Implementing Pediatric Sexual Assault Nurse Examiner Programs
Lucia Zuniga, Joan Meunier-Sham  -  2008/4/23
http://ovc.ncjrs.gov/ovcproviderforum
 
 
What part does rape care advocacy play in the pediatric SART response? Is it beneficial to offer support to the non-offending parent during the pediatric SART response?
 
1.  sham
 Our one emergency department based Pedi SANE response does work closely with a local rape crisis center. A medical advocate responds to the emergency department as a support to the non-offending caretaker/guardian. The advocate may also occupy the child with diversionary activities while the caretaker/guardian is providing a history to the SANE. In follow-up, the rape crisis center offers support groups for guardians and teen victims of assault.
 
 
How do you define the pediatric patient (by age or Tanner stage)? Where are exams best performed CAC or emergency departments?
 
1.  Sarah
 Our CAC does not have facilities for providing medical examinations. They would like to contrac with the SANE Program (community based out of our sexual assault agency) to provide pediatric exams. Do you have any suggestions as to how to address the need for providing these exams, both acute and non-acute, in a hospital setting?
 
2.  sham
 Because our Pediatric SANE Program was preceded by an Adult and Adolescent SANE Program, which provides an emergency department response to patients 12 years and older, our Pediatric SANE Program focused on developing protocols and a forensic evidence collection kit for children 12years. All of our Pediatric SANE exams include both chronological age and Tanner Staging as part of the childs assessment. Our collective SANE Program is always looking at ways to best meet the development and physiological needs of our patients. We have altered our protocols to allow adult/adolescent SANEs the discretion of not using a speculum on a young teen, who has never had consensual intercourse or a pelvic exam. Additionally, we are currently discussing appropriate indications for the use of the pediatric evidence kit in young teens. Although we initially thought that our Pediatric SANE Program would replicate our Adult SANE Program by providing exams in emergency departments, the greatest volume of patients and the greatest need for services was in the states Childrens Advocacy Centers (CACs). Therefore, our initial focus for service implementation was within the CACs. Our Pediatric SANEs provide acute and non-acute exams for children 12years of age in 7 of the states 11 Childrens Advocacy Center (CAC). CAC based Pedi SANEs are cross-trained as Adult/Adolescent SANEs and also care for patients 12 years of age with chronic sexual abuse and/or non-acute assaults. Currently the CACs do not have 247 access, or the availability of post-exposure medications required for teen/adult patients. Therefore, Adult/adolescent SANEs provide care and acute evidence collection for patients 12 years of age in 27 designated SANE sites (mostly emergency departments) in MA. We currently have one emergency department in Northeastern Massachusetts which provides a 247 SANE response to child, adolescent and adult patients. Nurses working in this setting are cross-trained as both adult and pediatric SANEs.
 
 
How many states have barred the testimony of nurse-examiners because their evidence was not gathered for the purposes of treatment?
 
1.  lzuniga
 The role of the SANE is not only for purposes of evidence collection but also exam, treatment and referral. I have not heard of any states barring SANEs from testifying based on their role. We certainly have not seen this happen in Massachusetts.
 
 
Have you seen examples of Pediatric SANE programs participating in SARTs?
 
1.  sham
 Currently our Pedi SANEs are housed within a Children's Advocacy Center. These settings utilize a multi-disciplinary team approach to investigations that include police detectives, CPS, DA representatives and the Pedi SANE.
 
 
Do you suggest a pediatric SANE program stand alone or as part of a larger SANE program?
 
1.  mikki
 So you see a lot of benefit in standardization? Does every SANE in your State use the same kit and the same paperwork?
 
2.  lzuniga
 In Massachusetts we have seen a tremendous benefit in sustaining a SANE Program by each individual Pedi SANE being part of the larger program. The support, funding, oversight, management, and overall direction for the Pedi SANE Program is only enhanced through a larger system. The benefit from having one united program is actualized through standard of care, quality, mentoring, support, and uniformity. In Massachusetts as the Program Director I over see Joan Sham as the Associate Director for Pediatric SANE and Kathy Jolin as the Associate Director for the Adult and Adolescent Program. Joan manages all the 8 Pedi SANE providers and Kathy manages the 7 Regional Coordinators across the state.
 
 
How many pediatric SANE programs are there?
 
1.  Lynne Rybicki
 NJ is currently in the process of training pediatric SANEs for all 21 counties. Additionally, there are four Regional Diagnostic Centers and several CAC to handle pediatric cases.
 
2.  sham
 In Massachusetts we have Pediatric SANEs in 7 of the states 11 Children's Advocacy Centers. In addition we have one emergency based Pediatric SANE Program.
 
 
What is the best source of funding to enable hospitals to send staff to pediatric SANE training without paying for that training themselves?
 
1.  cyndi
 I agree that hospitals should support the training but sometimes they don't. I am curious if there is any financial incentives for hospitals to help offset the cost of sending nurses to training.
 
2.  lzuniga
 In Massachusetts we have had the benefit of a State Appropriated line item to pay for the statewide 7 week SANE certification training. I think hospitals need to support nurses who are willing to go through a training program to become certified. It only benefits their facility because of the in kind benefit from having their staff with a unique body of knowledge.
 
 
Our SANE Program is community based out of our sexual assault advocacy office. Our local CAC is interested in contracting with us to provide SANE services for pediatric sexual assault/abuse cases. Are there other community based programs contracting in such a way? And if so, can you provide contact information for those programs?
 
1.  lzuniga
 As Joan mentioned our SANE program is centralized and we hire and oversee the Pediatric SANE Services through our central office in Boston. Our Child Advocacy Centers are dispersed across the state and 7 of our 11 CAC's have a Pedi SANE working on site within the Child Advocacy Center. The SANE partnership is a collaborative model but the direct oversight and management of our Pedi SANEs happens within the SANE Program and not through the CAC's. We do not contract with the CAC's. We provide Pedi SANE services on site through a collaboration via a memorandum of understanding. The CAC's are critical partners in helping interview and identify the Pedi SANE that best meets the needs of their unique Child Advocacy Center. To discuss this further please feel free to contact us directly for some technical assistance with setting this up.
 
 
What are the similarities and differences between adult/adolescent exams and pediatric exams? And what specific training is needed for a nurse trained in SANE-A to learn these components?
 
1.  lzuniga
 There are many differences within the scope of a Pedi SANE working within a Child Advocacy Center and the AdultAdolescent SANE working within the Emergency Department. Background, education, years of clinical experience working with children, are some of the important considerations. We have a separate Adult/Adolescent Training from that of our Pediatric Training. They are very different but complimentary models of service. We only have a handful of SANEs who are trained and qualified to do both adult and pediatric exams. We are looking into expanding the scope but we need to do this very thoughtfully and carefully. I think beyond certification training, ongoing training and education, oversight, management, support, quality assurance, meeting, supervision, etc.. are necessary to ensure standard of care.
 
 
Are there typically grants that cover the position of a SANE position and how are they obtained?
 
1.  sham
 Our Pedi SANE positions are provided by state funding. We do not use grants sources for these positions.
 
 
I am interested in how much standardization of policies and procedures exists between the Pediatric SANE programs in your state. Is there much variability in process from one site to the next?
 
1.  sham
 Our Pediatric SANE Program is statewide with a centralized management structure. All of our Pedi SANEs follow the same protocols and were trained using a standardized curriculum that was developed through the MA Department of Public Health. In addition we developed the MA Pediatric Evidence Collection Kit that is used for acute evidence collection ( 72 hours) for children 12 years of age. Our Pedi SANE meet on a monthly basis for training and case review.
 
 
I recently attended a workshop for Native American grantees under an OVC grant where a guest Asst USAGO reported that a copulscopic vaginal exam was promoted regardless of timeframes in the Pac NW area. Is this a new finding from the 72 hour collection period that was previously taught in SANEs?
 
 
I am a detective specializing in crimes against children in Colorado. We are fortunate to have a great Children's Hospital with skilled physicians in child abuse. Is there an age or size of child that should go to children's rather than to a SANE nurse? We have both and just want to do what is best for the child. I am told there is a difference in the size of equipment, etc.
 
1.  sham
 You are fortunate to have both resources available to you. Sexual abuse examinations of young children are generally done in a manner that is non-invasive utilizing a Medscope or colposcope that allows the examiner to illuminate and magnify the child's external genitalia. If your SANEs have access to a Medscope/colposcope and are trained in using this tool than you should feel confident using them to conduct your exams.
 
 
A nearby hospital has pediatric SANES, but they only work M - F. Any suggestions for an advocacy program hoping to encourage broader hours? We have had a couple of weekend cases where what the regular SANE stated at the time of the initial exam and what the Pediatric SANE stated later did not match, making it very difficult for the prosecution and very frustrating for the parents.
 
1.  rinne
 As all of our nurses working are both AA and Pedi SANEs, we are able to provide 247 coverage. If a child is within 5 days (acute) we will see immediately if not we will see during office office hours (M-F).
 
2.  sham
 Our Pediatric SANE Program is only 2 years old and our initial focus has been to provide services in a CAC setting. Currently none of our CACs provide services beyond regular M-F business hours. We are also looking at ways to increase access to Pedi SANE expertise during times that the CAC is not open. We are currently providing one Emergency based Pedi SANE response and looking at ways to expand that respond to other emergency departments
 
 
Does a template exist for policy and procedure to be used by Emergency Rooms or Prosecutor's Offices that can be tailored to county or state specific needs in the implementation of a child sexual abuse policy?
 
1.  lzuniga
 We have both an Adult/Adolescent SANE protocol and Pediatric SANE Protocol for hospitals statewide that we would be happy to share with you. please send your request and contact information to Lucia.Zuniga@state.ma.us
 
 
Because of the volatile nature of child exams, is there any method of debriefing or defusing that can be used with Pediatric Nurse Examiners that does not violate patient confidentiality or case sensitive information?
 
 
How much clinical experience observing "normal genital" exams is necessary before beginning pediatric assault exams? Any ideas about how "new/in training" nurses can acquire this type of experience?
 
1.  sham
 It is important that along with observational experience that Pedi SANE candidates recieve adequate didactic training/readings regarding normal and abnormal genital exam finding in children. All of our Pedi SANE spent 1- 2 days observing other child abuse experts performing exams and then worked under the supervision of that expert to perform the exams independantly. Most of our Pedi SANEs were quite competent in performing exams after 6 - 8 exams. Their clincal preceptors completed paperwork indicating the Pedi SANEs' competency in these exams. After that time Pedi SANE were able to perform exams independantly but all of our exams are reviewed by clinical experts. Your best option is to find some local experts who would allow you to shadow/observe.
 
 
What have you seen as some of the best practices for handling defense tactic of getting an MD to counter the nurses' testimony. (Medical license trumps nurse theory)
 
 
Why did your state choose to develop a separate kit for pediatric cases?
 
1.  sham
 We only had an adult/adolescent evidence kit that well-meaning but often misinformed clinicians tried to alter for use in younger children. This often led to kits not being done because clinicians did not feel comfortable choosing what steps to do or did steps beind done (such as using a speculum) that was absolutely not indicated. We decided to develop a kit on do no harm priniciples so that the provider would know exactly what to do and what not to do (e.g.conduct an indepth interview of the child). We also wanted to make the kit child-friendly and not frightening and we removed any painful procedures (such as blood drawing) and replaced with other non-invasive steps (buccal swabs). We also believe that the pediatric kit was a powerful tool when we were requesting state funding for our program.
 
 
In addition to the Pedi SANE training, what other clinical requirements do you have for Pedi SANE certification? Are the nurses required to do work in well-child clinics?
 
1.  sham
 I have spoken to the clinical requirements on a previous post so please review. All of our CAC based Pedi SANEs are advanced practice nurses with experience in Pediatrics therefore we did not have this as a requirement for training.
 
 
I am in the process of getting a pediSANE program up and running in a rural mountain area. We've been providing SANE services for adult/adol for appx 6 years. Can you please speak to retention of SANEs. How do you keep members of your teams motivated to stick with the program. Pay, benefits, incentives, issues re: burnout, etc.
 
1.  lzuniga
 Wow! loaded question but one of the most important. Sustaining a successful SANE program takes many ingredients. We have always infused taking care of yourself principles within our training, monthly staff meetings, SANE newsletter, Update Trainings and various other avenues. Still we work on retention with our SANEs. We have seen tremendous improvements with better pay structure but the critical reason I believe SANEs stay is when they know they are making a difference in the lives of patients. When we began our SANE Program in Massachusetts 10 years ago our SANEs were getting reimbursed $3.25/hour for on call and our management team were all consultants and not employees with benefits. Over 10 years we have built our program from 200,000 annual funding to 2.6 million annual funding. Although funding is only one part of retention it is an important piece to sustaining positions and salary. Our SANEs in Boston are paid $20.00/hour for on call, the other regions receive $13.65/hour for on call. They get reimbursed $200.00 for second and third exams, they are paid $40.00hour to attend meetings, trainings, testimony, QAEvaluation, and annual performance reviews. With regards to retention and sustainability I will be speaking this Fall at the IAFN Conference on MA SANE Sustainability. The 7 Pyramid Principles are -Funding,Leadership,Quality,Services,Support,Oversight,Protocols!
 
 
Do you distinguish between acute and non-acute exams in terms of who (RN-NP-MD) performs the exam?
 
1.  lzuniga
 Massachusetts: Adult Adolescent Acute Exams, over the age of 12, within 120 hours are performed by our Adult and Adolescent SANEs in 27 emergency departments across the state. Adolescent Non-Acute andor Chronic Exams, patients 12-17, after 120 hours are performed by our Pediatric SANEs within the 7 Child Advocacy CentersPediatric Exam, Under the age of 12, Both acute and chronic are performed by our Pedi SANEs in our Child Advocacy Centers.Please read Joan's email about our unique emergency response in the Northeast region of the state. We hope to some day expand this model across the state.
 
 
Our state is trying to implement a state-wide pediatric SANE protocol for the clinical component. What are your clinical components? Do your SANEs have to be Adult/Adolscent trained first?
 
1.  sham
 Our state had an adult/adolescent SANE Program in place for patients 12 years and therefore when we initially implemented a pediatric SANE program, recruited nurses and nurse practitioners with pediatric experience to participate in the training. We also cross-trained 5 of our adult/adolescent SANEs who work in an emergency department based SANE site as Pediatric SANEs. All of our Pedi SANE completed a 48 hour curriculum, successfully passes a written examination, demonstrated competency in the use of our Pedi evidence collection kit and use of the Medscope. Our CAC pedi SANE also spent clinical time with child abuse experts conducting sexual abuse examinations. All of the exam images obtained by our Pedi SANEs are reviewed internally by our MD reviewers for quality assurance.
 
 
Our crime lab would like to make a pediatric evidence kit, can you give or send us some specifics. What is in your kit; different than your adult/adoscent kit.
 
 
I've received training from several pediatric examiners in several states/locations. With regards to obtaining a history and maintaining objectivity, I have found that prior to exam some examiners get as much info from investigators as possible AND hx from patient/parent whereas others ONLY obtain hx from the child (or non-offending parent if child is preverbal) because they feel that is more objective. What is your protocol in MA and why?
 
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