SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities.
I'm Sarah Hexem-Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.
As part of our special access to care series, we're going to hear from sexual assault nurse examiners – or SANE’s – from across the country about new national standards under development for rape kits. The National Institute for Standards and Technology launched the effort this past summer, with support from the Department of Justice and the International Association of Forensic Nurses. In the past, the IAFN has taken a leading role in developing DOJ guidance for sexual assault exams, evidence collection, survivor support and more. Several updates have come out since the Violence Against Women Act first mandated the guidelines more than 20 years ago. But despite the efforts to standardize, variation among guidelines persists, and we'll learn how that can complicate care for survivors. For example, in some instances, survivors may report in a state or county different from where they were assaulted, and that can diminish reimbursement to the hospitals, crisis centers, shelters and other organizations where they received care. When these systems don't align, it can make it harder to sustain SANE programs that are already facing challenges like staff shortages and burnout.
We detailed some of these obstacles and potential solutions previously on at the core of care as part of a profile we did about Penn State's SAFE-T Center. If you haven't heard that episode already, I recommend listening to that one as well.
SAFE-T stands for sexual assault forensic examination telehealth. The initiative pairs more experienced SANE’s with less experienced providers to team up on exams using telehealth, including across state lines.
For this episode, we reached back out to the SAFE-T Center and talked with experts SAFE-T Caitlin Yerkes. Caitlin currently supports her Pennsylvania-based counterparts over zoom from her home outside Washington, D.C.
Later, we'll hear from SANE Kayce Ward about how rape kits have been standardized across Texas in recent years, and the state's Teleforensic Remote Assistance Center or Tex-TRAC. Kayce is the forensic nurse program manager for text track, which is a collaboration of Texas A&M College of Nursing and the Project ECHO initiative, and is working to improve health care access in rural and other underserved areas.
But we're going to begin our episode with Vikki Vodosia, a SANE at Children's Hospital Intervention and Prevention Services in Birmingham, Alabama. Recently, Vikki talked with us over zoom from her office at the CHIPS Center. She showed us just how different kits can be from state to state – and what that means for survivor care, evidence collection and more.
VIKKI: My name is Vikki Vodosia and I'm a pediatric SANE nurse at CHIPS Center which is located at the Children's of Alabama Hospital in Birmingham. I'm also a medical provider in the CHIPS clinic. So, we see patients that have been sexually abused, physically abused and any type of maltreatment.
I also hold a certification with SANE-A and SANE-P. I also work at Rape Response - Crisis Center, which is our adolescent and adult facility. They see children age 14 to death there. And so, I do SANE kits there, collect evidence, do strangulation, DV cases, things like that. I'm also at the Shelby County SAFE Center, which does the same thing. My role in Montgomery is I helped start that program and 2014. It got off the ground in 2015. And it's growing. They have the adult program there. So, we see infants to death there as well. And what I mean by “death”, is that we can go to other places. They call us to collect evidence on a deceased victim.
I've trained in Tennessee several times. I've been in Florida. I train all over the state of Alabama. And by training, that can entail training nurses to be SANE nurses, as well as nurses in the ER’s that do not have a SANE facility available. They can actually do the kits. And so, I'll go and train them to do kits on victims.
So, I have the kits here. I can show you all three of them, if you want to see ‘em. You want to do that?
So, this is Tennessee's. Very tiny. Can’t get a lot in there. No clothes, you can't get panties there.
This is our kit.
So it's a little bigger.
This is Virginia's kit. It’s a lot bigger.
So, with Tennessee's kit, they are just limited on things I can put in there. So mainly they're collecting swabs. I’ll open it. It's been a while since I looked at the Tennessee kit. So, they have one package for underwear. And then they can collect pubic hair combings and fingernail swabs. And these are questionable saliva swabs. So that could be say the perpetrator ejaculated to their mouth and they would swab this and put that's what that is. Because they also have a known DNA – or they’re supposed to have a known DNA swab in here. So, you can get the victim's DNA to compare it with. But that's it. That's their whole kit.
Where you have Alabama's – ours is head to toe. We take hair clippings. We do fingernail scrapings, or swabs depending on if they have long nails or short nails. We do pubic hair cuttings as well as combings – if they have pubic hair; most people now don't have pubic hair. And then, our swabs are oral, if there's been oral sex. If there's a bite mark or hickey, we swab that. We have a kit for that. We do four vaginal swabs and four anal swabs. And then we do a known DNA swab. We collect underwear.
We collect any clothes that might have biological evidence on them – blood, semen, anything like that. Other than that, our forensic officers do not want blue jeans, unless they need them. They don't want your belt, they don't want shoes anymore. They don't want a jacket. We used to have to collect all of that. Like, whatever the patient came in, we kept everything and then we gave them clothes to go home in. Now, they've changed a lot of that, because they don't need it. So we don't collect a lot of jackets anymore. Unless there's blood on it or something.
I know we had a case last week, the girl was just beaten bloody. Just head-to-toe blood everywhere, even blood inside her phone case and on her phone. And so, she offered up her phone case. She said, ‘Y’all take my phone, too. I don't care. If it's got his blood on it, take it.’ But they chose to take her phone case and then swab her phone. Because, you know, she needed her phone. People need their phones nowadays.
And then touch DNA is a yes or no kind of thing. Now, they're saying that in some places that when the perpetrator rips the pants down that on the inside of the pants or panties, you can get touch DNA from the perpetrator. So, we can swab the panties to get touch DNA. So, that's good. We've not always had that in Alabama. But they're starting to do touch DNA, which is great – especially for pediatrics. It's just evolving. You know, I went to a conference in California. And they took us to their lab, the forensic lab, and they were already collecting touch. That that was probably, I wanna say five years ago, at least. And so, it's gradually, you know, it happens out west and then it gradually makes it across the states. So, we're doing it now.
I have not opened up this Virginia kit. I wanted to say what was in it and how it different from ours. They have something called lips and lip-area swabs. So that's what they call for if the patient had oral sex. So, they would do all that they have one for that. They have the pubic hair combings. They have the vaginal swabs, the anal swabs that we have. Then they have additional kits for additional swabs, which is great. Because you never know how many bite marks or hickeys or you know, they ejaculated on them. And you always want to collect in the belly button because if they ejaculate on their tummy, DNA goes in that belly button. So, you always want to swab the belly button. So that's – they have a lot of that in here for the extra stuff. And it looks like they draw blood. We don't draw blood unless it's drug-facilitated sexual assault. Then we draw blood and get urine. So, their kit’s a lot bigger. It has some of, a lot of the same stuff we have in it, but a little a bit of extra.
So, it would be great to have a standardized kit for the United States. That would be great.
SARAH: Now we're going to hear from Caitlin Yerkes of Penn State's SAFE-T Center, where she supports Pennsylvania nurses remotely during sexual assault exams. Caitlin also frequently handles multi-jurisdictional sexual assault cases at the hospital where she works in person near her home outside Washington, DC.
CAITLIN: My name is Caitlin Yerkes and I work as a forensic nurse examiner in Virginia. I also work as an telecine expert consultant at the SAFE-T Center at Penn State. I've been involved in forensics for about six and a half years. Before that I worked as a public health nurse.
As a forensic nurse examiner, I care for patients who have experienced sexual abuse, sexual assault, interpersonal violence and strangulation. And basically, I get called in when a patient presents with any of those complaints. So, it used to be more commonly known as a SANE – sexual assault nurse examiner – and a lot of the job titles are expanding to forensic nurse examiner. Because we are doing strangulation, we are doing interpersonal violence aspects that aren't encompassed in the word “SANE”. So, that's kind of the difference there. But I have specialized training in medical assessment, in evidence collection, in trauma informed care, patient-centered care. And I'm able to provide all of those services to patients, depending on what they're looking for.
SARAH: Caitlin went to college at Penn State and says that connection drew her attention to the opportunity.
CAITLIN: Noticing Penn State on the job description certainly caught my eye, right. But um, part of it is just where I am and thinking about public health. Because just because you live in a small, rural town doesn't mean that you don't deserve the best care possible. And when you live in a smaller town, and the hospital only sees eight, ten, fifteen sexual assault cases a year, it's really hard to maintain ultimate proficiency in caring for patients with this really specialized and nuanced work.
So, I'm responding to my computer. I have a green screen that is not up in the background right now. But I have a green screen up in the background, I have kind of a work shirt or a work jacket on. And I'm in that same secure location with a locked room where no one else is in here except for me. And I'm available for the nurse and the patient for as long as they want or need my help.
So, these exams can run a couple of hours till six hours. And it really is the patient who runs the show. You know, I always say to my patients, ‘What happened to you – whatever it was, I don't know what it was yet – I just know that you're here because of some unfortunate situation. And it was completely out of your control. And so, my job and the nurse’s job in the room is to make sure that you are totally in control of what goes on in here.’
You know, there's a lot of setup, there's a lot of behind the scenes. It’s not just hopping on a Zoom, and having someone assists you with a sexual assault or interpersonal violence exam. There's a lot of ways to make sure that people are trained. There's a lot of I.T. and security considerations in that. So, I think if it was easy, there would be more telehealth out there. But it's really challenging in making sure that everyone is safe and that information is secure as well. We really work as a team in order to provide that care. It not only helps the patient receive really high-quality care, but it also helps to like passively educate the local nurse. They're able to kind of feel more confident in what they're doing with this sexual assault patient, and then put that into the next case that they see.
SARAH: We talked to Caitlin not long after the National Institute of Standards and Technology, or NIST, announced it's taking applications for the committee that will develop new standards for sexual assault kits (when it comes to both storage and collecting evidence).
NIST expects the process to take several years and plans to tackle related standards for elder abuse, human trafficking and other survivor populations in the future.
CAITLIN: That's a great idea, but there already are national guidelines that haven't been updated. And then, they're guidelines – but they're not necessarily applicable. Because different jurisdictions have different laws. And different evidence is collected based on those different laws and different trainings are done based on where people live. So, certainly, a box that allows the same evidence to be collected for every patient is an awesome idea, right? Because it would mean that someone like me who works in different states, I would just have one box, I’d know exactly what went in it. But if that box is then being delivered to different crime labs in different jurisdictions, different things would be tested based on what that crime lab wants.
I mean, there's a lot of different pieces to that, you know, talking about standards, I live outside of Washington, DC. So, there's three states within 10 minutes of each other. So, we see patients from across state lines very frequently. So having a standard kit would be really great, because you would know exactly what to collect. Versus, ‘Oh, I haven't used a Maryland evidence kit in a while, let me refresh my memory on what I'm actually collecting.’ So having a standard kit would be really helpful in situations like that. But it's ensuring that all of your examiners have the same training behind it. And then that the laws in each location backup, what you're collecting.
So, evidence is collected in different states based on different amounts of time. And that's dictated by the crime lab. So, in Virginia, we collect evidence up to five days. Not all states do that.
One of the tricky parts is that it's very difficult to get reimbursed for an assault that happened in another jurisdiction. So, most of the time, you know, we live in a super metropolitan area, and people are on cruises, or they're out of town, and then they come home and have an exam done. They're on vacation, they're at a conference, whatever it is, and they fly back here. And so, oftentimes, in our evidence closet, we have kits from all over the country and other countries, and many of those we are not reimbursed for because they didn't happen in Virginia. Yeah, it would be great to collect someone else's evidence. And oftentimes we do we use a Virginia kit, which other jurisdictions may not be able to process in the way that we are in Virginia. But you know, we're doing the best that we can because we have a Virginia kit. And then, are they able to move forward legally, in the same way that we are in Virginia? That I don't know, right, because I'm a nurse, and so I am able to work on my end of things. But all of that is really connected.
And then on, like, the bigger scale in terms of reimbursement. We're reimbursed by the state for exams, but we've been reimbursed at like a pittance like at like 30-something percent. Recently, we have gone up to it's like a little bit over 60 percent. So, hospitals and facilities are like eating the cost of these exams.
There needs to be kind of – the whole thing needs to be standardized, in my opinion. If you're talking about a standardized box.
SARAH: Standardization is still happening at the state level. Just a couple years ago, Texas standardized sexual assault kits, and we talked to a long time seen on the state's Evidence Collection Advisory Board, Kayce Ward. She also oversees sexual assault exam training for nurses and other health providers all over the state as the forensic nurse program manager at the Texas Teleforensic Remote Assistance Center or Tex-TRAC. Texas A&M College of Nursing launched the initiative last year in partnership with Project ECHO, which works to expand access to care in underserved regions.
KAYCE: My name is Kayce Ward. I'm a forensic nurse program manager at the Center of Excellence in Forensic Nursing College of Nursing at Texas A&M University. I'm in charge of the Texas Teleforensic Remote Assistance Center, otherwise known as Tex-TRAC.
We do collaborate with Project ECHO. We provide ECHO sessions twice a month on different topics related to primarily sexual assault or those clinicians that are tele-SANE’s that are participating in Tex-TRAC.
I moved to San Antonio began working in the emergency department at a one of the hospitals in San Antonio and was introduced to a program that was being started as a sexual assault nurse examiner program. I never heard of such a thing. I thought if you were sexually assaulted, you went to the police. I didn't know that you went to the hospital. And this was in 2000. And so, I became interested, very interested. I was hired on actually, as one of the full-time SANEs, they put me through the training, and I became a sexual assault nurse. And it really is the type of nursing that I do, that I enjoy, that I specialize in and that I have dedicated my career to.
There are people that become SANE’s that stick with it for years and years and years, such as myself. And there are some SANE’s that – the lifespan of a sexual assault nurse in Texas, I believe, is about two years. That's not very long in the lifetime of a registered nurse. So is it because of the secondary victimization, the trauma that you experience as you hear and take care of these patients? Possibly, probably all of that. Some communities may not have a very high caseload of sexual assaults that come forward either because of lack of community awareness, or law enforcement participation in investigating these cases. There’s not a big community, knowing that program might be available. So, you have that low caseload that translates into programs not being sustainable in a hospital. So, there may be people that want to be SANE’s, but then they can't maintain their certification because they don't have the caseload to do so.
Right now, our ECHO sessions are only being offered to the tele-SANE’s that are a part of Tex-TRAC, and also the clinicians at the hospital sites. This is just an entirely different area of forensic nursing that really is its infancy. And I've just had the pleasure of being kind of in on the groundwork of that program here in Texas.
I think that having a standardized kit is important. Recently, in 2019, the Texas evidence collection protocol was updated. And in Texas, we did standardize the kits. And there are two that are available, and they were updated.
And now, it doesn't matter where you go in Texas, it's one of two. And they've got the same contents in it. That allows us to, for instance, like with tele-SANE, it doesn't matter where we are doing an exam, we know they've got one or two kits. So, it's very easy for the nurse to know what's in the kit, the contents of the kit, and stuff like that.
So, I do think that standardizing the kit is a great idea. I just think it would just make things easier, I think it's beneficial, too, for the crime labs to have things collected, that are useful. You know, because if you don't have fenders that people follow, you can get people that just collect things that are not helpful for the crime lab. And then there's questions that we put on our paperwork that were helpful to the crime lab, and also help provide inclusive care and wasn't investigative. Because we have to be very careful that these exams – the paperwork and stuff – don’t kind of lean over into the investigative piece, but still provide information that satisfies that medical forensic exam that we're doing. So, I think it's a great idea. I think the standardized kit, accessible nationwide is a good thing.
Updated paperwork that the Texas evidence collection protocol came up with just help paint a better picture. We had the consultation of a bunch of a multidisciplinary team to kind of give input of, ‘Hey, you know, that question is investigative, maybe reword,’ or whatever. Or, ‘You know, that would be helpful if we knew if it's a biological male, biological female – that’s very helpful to the crime lab. Well, how can we as a forensic nurse, as a sexual assault nurse, word that in a way that is trauma-informed?’
So, making sure that that paperwork is trauma-informed, even though it's not going to be a patient that's reading the form and filling it out. And, of course, these exams are, you know, a patient can decide at any point they do or do not want to answer a question that we ask. But also, you know, letting them know why it's important that we're asking these questions. So I feel like the improvements that were made to the kids that we're using here in Texas will make a difference.
CREDITS
SARAH: Funding for our special Access to Care series comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP and AARP Foundation.
For more about us and our programs, log onto paactioncoalition.org and nurseledcare.org. And keep in touch with us on social media @PaAction and @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
