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Decision Support Tools for Sexual Assault Nurse Examiners


The following decision support tools (DST), competencies and other documents have been developed to assist RN working as sexual assault nurse examiners (SANE) to assess risk of exposure to sexually transmitted infections (STI) including HIV, and safely dispense appropriate prophylactic agents to prevent infection following a sexual assault. Dispensing immunoprophylactic agents and post-exposure chemoprophylactic agents for the purpose of preventing infection is a Section 6 restricted activity with limits and conditions as set out in the Nurses (Registered) and Nurse Practitioners Regulation under the Health Professions Act.

CRNBC Limit and Condition

Registered nurses who compound, dispense, or administer immunoprophylactic or chemoprophylactic agents to prevent infection following sexual assault must either:

  • possess the competencies established by the BC Women's Sexual Assault Service (BCW SAS) and follow decision support tools established by BCW SAS [Note: This applies to sexual assault nurse examiners.] or
  •  possess the competencies established by the BC Centre for Disease Control (BCCDC) and follow DST established by BCCDC. [Note: This applies to registered nurses who hold CRNBC certification in STI management].

Application Parameters

DST and other documents have been developed for SANE working in hospital-based emergency departments with access to an emergency physician, attending patients age 13 and over who have been sexually assaulted within the previous seven days. RN must have employer support to use the aforementioned DST.

SANE refer to the emergency physician for patient-specific medication orders when the patient is pregnant or breastfeeding. It is recommended that RN utilizing the DST and other related documents follow established criteria for referral and transfer of care to the emergency department physician.

While every effort has been made to assure accuracy of the information, data, or material contained in these documents, the developers assume no legal liability or responsibility for the completeness or accuracy of any of the information.

Context for the Use of These Documents

Assessment of risk of exposure to STI including HIV, and the safe dispensation of appropriate prophylactic agents is one aspect of sexual assault patient care. Other prophylactic medications to be considered following a sexual assault may include the progesterone-only emergency contraceptive pill (ECP). Dispensing ECP is not covered in this DST.

Comprehensive sexual assault care is much broader than prophylactic medication and includes both general competencies and core competencies. General competencies include:

  • Providing sexual assault crisis counselling, advocacy and support
  • Performing sexual assault health assessment and examination
  • Explaining sexual assault medical-forensic options
  • Offering preventative health care options
  • Offering appropriate community referrals
  • Collecting and managing forensic samples
  • Providing credible court testimony
  • Interacting appropriately with other sexual assault related services

General competencies are to be understood and applied in a manner that reflects foundational concepts central to best practice in sexual assault. Foundational concepts are reflected in the following core competencies:

  • Understanding the social context of sexual assault
  • Understanding and applying principles of women-centred-care

Instruction in comprehensive sexual assault care reflecting all of these competencies is beyond the scope of the following DST and accompanying documents.

DST are evidence-based documents used to guide the assessment, diagnosis and treatment of client-specific clinical problems or potential problems. When decision support tools are used to direct practice, they are used in conjunction with clinical judgment, available evidence, and possible discussion with colleagues. Nurses must also consider individual patient needs and choice when using DST to make clinical decisions. 

SOURCE: Decision Support Tools for Sexual Assault Nurse Examiners ( )
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