patient wakes up with vaginal and/or rectal pain

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Collect urine if DFSA suspected
Do not package inside Evidence Collection Kit
How to Communicate
31

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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
Convey
32
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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
Best Practice Patient Care
33
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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 as required by EMTALA*
Medical-forensic examination and medications ordered by
physician*
Specially trained health care provider performs medical-forensic
examination

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Includes patient history, head-to-toe assessment, genital assessment,
evidence collection, medication administration and discharge instructions
Patient only has to disclose full account of sexual assault to one
health care provider
One provider completes entire medical-forensic examination
Medical-forensic examination begins in a timely fashion (within one
hour of ED arrival)
*required by federal or state law
Best Practice Patient Care
34
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Health care provider spends as much time as needed with patient (one-toone patient ratio)
Medical 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 if deem appropriate and initial dose or doses*
Hepatitis B/tetanus vaccination if warranted
Pregnancy test*
ECP medication or referral for immediate ECP access*
*required by federal or state law
Best Practice Patient Care
35
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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*
*required by federal or state law
SANE Supporters
36

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Illinois General Assembly
Illinois Attorney General Lisa Madigan
Illinois Hospital Association
Illinois Coalition Against Sexual Assault
American College of Emergency Physicians
Emergency Nurse Association
American Nurses Association
United States Department of Justice
Benefits of SANE
37
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Increase the standard of patient care available to sexual assault
survivors
Increase the quality of evidence collection and documentation
Reduce the risk of re-traumatization of the sexual assault patient in
the healthcare setting
Increase the likelihood of sexual assault survivors reporting the crime
to law enforcement
Increase prosecution rates and conviction
Create community change by providing an area-wide response and
structure for care
Bring services together and increase collaborative relationships
between disciplines
Benefits of SANE for Hospitals
38
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Improve patient care
Decrease medical-forensic examination time
Decrease patient time in emergency department
Decrease time physician and emergency department nurse
spend with patient
Increase emergency department efficiency and patient
turnover time
Decrease cost of medical-forensic examination
Benefits of SANE for Hospitals
39
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Increase public relations opportunities and fund raising
Assist with Illinois Department of Public Health (IDPH) Sexual
Assault Survivor Emergency Treatment Act (SASETA)
compliance
Assist with Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) compliance
Reimbursed at 100% by Illinois Sexual Assault Program for
uninsured patients who are not Medicaid or Medicare eligible
Reduce need for physician and emergency department nurse
to testify in court
Decrease liability (SANE model proven effective since 1976)
SANE Practice Guidelines
40
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National protocol:
 Department
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of Justice – OVC
International Association Forensic Nurses
American College of Emergency Physicians
Emergency Nurses Association
Centers for Disease Control
Agency specific protocols
Research – Evidence based practice
Hospital-based SANE Best Practice
Models
41
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Staff of specially trained healthcare providers (SANEs)
SANE Coordinator (should be an invested staff member within
facility, can have dual role as a staff RN, trauma coordinator,
emergency department educator or other)
Medical Director (can be emergency department medical
director)
24/7 availability of SANE
Established protocols to provide best practice and timely
medical-forensic patient care
Hospital-based SANE Best Practice
Models
42
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SANE performs entire medical-forensic examination

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Includes patient history, head-to-toe assessment, genital assessment,
evidence collection, medication administration and discharge instructions
Increased compensation for SANE staff
On-going peer review and continuing education for SANE staff
Photography and ability to store photographs
Designated room for examinations (can be room outside emergency
department)
Designated billing procedures so sexual assault patients are not directly
billed
Community partner involvement (law enforcement, State’s Attorney’s
Office, advocacy)
Expert witness testimony provided by health care provider if
requested (SANE)
Initiation of SANE Training Program
43

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
Initiation of SANE Training Program
44

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
Initiation of SANE Training Program
45



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
SANE Training Program
46

Mission:
 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

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Provides free didactic SANE training
Sets clinical training guidelines and provides
assistance with requirements
SANE Training Program
47
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Provides:

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40-hour Adult/Adolescent (basic) SANE training
 Developing 16-hours of online content
40-hour Pediatric SANE training
16-hour Advanced SANE training
Adult/Adolescent clinical SANE training
Pediatric SANE case review training
Updated Adult/Adolescent SANE clinical guidelines
Pediatric SANE clinical guidelines
Partnership with Planned Parenthood Illinois to facilitate speculum
placement training
Nursing contact hours for every training
SANE Training Requirements
48

Adult/Adolescent SANE training
 40-hour training
 Now a combination of online and classroom training in Illinois
 Additional clinical training
 Clinical log provided during classroom training
 Series of activities – updated in 2010 to make more obtainable
 Update incorporates an interactive DVD to be completed on own time
 If you completed the 40-hour classroom training within the past 2-3
years and have not completed the clinical training, please contact
Shannon Liew if you are still interested in being a SANE
*Note that Pediatric SANE practice requires additional classroom and clinical
training
Critical Access Hospitals
49
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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?
50
Area-wide Sexual Assault
Treatment Plan

Hospitals in a community may develop and
participate in an area-wide sexual assault
treatment plan
 Plans
must describe the hospital emergency services
and forensic services to sexual assault survivors that
each participating hospital has agreed to make
available, as well as individual treatment or transfer
plans for each hospital
 Hospitals that develop area-wide plans must obtain
IDPH approval before implementing the plan
 IDPH’s form for area-wide plans can be found in the
administrative rules
References/Resources
51

SASETA (Act)


SASETA (Administrative Rules)


http://www.idph.state.il.us/healthcarefacilities/SASETA/index.htm
CDC guidelines for STI treatment


http://www.ilga.gov/commission/jcar/admincode/077/07700545sections.html
To view a listing of treatment/transfer hospitals


http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1531&ChapAct=410%26
nbsp%3BILCS%26nbsp%3B70%2F&ChapterID=35&ChapterName=PUBLIC+HE
ALTH&ActName=Sexual+Assault+Survivors+Emergency+Treatment+Act%2E
http://www.cdc.gov/std/treatment/2010/sexual-assault.htm
ACEP guidelines and link to Evaluation and Management of the Sexually
Assaulted or Sexually Abused Patient

http://www.acep.org/content.aspx?id=29562
Questions?
52

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]

Barbara E. Haller
Illinois Hospital Association
Director, Health Policy & Regulation
1151 E. Warrenville Road
Naperville, IL 60566
630.276.5474
[email protected]

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
[email protected]

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