Karen Scott, RN, SANE, had been a nurse in the ED at Freeman Health System, Joplin, MO, for several years when she decided she needed to become more involved in the care of patients who had experienced sexual assault.

"In our emergency department, as is typical in emergency departments that don't have an organized sexual assault program, the way patients were handled or the experiences they had in the emergency room after a sexual assault were just poorly done," she explained.

At the time, she said, victims of sexual assault might or might not have seen a clinician with special training in collecting forensic evidence in a timely manner. Shift changes often led to a discontinuity of staff tending to the victim. And logistical issues such as ED throughput could make addressing sexual assault cases in a timely manner challenging.

"It was just bad on so many levels, but particularly the lack of training for nurses and physicians as far as what to look for, what kind of evidence to collect and that sort of thing," Scott added.

"We just wanted to find a way to make the process better and avoid re-traumatizing the patient."

Seeds of Change

So, in 2000, Scott underwent the training necessary to become a sexual assault nurse examiner. Scott and her colleagues at Freeman also began to consider how they might provide a more comprehensive medical resource for patients following a sexual assault.

"At the time our hospital and a couple of other hospitals in the area were trying to set up a community-based program at our women's shelter," she said. "Unfortunately, we ran into obstacles and were not able to get that done, so at that point we started considering how to start our own program within the hospital."

A major obstacle to the creation of a program for victims of sexual assault was reimbursement. That changed in 2008, when Missouri passed legislation to cover the cost of the forensic exam for patients who were sexually assaulted.

Internally, Scott and her colleagues at Freeman set about the task of educating more of its nurses and clinical staff about the intricacies of caring for sexual assault victims. They also took steps to augment ED processes and staffing to ensure a more cohesive care protocol for these patients.

Another critical step was to reach out to local law enforcement and other community resources to strengthen their partnerships and help sexual assault victims coming through the ED navigate both the legal and social service options available to them.

A SANE Staff

The Freeman SANE program officially launched in April 2009.

"What we were able to do is put in place a comprehensive program based on a pool of specially trained, on-call SANE nurses so that when a patient comes to the emergency room after a sexual assault, one of those nurses is always available," Scott explained.

Sexual assault nurse examiners at Freeman go through extensive training that includes approximately 40 hours of classroom time, Scott said. The coursework trains nurses to provide nonjudgmental, compassionate care to victims of sexual assault while also teaching them about the legal and forensic complexities such cases entail. As such, nurses in training meet with representatives from law enforcement, local prosecutors' offices, crime labs and coordinating services.

Nurses must also demonstrate their abilities to properly conduct a forensic examination of the patient. "Our program requires that a nurse receiving the training perform 15 pelvic exams under supervision of a physician or nurse practitioner so that they are comfortable using the equipment, collecting evidence and documenting anything they may find while conducting the exam," Scott explained.

"Our program also requirescourtroom observation time so they get familiar with the legal process. One of the basic tenets of a SANE program is that the sexual assault nurse examiner can serve as an expert witness if the case goes to trial, so they must be ready to testify regarding the evidence they have collected and what they observed."

Comprehensive Care

In addition to these specially trained nurses, behavioral health specialists are available 24/7 in the Freeman ED, and licensed social workers are available a minimum of 12 hours a day.

Patients who now present in the ED following a sexual assault are immediately transferred to a medical treatment room or private waiting area, eliminating potentially traumatic waits for victims.

Freeman also created a private exam room, developed specialized charts and invested in the equipment necessary to carry out evidence collection.

Another vital service for victims of sexual assault coming to Freeman is its network of community partners. Lafayette House, a local nonprofit focused on women's services, provides "emergency room advocates," trained volunteers who assist victims both during their ED visit and beyond.

"The advocate's role while at the hospital is to comfort and educate the victim, help her understand that what's happened to her is a crime, and to just believe her and support her," said Amy Lane, assistant director of community services at Lafayette House. She noted the advocate is also available to provide comfort and education to victim's families.

"Advocates can stay through the exam, if the victim so chooses; stay with the victim as they speak with law enforcement if she decides to report the crime; and also give her information about reporting and what she might expect while working with law enforcement and the judicial system."

Advocates also ensure victims have a "safety plan" for when they leave - i.e., that they have a safe place to go and are not in any imminent danger. And should a victim's assault result in a criminal trial, advocates from Lafayette House will even attend hearings and trials in support of the women they serve.

In 2009, as the Freeman SANE program launched, it received an additional boost from the Missouri Foundation for Health, which awarded Freeman a grant for $150,000 to support community outreach, education and prevention; administration; equipment; and additional SANE training for staff.

"Just recently we were able to use some of our grant money to train seven additional nurses, and they are just finishing up their orientation before they can join our on-call pool," Scott said. That will bring the Freeman SANE staff up to 14.

Making Strides

Initial indications are that the SANE program at Freeman is already making a difference in the community.

"We looked back at various statistics while we were setting the program up, and historically we saw about 25 sexual assault victims a year, so we projected a modest increase to about 30 patients for the first year of the program," Scott said. "We ended up seeing 45."

Lane of Lafayette House said her organization has also seen a difference since the launch of the Freeman SANE program.

"We definitely are getting more calls to come out to the ED since the SANE program started," she said. "We have had the advocate program for 15 years, but before this program was set up it was never really a protocol, and maybe the nurses on duty that night didn't even know about our services. ... We have also seen a small increase in the number of victims that have sought treatment services at Lafayette House since the program's formalization."

More to Do

Ultimately, Scott and Lane hope the SANE program will help Freeman, Lafayette and their partners to serve the victims who come to them for help. But they also hope it encourages more victims to seek their services, because many sexual assaults go unreported, particularly when no significant physical injuries are inflicted to the victim.

And even when victims seek treatment in the ED, many never file a report with the authorities. According to the Rape, Abuse and Incest National Network, 60 percent of sexual assaults go unreported to police.

What's more, even when victims do seek attention in the ED and do report the assault, cases rarely make it to the inside of a courtroom.

"One of our goals is that better examination, evidence collection and documentation, coupled with nurse examiners acting as expert witnesses, will strengthen cases and get more prosecutions," Scott said.

Currently, Scott is using data collected through the SANE program to track how many of the sexual assaults they see in the ED actually make it to court, hoping the information will be useful in future research. Likewise, she hopes to work with Freeman's network of partners to create a shared database to support additional research.

"We've come a long way, but there is still a lot of work to be done," Scott said. "It's been quite an adventure."

Timothy A. Mercer is a contributor to ADVANCE.