Efficacy of SANE Evidence Collection: A Minnesota Study

Abstract

This article was originally published in JEN in the February issue of 1997;23(1):75-77. This article was originally published in JEN in the February issue of 1997;23(1):75-77. The first sexual assault nurse examiner (SANE) programs were developed in Memphis, Tennessee (1976), Minneapolis, Minnesota (1977), and Amarillo, Texas (1979). These programs were developed and worked in isolation from each other until the mid-1980s when they began to publish their work. This began a collaborative relationship between existing SANE programs and with other nurses interested in developing similar programs. In 1992, after a national listing of SANE programs appeared in the Journal of Emergency Nursing,1ENA sexual assault nurse examiner resource list.J Emerg Nurs. 1991; 17: 31-35AGoogle Scholar 31 programs were represented at the first national meeting of SANEs held in Minneapolis, sponsored by the Sexual Assault Resource Service (SARS) and the University of Minnesota, School of Nursing. It was after that meeting, where the International Association of Forensic Nurses (IAFN) was founded, that the development of SANE programs throughout the United States and Canada began to proliferate. Today there are more than 80 existing SANE programs and literally dozens of nurses in cities across the country attempting to develop SANE programs. With this proliferation of development comes the need for quantitative data on the efficacy of the SANE model. To date the evidence supporting the utility of this model, although persuasive, is primarily anecdotal and testimonial. We know from the existing literature that the use of a SANE speeds up the evidentiary examination process by shortening the time a victim may have to wait for a physician to be available to complete the examination in a busy emergency department, and by shortening the time to complete the examination, because it is being done by an experienced nurse examiner.2Ledray L.E. The sexual assault nurse clinician: a fifteen-year experience in Minneapolis.J Emerg Nurs. 1992; 18: 217-222PubMed Google Scholar,3Sandrick K.M. Tightening the chain of evidence.Hosp Health Netw. 1996; 6: 64-66Google Scholar Not only are SANEs doing the examinations in less time, but we expect that the quality is improved because a trained, experienced SANE knows what evidence to collect and how to meet the crisis intervention needs of the survivor.4Lenehan G.P. Sexual assault nurse examiners: a SANE way to care for rape victims.J Emerg Nurs. 1991; 17: 1-2PubMed Google Scholar The literature also indicates that prosecutors are obtaining increased numbers of guilty pleas from offenders. They attribute this to the more thorough examination completed by the SANE, resulting in better evidence collection, especially evidence of force.3Sandrick K.M. Tightening the chain of evidence.Hosp Health Netw. 1996; 6: 64-66Google Scholar The director of a Wisconsin SANE program reported that during a three-and-a-half year period, they had a 100% conviction rate in cases where a SANE testified at trial.5O'Brien C. Medical and forensic examination by a sexual assault nurse examiner of a 7-year-old victim of sexual assault.J Emerg Nurs. 1992; 18: 199-204PubMed Google Scholar She attributed this to the quality of evidence collected and the knowledgeable testimony of the SANE. Prosecuting attorneys who were initially concerned that the SANEs would not be as credible witnesses in court as physicians were quickly won over and the literature reports their satisfaction with the use of the SANE. Not only does the testimony of the SANE hold up well in court, but the SANE considers testifying a part of her job. As a result, she is a more willing witness than the physician who happened to have been on duty when the rape survivor was seen, but who has very little experience or expertise in this specialized area of practice.2Ledray L.E. The sexual assault nurse clinician: a fifteen-year experience in Minneapolis.J Emerg Nurs. 1992; 18: 217-222PubMed Google Scholar,6Di Nitto D. Yancey Martin P. Blum Norton D. Maxwell M.S. After rape: who should examine rape survivors.Am J Nurs. 1986; 86: 538-540Crossref PubMed Scopus (15) Google Scholar Another indication of the credibility of the SANE in the courtroom is the fact that her testimony alone is sufficient. A common concern of physicians turning the examination of sexual assault survivors over to the SANE is that they will still be called to testify in court. In the now thousands of cases in which the examination was completed by the SANE in Minneapolis, there has not been one case in which the nurse's testimony alone was not sufficient and the prosecutor also subpoenaed the emergency physician.7Ledray L.E. The sexual assault resource service: a new model of care.Minn Med. 1996; 79: 43-45PubMed Google Scholar Also persuasive is quantifiable patient satisfaction information collected from SANE program patients. The Memphis SANE program mailed satisfaction questionnaires to 201 patients 2 weeks after their initial visit. The 33 survivors (16.4%) who returned the questionnaire were 93% satisfied with the care they had received.8Speck P. Patient satisfaction survey and memorandum to nurses. Memphis (TN).Memphis Sexual Assault Resource Center. Jan 31, 1995; Google Scholar The Minneapolis SANE program has periodically conducted patient satisfaction surveys in conjunction with other studies of treatment outcome. The most recent study asked 34 patients to rate their satisfaction with the care they received by the police, hospital staff, and SANE on a 5-point Likert scale. Of the 29 survivors (85%) who responded, they rated their satisfaction with the police 3.4, with the hospital staff 4.0, and with the SANE 4.4.9Ledray L.E. Simmelink K. Service utilization among sexual assault clients [unpublished data]. Sexual Assault Resource Service, MinneapolisOctober 1996Google Scholar Recognizing the need for more factual data on the efficacy of SANE-completed evidentiary exams, the SARS, a SANE program based at Hennepin County Medical Center in Minneapolis, decided to ask the Minnesota Bureau of Criminal Apprehension (BCA) to complete an audit of 100 rape kits sent to their laboratory for analysis. In the mid-1970s, Minnesota BCA worked closely with Hennepin County Medical Center in Minneapolis to develop a standardized rape examination kit that is now used throughout the state of Minnesota. It is provided to health care institutions and individuals free of charge by the BCA. Local police and the State Patrol also have a supply of these rape kits available for community use. SARS worked with BCA laboratory personnel to develop a checklist to evaluate each kit for completeness of the specimens collected, documentation, and maintenance of chain of custody. The checklist asked for information such as: Who completed the kit: SANE, physician, or another nurse? Was the kit properly sealed with evidence tape? Were the appropriate swabs collected to match the documented orifices involved in the assault? Was the source identified for miscellaneous or skin swabs? Was the blood stain evidence collected properly? If clothing was obtained as evidence, was it properly placed in separate paper bags, sealed, and labeled? Was the documentation complete, including information such as last consensual coitus, number of assailants, and location of assault? The BCA began analyzing kits in February 1996 and completed 97 kits in October 1996. The completed checklists were sent to SARS by the BCA for tabulation. Of the 97 kits analyzed, 24 were completed by SANEs from SARS in Minneapolis. Because SARS is currently the only SANE program in the state of Minnesota, it was assumed that the remaining rape kits were completed by a non-SANE. Of the remaining 73 kits, 5 gave no name, title or institution, so it is impossible to know who collected the evidence in the kit. On another 8 kits this information was completely illegible. Thus for a total of 13 kits it was impossible to identify the person who collected the evidence and it would also be impossible to use this evidence in a court of law. Of the remaining 60 kits, 30 were signed by a physician alone, suggesting the physician collected the complete evidence; 23 were signed by both a physician and a registered nurse, indicating they had both been involved in the evidence collection; and 7 had only the signatures of a nurse. The chain of evidence was most seriously broken in the 13 kits where there was no identification of the examiner anywhere inside the kit or on the outside of the box used for chain of evidence. In the non-SANE kits, information on chain of evidence was also present on the outside of the box in 73% (N = 53) of the kits. It was documented in 100% (N = 24) of the SANE cases. Ninety-seven percent (N = 71) of the non-SANE kits and 100% (N = 24) of the SANE kits were properly sealed. Clothing was properly stored in separate paper bags, sealed and labeled in 88% (N = 64) of the non-SANE kits and in 100% (N = 24) of the SANE cases. The police properly completed the chain-of-evidence record on the kit 74% (N = 54) of the time on non-SANE kits, and 71% (N = 17) of the time on SANE kits. In most instances the kits are left in a locked refrigerator for the police or their representative to pick up after the examinations are completed; therefore the individual completing the examination has no control over this aspect of maintaining chain of evidence. Unfortunately, all breaches in chain of evidence make it impossible to use the evidence collected in court, even if the correct evidence was collected and if the results were positive. Comparing the SANE kits with the other kits for completeness of evidence, we found 96% (N = 23) of the SANE kits and 85% (N = 62) of the non-SANE kits collected the correct swabs to match the recorded orifice of penetration. Ninety-three percent of the non-SANE kits (N = 68), and 100% (N = 24) of the SANE kits contained blood for blood type identification. Ninety-two percent (N = 22) of the SANE kits contained an extra tube of blood for blood alcohol and/or drug analysis, and only 15% (N = 12) of the non-SANE kits contained this second tube of blood. The blood stain card was prepared properly in 100% (N = 24) of the SANE kits and 81% (N = 59) of the non-SANE kits. The source for miscellaneous swabs was identified in 100% of the SANE kits and 96% (N = 70) of the non-SANE kits. The proper documentation was included with the kit in 100% of the SANE kits and 79% (N = 58) of the non-SANE kits. A synopsis of the assault was recorded including location of the assault in 68% (N = 50) of the non-SANE kits and 71% (N = 17) of the SANE kits. Orifices involved were recorded in 100% of the SANE kits and 77% (N = 56) of the non-SANE kits. The number of assailants was reported in 92% (N = 22) of the SANE kits and 74% (N = 54) of the non-SANE kits. The SANE kits are significantly more complete and better documented. They maintained the proper chain of evidence more consistently than kits completed by other nurses or physicians. In addition, the errors made by SANEs were in no instance major errors that would threaten the integrity of the evidence collected. Unfortunately, 13 kits (18%) collected by non-SANEs would not be admissible in court. This supports the expectations4Lenehan G.P. Sexual assault nurse examiners: a SANE way to care for rape victims.J Emerg Nurs. 1991; 17: 1-2PubMed Google Scholar that SANEs will collect better evidence as a result of their experience and training. Because of our review of kits in studies such as this one, the SANE is also in a better position to learn from her mistakes and to take corrective action. For example, before this study we were not aware of the importance of documentation of the assault location (e.g., indoors versus outdoors) for the BCA records. Although we still recorded that information in our synopsis of the assault more often than non-SANE programs, we did not consistently do so. We will, however, do so in the future. Studies such as ours that document the results of the evidence collected are an important step toward more effectively documenting the efficacy of the SANE model. Those of us who remember the quality of service delivery before the implementation of the SANE model have no doubt about the benefits, but this primarily anecdotal and testimonial evidence alone no longer is sufficient. Nurses attempting to develop new programs need facts and quantitative evidence of the efficacy of the SANE evidence collection model to support their efforts. Linda E. Ledray was Director, Sexual Assault Resource Service, Minneapolis, MN, when this article was originally published in JEN. Kathy Simmelink was a Sexual Assault Nurse/Counselor, Sexual Assault Resource Center, Minneapolis, MN, when this article was originally published in JEN.