TREATMENT OF SEXUAL ASSAULT SURVIVORS IN ILLINOIS – TREATMENT HOSPITALS

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

2. Objectives • 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

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

4. Treatment of Sexual Assault Survivors in Illinois • 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

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

6. SASETA Designation • 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

7. SASETA Requirements • 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

8. SASETA Requirements • 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

9. SASETA Requirements • 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

10. SASETA Requirements • Explain and distribute information • 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

11. SASETA Requirements • Explain and distribute information • 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

12. SASETA Requirements • 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 217-782-4975 or rhonda_carter@isp.state.il.us • Provide information regarding evidence collection, and the process and use of evidence in criminal investigation/cases

13. SASETA Requirements • Refer to appropriate resources • 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 community-based rape crisis center, if such a center is available, or referral to other counseling

14. SASETA Requirements • 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

15. SASETA Requirements • The hospital record must • 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

16. SASETA Requirements • 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 • 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…

18. SASETA Requirements • 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

19. SASETA Requirements • A sexual assault evidence collection kit may not be released by a hospital without the written consent of the sexual assault survivor • 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.

20. SASETA Requirements • Privacy and emotional support • 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

21. SASETA Requirements • 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)

22. Evidence Collection Kit Testing • 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

23. SASETA Requirements • 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

24. SASETA Requirements • 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

25. Patient Care Billing • Illinois Department of Healthcare and Family Services (HFS) oversees billing • Patients with private insurance – transfer hospital must bill private insurance • Any monies normally covered by patient – bill the Illinois Sexual Assault Program • 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 kathleen.prunty@illinois.gov or 217-782-3303

26. Authorization for Payment Voucher • 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

27. Mandated Reporting • 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: 1-800-25-ABUSE; 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

28. Evidence Collection and Preservation • 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

29. Drug Facilitated Sexual Assault • 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

30. Drug Facilitated Sexual Assault • 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 • Collect urine if DFSA suspected • Do not package inside Evidence Collection Kit

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

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

33. Best Practice Patient Care • 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 • 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

34. Best Practice Patient Care • Health care provider spends as much time as needed with patient (one-to-one 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

35. Best Practice Patient Care • 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

36. SANE Supporters 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

37. Benefits of SANE • 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

38. Benefits of SANE for Hospitals 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

39. Benefits of SANE for Hospitals 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)

40. SANE Practice Guidelines • National protocol: • Department 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

41. Hospital-based SANE Best Practice Models 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

42. Hospital-based SANE Best Practice Models • SANE performs entire medical-forensic examination • 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)

43. Initiation of SANE Training Program • Illinois General Assembly charges the Illinois Criminal Justice Information Authority (ICJIA) to conduct the SANE Pilot Program in 1999 • Findings include: • Illinois’ SANE Pilot Program substantially improves community response to victims of sex crimes • Illinois’ SANE Pilot Program improves the quality of evidence collection

44. Initiation of SANE Training Program • 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

45. Initiation of SANE Training Program • 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

46. SANE Training Program • 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 • Provides free didactic SANE training • Sets clinical training guidelines and provides assistance with requirements

47. SANE Training Program • Provides: • 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

48. SANE Training Requirements • 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

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

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