Last year, you added to your busy schedule the role of your hospital’s Sexual Assault Nurse Examiner (SANE) Program medical director. As your hospital also has recently become a trauma center, your department now treats many patients who are victims of violence. The department has a very active Sexual Assault Nurse Examiner (SANE) program. The emergency department (ED) nurse manager comes to you one day and asks for your help in converting the SANE program into a forensic care program. How should you proceed? What is your answer?

Discussion: SANE programs in the United States were first established in the mid- to late 1970s, to address inadequate or unprofessional treatment of sexual assault victims in EDs and to improve the collection of forensic evidence.¹ Since then, more than 1,000 programs have been established across the country to provide this vital service.² Over the past one to two decades, many hospitals have transitioned these programs into comprehensive forensic programs. These programs use SANE nurses as forensic nurse examiners to provide comprehensive care for all victims of violence. Typical victims treated include adult/adolescent sexual assault, domestic violence, pediatric sexual assault, child abuse and neglect, elder/vulnerable adult abuse and neglect, strangulation, assault, firearms injury, stabbings, and other violent crimes.

The backbone of these programs is SANE training. Another important part of the program is providing survivor-centered, trauma-informed care. These services complement the emergency/trauma care already provided by the hospital and provide a crucial link to the criminal justice response for victims of violence. Studies have shown the importance of a criminal justice response for victims.³ Historically, studies have found improper injury identification, gunshot wound identification, and forensic evidence handling in the ED.^4-6

Several recommended steps can guide the expansion from a SANE program to a comprehensive forensic program.

Step 1: Define the Expanded Scope

This answer will help guide you along the rest of the process. Which of the previously mentioned patient types will be included in your scope of services? Once determined, you will need to create scope statements for the patient populations, examination types, and on-call/on-shift coverage expectations.

Step 2: Update Clinical Protocols and Policies.

Your SANE policies will not be enough on their own. You will need to expand examination policies and procedures beyond sexual assault and create a policy for each category of patient. You will also need a non-sexual assault evidence collection policy and procedure. You should also create strangulation and physical assault documentation standards if those are not already a part of your forensic documentation. Consent forms will need to be updated highlighting the uniqueness of different exams and potentially different evidence pathways. You will also need to address how to manage patients who decline law enforcement involvement. Other key policies that will require development and/or revision include: