Sexual Assault Response Teams
Dr. Linda Ledray, Elise Turner  -  2007/4/26
http://ovc.ncjrs.gov/ovcproviderforum
 
 
Any suggestions on pulling SANE trained RN's into the SART that are practicing on their own. We have had some issue with RN's who have taken the course but are not working with established SANE programs, my concern is that I don't know who is keeping them up on changing standards, testing their competency, what policy and procedures they are operating under. I want to try to ensure that the standard of care is the same across the board.
 
1.  Mary Pat DeWald
 You may want to begin by inviting the nurses who have received SANE education to SART meetings. Many nurses who are have been credentialed as SANE's do not work with established programs and there are many reasons for this. Each licensed RN is responsible for their practice and competency and must work within their scope and standards set by their state nurse practice act. The conceptual framework for SART is a wonderful foundation but as Elise mentioned you cannot regulate the practice of another nurse and not all practicing nurses who are SANE will join a SART secondary to multiple factors. Again as I mentioned, invite them to the table and begin the dialogue.
 
2.  Elise Turner
 Creating an International Association of Forensic Nurses chapter is a good way to come together professionally. You can also invite them to visit your practice site to exchange ideas and find out what they know about the local SART, and make sure the other SANEs feel welcome and needed. You can remind how the SART concept is one of the basic concepts of SANE practice. None of us can practice in a vacuum. Reviewing best practices standards together is helpful, but you can't presume to try an regulate the practice of another nurse.
 
 
Are any Rape Treatment Centers collecting forensic evidence after 72 hours of the assault and/or any Crime Labs performing DNA analysis on these samples? Do they work?
 
1.  Linda Ledray
 While the 72 hour limit is currently recommended by ACEP, and the National Protocol, most SANE programs will do exams beyond this cut off in some extenuating circumstances. This is an area where further research is needed with the recent advances in DNA recovery techniques. I do not believe there is sufficient evidence available to arbitraily extend that time yet, especially in oral and anal exams, but in the future, with additional research we may decide to extend the time for vaginal assaults if research shows we can indeed recover DNA for longer. It is invasive to the victim and costs the system nearly $4000 to do an evidentiary exam and have the lab analyze the specimens, so to be responsible we do not want to start doing additional exams that will not be helpful.
 
2.  Elise Turner
 If you look at the National Protocol, 72 hours is supported by the literature as a good outside limit for consistent recovery of biolobic evidence. After 72 hours, recovery drops off significantly. The site sampled also has drop-off points too- mouth 12 hours, rectum 24 hours, vagina 72. Literature reports findings in endocervical samplings for up to 14 days later, but that is anecdotal, not controlled research.
 
 
Three things: 1) I would like to find out how much decision making power (re: policy and procedure) the SART coordinator has in other places. 2) What do you think is the best/most efficient organizational chart, given the number of agencies that participate in SART. 3) Can anyone share their policy & procedure manual?
 
1.  Caroline Fisher
 In Indianapolis IN, we have been meeting every other month for over 10 years. We do not have an org. chart, we have no formal leaders. We have coordinators at each of the 6 Centers of Hope (one center at each hospital) and one of the coordinators usually chairs and sets the agenda with help via e-mail the week before. One of us usually volunteers to take notes and send out minutes at each meeting.
 
2.  Elise Turner
 More important than power and organization charts, consensus in decision making is key to longevity in SARTS. Too many SARTs are bogged down in endless documents everyone has to sign, or one person is left making all the decisions by default. These SARTs don't last. All members should feel they can bring matters to the group, talk and decide as a group for matters that affect all. Individual agencies can tend to their own internal issues based on feedback and needs identified by the group. Ad hoc committees can work on specific issues and bring recommendations back to the group.
 
 
There has been some confusion regarding SANE and SART on the national and state levels. Some professionals and commununities equate the two rather than seeing SANE as a component of SART. How do you ensure that the four MAIN (not necessarily sole)components of a SART (LE, medical-SANE, prosecution and advocacy) are balanced? Thank you!
 
1.  Elise Turner
 How many representatives do you have from each discipline on your SART? If you have a big SART, you may need to establish a steering committee of just one of each of the four disciplines to set agendas and keep things balanced. Linda's earlier post about letting each discipline be responsible for hosting the meeting by turns is great. A GREAT resource for your criminal justice folks are the DOJ guides found at http://www.vaw.umn.edu/documents/promise/pplaw/pplaw.html
 
 
Do you have any ideas for making quarterly SART meetings fresh and new? If you have any innovative ideas on presenting cases in a way that engages all the team members, or ideas on topics that other team members (not just advocates) would find interesting I would love to hear your thoughts.
 
1.  Linda Ledray
 It is, of course, important to always have an agenda. Case studies either cases that went well...or cases where there are lessons to learn often are of interest to all SART members. You might want to rotate the meeting and the responsibility for determining the agenda eg from the SANE program, to law enforcement, to advocacy, to the prosecutor so everyone gets a chance to decide on a topic of interest. If there is not a case they want to treview they can be responsible for a short training session.
 
 
Any suggestions as to how to overcome administration resistance from the hospitals in trying to implement a SANE program in the community.
 
1.  Jennifer
 Writing up a business plan is easier said then done. Most are not experts in writing business plans. Is there a business template available that has historically been successful and effective? It would be very helpful agreed. Any help with this would be great.
 
2.  Elise Turner
 Money- its all about money. You need to be able to present a business plan that shows a detailed expenditures/profit balance sheet. If your state has a payment system for forensic exams, you have to factor in that, or victims comp or third party payer such as Medicaid or private insurance. The issue is not whether or not a SANE service benefits the community or other team members, the issue is how does a SANE program fit in to already stressed budgets? Can the SANE program become a profit center for your hospital? It is possible!
 
3.  Linda Ledray
 First you need to determine why your hospital administration is resistant to the SANE program. This is typically because they are fearful that it will cost the hospital money that will not be recovered. This has historically been true. SARS in Mpls not only pays our nurses on call and a good wage for doing the exams (which is also important to maintain a competent staff), but we are making the hospital money. We do this through a combination of billing the prosecutorlaw enforcementstate for the forensic evidence collection and billing the victim's insurance (when available ) for the non forensic components. We never bill the client/victim.
 
 
How are most hospitals handeling their SA exam photos? Are they giving copies (CD and or photos) directly to law enforcement or are they requiring a sepoena before they release photos?
 
1.  Ann Marie
 We give copies if the police ask. We have the patient sign release papers giving us permission to share these photos if needed with the involved police dept. It makes life easier and much smoother with us and the police. We are all on the same team so we try and work together and help out vs working against each other.
 
2.  Elise Turner
 Our states (Mississippi) sexual assault exam documentation form contains a HIPAA compliant consent section that includes specific consent to the taking of photographs and immediate release to law enforcement. For great info on handling digital images, go to the FBI website (www.fbi.gov) and search digital imaging guidelines in the Forensic Science Communications publications.
 
3.  Linda Ledray
 I believe it is essential that each SANE program have a system in place that allows them to AUTOMATICALLY give law enforcement all evidence: the evidence kit, the exam record, clothing and pictures. They should never be required to get a subpoena as this unnecessarily delays their access to the evidence thay have a right to by law. We are doing the exam for the victim, to provide evidence to assist in the investigation. The sooner the evidence is in the hands of law enforcement the more useful it will likely be in assisting them to move forward with the case.
 
 
As an APRN, do I need to take advance practice liability insurance versus RN insurance to do SANE exams? I am a private contractor, not connected with a clinic or hospital. We do have a medical director, as well as, policies and procedures.
 
1.  Theresa
 Do you practice as an independent contractor or as an employee?
 
2.  Elise Turner
 This question should be asked of your own malpractice insurance provider. Different insurers have different rules about this. It often depends how you are licensed in your state under your Board of Nursing. If you hold a APRN license, then your actions may be held to that standard even if those actions may be within the scope of a registered nurse. Again, your own malpractice insurance provider can give you an answer specific to your situation.
 
 
Are there sources of funding (either governmental or private) available to existing SANE progams and SART teams?
 
1.  Linda Ledray
 OVC, OVW, NIJ have grant programs, however, these do not cover ongoing progrm costs. Those are typically covered by fee for service or local individual and foundation funding. Many SARTs have been successful by soliciting help from local women's groups or corporate grants.
 
 
Please emphasize the importance of continuing education for the SANE. There are few continuing education programs in Georgia for the SANE A. Who offers CEUs for SANEs in the Southeast?
 
1.  Elise Turner
 The International Association of Forensic Nurses is now offering free on-line CEUs to its members- www.iafn.org. I'm sure there are other organizations that do too. The great website, www.dna.gov, has all kinds of training resources too.
 
2.  Linda Ledray
 You are absolutely right CEUs are very important. I just did a basic SANE training that was attended by a SANE who was initially trained 12 years ago. Much has changed. I applaud her for taking the training again. Options might include the Fourth National SART Training Conference to be held in Tampa May 30-June 1, 2007 (see www.sane-sart.com for more details) There is also IAFN in Salt lake City Oct 17-21. 2007 (http://www.iafn.org/event/eventAssembly2007.cfm). I would also recommend you check with your local and near by IAFN SANE chaptrs. If they are not doing a yearly regional conference, perhaps they will consider seeking funding from IAFN to do so.
 
 
Where can legal and mental health professionals obtain training or information on sexual assault teams? Do you have knowledge of such assistance in the New York area?
 
1.  Michelle
 What about trainingassistance in other states such as Ohio?
 
2.  Elise Turner
 YES! Mental health professionals are key members of the team that cares for sexual assault survivors. Here are some local resources to contact: New York Coalition Against Sexual Assault(www.nyscasa.org) and New York City Alliance Against Sexual Assault (www.nycagainstrape.org). For the legal folks, the same organizations are great, plus American Prosecutors Research Institute is great too (www.ndaa-apri.org/apri). And the International Journal of Law and Psychiatry (http://www.ialmh.org/template.cgi?content=General/journal.htm) hits both!
 
 
We are struggling with getting law enforcement to contact the Rape Crisis Center when a forcible rape is committed. We aren't certain where the resistance is coming from though it appears it has been like this for years. Has anyone experienced the same resistance and overcome same? Any suggestions? Although we have a CART (Child Abuse Response Team) we don't really have a SART and are working to establish one.
 
1.  Rick
 You need to talk to your County's investigators. Let them know what you are able to do for them. And also that you are able and willing to work with them during the investigation, that you won't stand in their way, during the investigation, when they have to ask the tough questions. I work with the two separate groups, New Horizon's, and WRAP (Womens Rural Advocacy Program) here in MN. When I get a report of a sexual assault, I will call the main office, or one of the local advocates on my way to the hospital/home and they will usually be able to meet me there when I arrive, or shortly after. These are Great ladies that I value their services that they provide to me during my investigation and to the victims during and after and throughout the court proceedings. We have worked together and developed that working relationship and cooperative connection that is so important. I encourage other investigators to foster those connections. You may not be able to work smoothly with every Advocate, or with every Officer, everyone has a personality and sometimes they clash. But if you are fortunate enough to have some connections such as the ones that are available to me here, you will find that your job becomes much easier to accomplish.
 
2.  Lee Perales
 I would be really interested in any materials you would be willing to share. I do believe you are correct about LE's perceptions. We have experienced that they get angry with the program when the program will not pressure the victim to report or pursue prosecution. I agree that education is hopefully the answer and getting to know the center staff and scope of service we provide. Thank you for your response.
 
3.  Jennifer Senick
 In my experience resistance by law enforcement typically is based in a lack of understanding of the role of advocates, the value of advocates to victims and finally of what value advocates can be to law enforcement. In regards to the role of advocates law enforcement sometimes view advocates as obstructionists andor wanna-be investigators. I would encourage you to do some training on the importance of meeting the medical, legal and emotional needs of victims as well as the role of the advocate when providing accompanimentadvocacy during law enforcement interviews. Explaining the legal advocacy training that advocates receive in addition to doing role plays with officers where an advocate is present can be enormously helpful as well. We have also found that survivor presentations are amazingly powerful when training law enforcement.
 
4.  Lee Perales
 We actually don't know if the victims are taken to the hospital because we aren't being contacted. When we checked our county statistics, we discovered that there were a number of forcible rapes reported to our Sheriff's department and we hadn't been contacted even once by our sheriff's department.
 
5.  Linda Ledray
 Are the victims of forcible rape taken to a hospital for the SANE exam? If so I would recommend you contact the hospital and offer to be available as advocates. I would meet with law enforcement and let them know how this will be helpful to them andor to the victim; what do you plan to do with the information; and what services you can provide.
 
 
The 2005 VAWA prohibits states from requiring sexual assault victims to participate in the criminal justice system or cooperate with law enforcement authorities in order to be provided with a rape examination or reimbursement for the cost of the examination. In Virginia, it appears that currently law enforcement and hospital practices convey the message that cooperation and/or participation are required for a rape exam to be authorized or reimbursed. Given current practice and policy in Virginia, this new VAWA certification presents significant challenges and there are several ways one could comply with this requirement. Guidance on implementing practices is needed. What would you recommend as the best way that protocols, such as SART protocols, recommend compliance?
 
1.  Laura
 Regarding the posting from NANCY on the fact that Victims Compensation pays for exams. Can you contact me regarding the protocols you use around that? Thanks! 401-421-4100 x140
 
2.  Eleanore Ashman
 What do you think though about blind reporting versus victimless prosecution as ways to comply with the VAWA 2005 certification? As an advocate in background, I argue for blind reporting. But law enforcement feels very strongly that the decision should not be left up to the victim about whether or not to press charges (even though that's really what they do now when they say, I won't authorize an exam unless you prosecute). In Virginia, the exam's authorization and payment is totally linked to the criminal justice system, as evidence collection, so law enforcement authorizes the performance of the exam and prosecutors authorize payment.
 
3.  Nancy
 In our State the exams are paid by the Victim's Compensation fund. This fund is available because of charges that defendants have had to pay (surcharges and such). Rather they want to report or not the exam is covered, which is wonderful!
 
4.  Eleanore Ashman
 Lee, are you asking me or the experts here?
 
5.  Jennifer Senick
 Our state has created a separate fund called the Sexual Assault Forensic Exam (SAFE fund) which only pays for the exam and expenses related to the exam (medications etc)in cases where the victim does not want to report to law enforcement, or does not want their insurance company to find out etc. We have also done a lot of training with the folks who process the Crime Victim Compensation applications about the dynamics of sexual assault and what barriers victims encounter. We encourage all victims to apply for crime victim compensation and if they don't qualify their application to receive compensation for the exam is automatically diverted to the SAFE fund. This year the SAFE fund has a good chance of becoming a permanent fund.
 
6.  Eleanore Ashman
 Thank you. That is helpful information to present to folks here.
 
7.  Lee Perales
 How are the forensic examinations being paid for in other areas? If rape victims don't report in our community, they are told that they are responsible for the examination charges, currently $1,200. The majority of victims could not afford to proceed with a forensic exam therefore changing their mind later, while still possible, most likely will not be supported with any physical evidence. We are located in a very rural, limited income area.
 
8.  Eleanore Ashman
 I agree that this is a good thing. I am finding though that there is significant disagreement among professionals on how to best comply. Some feel that we should adopt a blind reporting practice, while others feel strongly that law enforcement should not allow the victim to decide whether or not to press charges. These folks prefer a victimless prosecution scenario, like that of domestic violence, be applied to sexual violence cases. For example, they investigate and prosecute regardless of victim cooperation. What do you think is best?
 
9.  Linda Ledray
 Since I am not familiar with the current Virginia practices, I can only tell you how this might occur. First to comply if a rape victim comes to the hospital or calls a RCC the victim should be told she can have an exam, including evidence collection, STD and emergency contraception. The SANE should be activated and her services should be the same as for a victim who did choose to report. Activation of the advocate and SANE should not depend upon law enforcement involvement. We have found that when we do this we lower the number of victims who initially did not want to report (38) to 10 who actually do not report.
 
10.  Elise Turner
 This change requires a little change in our overall mindset. Historically, we provided this care with criminal justice coordination as a goal, therefore, the forensic examination. Under these rules, the victim can choose to access only part of the SART- medical and advocacy. We have to accept that decision is OK. Some victims, because of the great support they get from the SANE and advocate decide later to pursue their criminal justice option. Another reason this is good for the system, is that you will get incident data for your system that will show a more accurate picture of sexual offenses, than just those reported to law enforcement. The military's restricted and unrestricted reporting systems delineated these benefits very well- assaults not reported still are acknowledged, support given, and a better handle is obtained by the SART on the conditions in the community, and perhaps why some victims choose not to report.
 
 
I am trying to kick-start a S.A.R.T. and would like to find resources (not necessarily financial) to do this. Do you know of any specific resources that you could recommend?
 
1.  Elise Turner
 Another great document is the National Protocol for Sexual Assault Forensic Exams (http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf)- it has a section on SARTs and throughout takes into consideration decisions teams have to make in planning the medical component. See the website for Sexual Assault Forensic Examiner Technical Assistance: http://www.safeta.org Great help and documents. You can call and talk to a Real Person too- I love that
 
2.  Lee Perales
 In Califorina, you may contact CALCASA (California Coalition Against Sexual Assault). They have put together a Sexual Assault Response Team Manual. Their website is at CALCASA.org and their phone # is (916) 446-2520
 
3.  Linda Ledray
 CA (I believe San Diego), & WV have excellent SART Handbooks and Kristen Littel is also finishing up one funded by a grant. But I would start by finding a local champion SANE, advocate, law enforcement officer, and prosecutor to partner with and talk about how this can benefit your community. OVC has money available through their speakers bureau (www.ovcttac.org) to bring an expert to your community to talk re the benefits of a SART and help you get organized as well. Come to the Tampa SART Conf (http://www.sartconference.com). SART Development and sustainability will be important topics of discussion.
 
 
Can you explain a little more about what you bill Prosecution and Law enforcment (and other agencies) for and how you bill them?
 
1.  Linda Ledray
 In our state we bill the prosecutors office for the cost of collecting the evidence that they use in prosecuting the case. We have a state law that our State RCC coalition was instrumental in passing that requires they pay for the exam (In other areas the bill goes through law enforcement).
 
 
Has or is anyone out there working on providingt services to persons with disabilities? If so who are they? What has been their experience (e.g., what works and what dosen't/what are the barriers and how do you overcome them? Finally, what training is available for SARTs to prepare them to work with persons with disabilities?
 
1.  Elise Turner
 A wonderful resource for persons with disabilities as crime victims is www.disability-abuse.com. They presented a fabulous 22 hour online training course for SART members who respond to persons with disabilities. I would also recommend you form an ad hoc committee for your SART and pull in some disability experts to help you.
 
2.  Steve Rioux
 Thanks for you help. I also would hope that all SARTs are effectivelly serving all, but what's done in theory and done in reality often differ. We will be at the SART conference. See you then.
 
3.  Linda Ledray
 I would hope that every SART provides services to all victims including those with disabilities. If you go to the sane-sart web site and look on the agenda for the up coming SART conference you will find the experts on working with disabilities listed after those sesions.
 
 
Can you describe how the SANE program differentiates from other sexual assault victim programs? Do you think its easier for victims to report the crime with the aid of this program? Are there any psychological services provided as well?
 
1.  Linda Ledray
 A Sexual Assault Nurse Examiner (SANE) program is a group of specially trained nurses who are usually available on call to come in to a hospital and collect evidence, treat victims to prevent STD's and prevent pregnancy. They also work cooperatively with advocates to provide crisis intervention and meet the emotional needs of the victims. Our program has increased reporting by 17-20 across studies.
 
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