First, I wanted to start out just by saying hello, welcome, and thank you all for being here today. We are going to be going over guiding the care of patients experiencing IPV through a national protocol. And I'm very fortunate to have with me presenting today, Jennifer Markowitz and Marnie Shields. But before we jump into that, I am going to provide you with a brief overview of myself. So I am the Forensic Nursing Director with the International Association of Forensic Nurses. And I also was the project coordinator for this particular grant project. We have with me Jennifer Markowitz. Would you like to introduce yourself? Thank you, Angelita. I am Jen Markowitz. I'm a forensic nurse examiner, have been one for almost 30 years now. I run my own consulting firm, and I was the lead writer and researcher for the IPV protocol. Thanks, Jen. We also have here Marnie Shields. Would you like to introduce yourself, Marnie? Yeah. Hi, I'm Marnie Shields, and I'm one of the attorneys at the Office on Violence Against Women at the Department of Justice. And when I started back in 2001, I was assigned to work on the original adult adolescent sexual assault protocol. And since then, I've been responsible for all of the related products, which I'm going to talk about a little more in a bit. Thanks, Marnie. I'm so grateful to be here with the both of you. I always love being in the same space with both of you. So thanks for being here today. In addition to introductions, I also just want to point out that this particular webinar is supported by OVW funding. Neither any of these presenters on today's webinar or the planners have any relevant financial relationships that make us ineligible to present today. Additionally, upon completion of this webinar, you will get a course evaluation so that you will be able to get continuing nursing education contact hours for IAFN members. Everyone else will get a certificate of completion. And also that the IAFN is a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. Here are today's learning outcomes. So basically, we're going to learn about the history of VAWA and how it led to the development of the protocols. We're going to talk about the medical forensic exam in the context of intimate partner violence. And we're also going to go through the contents of the national protocol, as well as the TA enhanced version, which is available online. I want to start out with a couple of poll questions. So the first thing is we just kind of want to know who we have with us here today. So if you could just select the option that best describes your role out of the choices that are there. If by chance your role doesn't fit any of those choices, please put other and you can put in the chat what your role is and we'll give you a few minutes for that. So based on the poll, it looks like about 72% are saying nurses are forensic nurses, 12% are within health care, 7% advocacy. Looks like 1% law enforcement based off who voted and then we have some others. And in the others, it looks like we have some nurses in training. We have some OVW people on, legal consultants. So we have a variation of people, which is great, which is kind of what we anticipated. So just we wanted to be able to keep that in mind as we present to you so that we have an idea of who we're talking to when we're explaining the various components of the protocol. With that, I'll turn it over to you, Marnie. You're on mute, Marnie. Yeah, sorry about that. I want to give you a little bit of background of where this is coming from and why we developed this protocol. And so this is just showing some of the examples of the products, but I'll go to the timeline next. So in 1994, the first Violence Against Women Act was passed. It was the first really comprehensive legislation federally addressing these crimes, domestic violence, sexual assault, and stalking. And then there's been subsequent reauthorizations of that act, with the most recent having been in 2022. And so in 2000, that was the first time it was reauthorized. And one of the things that Congress put in there was for the Attorney General to develop a national protocol for sexual assault forensic medical examinations. And also for the Attorney General to issue training standards to go along with the protocol. And then also for us to recommend sexual assault education to all healthcare students. And so the first sexual assault protocol, adult-adolescent specifically, was issued in 2004. And then in 2006, we issued the training standards. And then in 2013, we did the first update of the adult-adolescent protocol. And then also in 2013, we issued a companion product specifically for prisons and jails and for some of the complexity that happens in that environment. And then we realized there's a big need for the same kind of standardization, the same kind of things we promote with the adult-adolescent protocol. There's really a need for the same thing for pediatric exams. And so we did the same kind of process for pediatric exams and issued that in 2016. In 2018, we updated the national training standards. And then now, woo-hoo, 2023, we have this IPV protocol. And again, it's something where we really saw a need in the field where these protocols are not required. They're not mandated. But they do represent the best practices as they stand at the time of issuance. So this one currently for 2023. And so it's something that we really encourage and recommend. We want it to be something that is usable for everybody. So we don't want to, you know, set it so high that someone in a rural area or tribal community can't use it. But at the same time, we really want to elevate the field to improve across the country and standardize the process for these types of exams. And so, you know, I think the concept of a forensic exam was more common for sexual assault. And that was why Congress put that in of let's create some standardization for sexual assault. But over the years since that was issued, we've realized that this is also a need for domestic violence. It's something that's happening in the field, but a lot more sporadically for domestic violence. So the hope for this protocol, in addition to all those things I mentioned, is to really promote the use of a forensic exam protocol for domestic violence. And the use of forensic exams for the domestic violence context. And so with that, I'll turn it back to Angelita. Thanks, Marnie. So I just wanted to provide you guys with a quick overview of what the process looked like for the actual development of the protocols. I'm minimizing this to two slides here, but definitely Jen and Marnie can tell you this was a long journey, but it was a fun journey, I would definitely say. So basically, once the call was put out and IFM was awarded the grant, the project partners were identified. And we gave the project partners the education guidelines for IPV nurse examiners to actually take time to review. Jennifer went through that as well, and then she kind of broke down the guidelines in 12 sections. And based on those 12 sections, we created focus groups where we had subject matter experts participate in those focus groups. In addition to the focus groups, we also did a focus group specifically for nurses that were currently in the field doing practice, just to kind of make sure that they were still seeing the same things that we had put in there and that we weren't missing anything. So all of that information was helpful to us. Once all of the information, feedback, resources that were shared during these focus groups, the knowledge that the subject matter experts brought to us, and additional literature that was pulled, Denmark was pulled together an actual draft of the protocol. Once the draft was completed, there was an internal review and an external review, where all the partners that were participating, as well as any contributing subject matter experts, were all able to review, add comments, and we made edits based on that. Additionally, we had some external people come, the external partners, well, external people that we reached out to, subject matter experts individually, both organizationally, and they also did a round of comments and review. All of those things were brought back. ISN reviewed them, Denmark was reviewed them, and then there was another round of edits from there. The final round of edits went through OVW, and then once we had OVW's approval, that version got sent to the federal attorney general's office for review, any edits they requested, and then finally there was a protocol that was publicly announced and released in May. There are a lot of people that were actually involved in the process. Again, I'm kind of minimizing it just for the sake of time, but there were definitely multiple areas of expertise that we actually tapped into during the entire process. So, we had healthcare providers that were a part of this, we had forensics that were a part of this, advocacy, the legal system, law enforcement, we had people who work with immigration, people who specifically work with disability, elder abuse, and exploitation, and then we reached out to multiple culturally specific organizations just to make sure that we were covering all of our bases. There was a core group of project partners that participated throughout the entire process. Here on this screen are the specific core partners that were a part of this project, so that included, of course, OVW, NISN, but also Equitas, we had FORGE, we had Activating Change, which is formally known as Vera Institute of Justice, we had the National Sheriffs Association, we had representation from Memorial Hermann Hospital, we had representation from Esperanza United, we had representation from the DoD, Defense Health Agency, the National Black Nurses Association, we had representation from the National Network to End Domestic Violence, International Association of Chiefs of Police, the Battered Women's Project, Alaska Network on Domestic Violence and Sexual Assault, Alaska Native Women's Resource Center, and then we also had representation from University of Colorado Health Hospital System. Oh, I almost forgot, we also had representation, sorry, from John Hopkins, we had the Danger Assessment Training and Technical Assistance Center for IPV assessments was also a part of this project. Thanks, Angelita. So I think we're going to do a couple more poll questions just to get a sense of what is happening in people's communities. So if you can let us know if medical forensic examination is part of the response to individuals experiencing IPV in your community. And you all are doing that pretty effectively here. Okay. I see a couple of you are coming from a statewide perspective. So obviously, that's not going to be true for everywhere. But for those of you who are operating within a single community, rather than from a larger regional or statewide perspective, if you can respond, and it looks like a little more than half of you say yes, some of you aren't sure whether or not you have that. But that's certainly helpful to be able to see that so many of you do have that. All right, and then let's see, our next poll. If you answered yes to the last question, are forensic nurses the ones who are conducting medical forensic exams in your area? Okay. Again, it looks like overwhelmingly the answer is yes. Great. Okay, great. Thanks. Okay, so let's talk a little bit about what's actually in the protocol. We're going to do a bit of a deeper dive into the IPV protocol itself. So I'm going to turn it back over to Angelita to talk a little bit about what, to start us off talking about what's actually in the protocol. Yeah, so it's good to see that we have so many forensic nurses on this actual webinar, but we do have some folks that are not necessarily forensic nurses or SANE nurses. So we do want to make sure that everybody at least starts out on the same page of the way that we're defining medical forensic exam throughout this protocol. Mostly because we want to make sure that, as Marnie has stated earlier, there's a little bit more consistency and what's going out and what's being done and how we're addressing our patients and how we're engaging with our community partners in regards to medical forensic exams. So we really felt it was important to make sure that everyone had walked through this particular webinar and had a good understanding of how we're defining that. So basically what we're saying is that the exam itself, of course, is a comprehensive assessment and it prioritizes the patient's health and well-being while also planning for preserving information for potential use by legal system. I have to say that the reason that we definitely put that first is that we see different definitions for the medical forensic exam in different places. So we just want to make sure that everybody is on the same page, what we are talking about when we talk about a medical forensic exam within this protocol. And then this slide is just covering the actual components that will be included with the medical forensic exam. So, of course, a complete medical forensic history is going to be done, comprehensive physical assessment, treatment of injuries that are identified. And then additionally, provision of any care on any other health care concerns that are identified during the exam process, sample evidence collection. And then if photography is being utilized, making sure that appropriate documentation of all findings is within that documentation, written documentation of the entire patient encounter, and that this medical forensic exam should definitely include safety and discharge planning and making sure that there's targeted referrals based on that patient's specific needs, not just on what the clinician feels needs to be done. So the National Sexual Assault Protocol had a specific structure, the way that it was broken down. So both protocols are broken down, it's overarching issues, operational issues, and exam issues. But in the IPV protocol, because we had a different perspective and a different thought behind what we were looking to happen across the board, it's broken up a little bit differently. So all of the contents fall somewhere in between these six components. So we start out covering the IPV, covering what IPV is, how we're defining it for this protocol, and then of course, what the appropriate response. Then the next sections are going to move into preparing, comparing to enclench the clinical response. And then the next is going to go into program operational issues, the actual exam process, judicial response. And at the end, there is the appendix and bibliography. So you kind of heard Marnie say this a little bit already in the beginning of this webinar, but really this protocol is really set up for all clinicians, regardless of the setting. We already know that all clinicians are actually encountering patients that experience IPV on a regular basis, regardless of where they're at. So what we want to really do is do a better job of actually making sure that the patients are actually being acknowledged of what they're experiencing, that we are providing appropriate guidance for those patients, and that there's some consistency in the care that those patients are receiving, regardless if they're being seen by a forensic nurse, regardless if they're being seen in an ER setting, or regardless if they're being seen in a non-acute setting. We want to really be able to see that shape up so that it really becomes consistent, and that clinicians also feel like they have a good resource to be able to do that. So basically, we're going to now go into the actual contents of the protocol. And I'll turn it back over to Jen. Thanks, Angelita. So when we were putting together this protocol, as Angelita said, this did take on a very different structure. And in a lot of ways, this protocol is more informational. And if you've looked at the protocol, especially if you've looked at the interactive protocol, you'll see that it's linked to a lot of research. There's a lot of articles that you can move to, and things like that. And so the initial part of the protocol is the IPV and the appropriate response component. And so when you start out with the protocol, you'll see that the first part of it is really looking at what the goal is, and then talking about the definition and grounding that part of it in the health consequences. Because it was important as we were writing this that this was a protocol that was really focused on the health and wellbeing of patients first and foremost. And so really why it's important to get involved from a healthcare perspective, and obviously part of that is the health impact that IPV has on patients. So within the definition component, there is that piece of the health consequences and then the prevalence. And then from there, there's of course the multidisciplinary collaboration, because we don't do this work in a vacuum at any point, whether you're a forensic nurse examiner or whether you are another type of healthcare provider. You don't take care of these patients in a vacuum, right? Patients have a multitude of needs, and we do better by these patients when we can make broad referrals to take care of the myriad needs that these patients come to us with. And so really talking about collaboration was gonna be important here. And we also know that for a lot of communities, either collaborative multidisciplinary models exist for care, or people are looking to potentially build collaborative models like family justice centers or other types of collaborative models. So that's what we have in the multidisciplinary collaboration component. But we also have within there intra-disciplinary collaboration, because when we go back to the concept of the health consequences, we know that our patients may have healthcare issues that require us to refer within the healthcare system. And it becomes really important for us to be able to build healthy collaborative relationships within healthcare systems, between healthcare disciplines to make sure that patients and the variety of healthcare issues they have are addressed when they come to us. So we talk a little bit about that. So we talk a little bit about that as well. Can I add something in before you- Yeah, please, by all means. Yeah, so thinking about from the multidisciplinary perspective, one of the things that we tend to see with IPV is when the patient actually doesn't present to healthcare first, but they may present to the multidisciplinary team. Yes, this protocol is really focused on addressing clinicians, but we also think that it's really important for multidisciplinary teams to also understand that it's there so that they have a better understanding of what the healthcare consequences and prevalence is and why it's so important for them to get that medical forensic exam in terms of actually referring patients for the medical component of a response. So we talk about that in the protocol as well. So I'm pointing that out so that as you go back to your communities and you work in your communities that you do actually share and help people understand what the purpose of it is knowing that we created it for clinicians, but how can it also be beneficial at those tables? Yeah, and that's a great point. Thanks, Angelina. And then still staying within this preparing the initial response component. Of course, we talk about both trauma-informed and patient-centered care. We actually break these into two individual components, but they're pretty inextricably intertwined. We did, though, introduce a couple of new sections into the protocol that we felt were important. In the focus groups, this came up in our dealings with patients. Of course, this comes up regularly. One is the use of interpretation and translation services to ensure equitable communication, really talking about how to build in access to equitable communication, as a foundational component of services and not as an afterthought. So that is in there. And then gender-affirming care, as well, you will find in there. And I do wanna say that throughout all of the protocol, if you turn to the interactive, and I know we'll talk more about this later, but within the interactive protocol, so the one that's online versus the one that's just a PDF, you'll find that there are a lot of downloadable tools for people to be able to use. And within the equitable communication section, the gender-affirming care section, those are places where I think you'll find a lot of very helpful tools that can stand alone to use in existing clinical programs, even if you don't yet have an IPV program. So there are some tools, I think, that we've built into this protocol, I think that are bigger than just for use in an IPV response. So I do put that out there. And then, of course, setting the stage for open communication is within this, which is really thinking about how do we make our programs hospitable for the kinds of conversations that we want our patients to have with us so they feel comfortable disclosing the violence they're experiencing in their lives, whether it's spontaneous disclosures or when we go and affirmatively ask about violence in their lives, they feel like this is the place they are safe in disclosing that kinds of violence. And so what are some of the things that we can do as clinicians? What are some of the things we can do in our physical spaces? What are some of the resources we can have available so that patients feel comfortable and secure in being able to disclose that information? Angelita, anything more here before I flip slides? No, I think that's good. I just want to reiterate, I thought I always felt like setting the stage for open communication is really important piece of this particular protocol because not everybody feels really comfortable clinician-wise, depending on where you're at, actually addressing IPV, let alone doing appropriate screening. So that's a good way for people to actually start to think about what it would look like for your facility. Yeah, thanks. And then in terms of just continuing on in this conversation about preparing to enhance the clinical response, of course, I don't think we could have a protocol if we weren't talking about screening for intimate partner violence. So in this protocol, we really try to provide options about screening tools. So again, in the interactive protocol, you'll find links to a variety of screening tools. And in both protocols, you'll see that we provide some data about what some of the science behind the protocols, what it looks like. So we've given an overview on some of those and what some of the medical and nursing organizations have to say about screening for intimate partner violence. And then of course, we talk about consent and what informed consent looks like. We do, I think, a little bit of a deeper dive on what the components of informed consent look like, of course, on confidentiality and some of the legal components of confidentiality. For those of you who are and have been doing the work as forensic nurse examiners for a while, there have been some developments in the last 10 years related to some of the confidentiality laws. So that piece is a little bit more expanded. And then of course, related to safety, patient safety, obviously being a pretty significant consideration in this work and also mandatory reporting. So all of these are discussed in the preparing to enhance the clinical response. Angelita, anything I've left out on that one? No, I don't think so. I think that it's really beneficial for people to go in because this protocol does look a little different than the National SAFE Protocol as it currently stands specifically in those sections. So just to think about, because we think about safety in general when we think about National SAFE Protocol, but when it comes to IPV patients, we have to think about it in additional layers. So we really get into what those things you need to consider throughout. So it's a safety section, but it's also intertwined throughout the protocol. So just to be clear, you will see plenty of places where it actually sends you back to another section because it intertwines so much. Yeah, and I think, again, we'll talk about what the interactive protocol looks like a little bit later in the webinar, but the nice thing about using the interactive protocol is that you can jump between sections a little bit more easily. So then moving into the program and operational issues, really looking at the different types of care models that are out there. I think for anyone who's been doing this work for any period of time as a forensic nurse, forensic clinician, I think if we've learned anything, we've learned that there's no one way to take care of forensic patients. And we've really tried to look at a variety of different models for providing medical forensic exams for patients who've experienced intimate partner violence or are experiencing it. So presenting care models. And then we really try to be realistic about what does it look like from a financial aspect to take care of these patients? So looking at both budgeting and billing, there are no built-in reimbursement models on a state-by-state basis like we have for sexual assault patients. So that was a real consideration as we were thinking about how does this happen? And what are some of the considerations for both doing this work, but also what are some of the considerations from a safety perspective where we know patients may be getting bills in the mail? And what do we need to think about as clinicians in terms of trying to consider patient safety while doing this work? So that is all built into the billing section of this. Protocols, policies, and procedures, compliance and privacy regulations, not surprisingly. Again, there are some expanded sections related to the compliance and privacy since the last iteration of the SAFE protocol. So I know that that's a little bit more, there's a little bit more information there because things have changed. And then there's a section on transferring patients because we anticipate a wide variety of locations in which patients who have or are experiencing IPV may actually be seen. We really wanted to think about the reality that patients may need to be transferred for a higher level of care, potentially depending on what is identified on initial examination, right? So patients, for instance, who've been strangled but are seen in a community clinic may need to be transferred to the emergency department for imaging and what have you. And so thinking about what would it look like to have to transfer a patient? Or what would it look like to have to transfer a patient from an ED to a location where they have more specialized medical forensic exams? So, we built that into this protocol as well. Angelita? I don't have anything. Got it. Okay. And then, of course, as we move towards the end of it, we actually do get into the actual medical forensic exam. And as I was reviewing this today, just to make sure I was thinking about this protocol, because I'm working on a different protocol now, and making sure that I was clear about what I was talking about today, it occurred to me that, boy, we talk about so much before we actually ever get to the exam itself. But we do, in fact, get to the exam itself. And so, finally, we get to the exam itself. And within the exam, not surprisingly, we talk about the things you would imagine we would talk about. We talk about medical forensic documentation. We talk about the medical forensic history. And we get into the physical assessment. And within the physical assessment, we have some very specific things broken out, including injury definitions, TBI or traumatic brain injury, strangulation, not surprisingly, physical assessment with images and considerations with intimate partner violence, specifically around the exam. Now, we break these out because within the interactive protocol, there are actual images that do go along with a lot of these components of the physical assessment. And there are also a lot of downloadable forms. So the PDF version, I think, is a lovely version, has everything you might need. The interactive version has the cool bells and whistles, if you ask me, has the extra stuff, has the pictures, and the other things that you can download. So that is where you'll find the image of, you know, what is an avulsion? We show you an avulsion, right? Like, that's where you'll find that stuff. So that is within the medical forensic exam process. And there's more, but Angelita, anything more on this slide? Yeah, I just want to reiterate that, you know, another part of the reason that we have so much more here and things breaking down in such defined ways, is just because we also recognize that we're going to be having people look at this, clinicians look at this, that may not necessarily normally work within this realm. So just making sure that they have enough information to be able to fully do the same stuff without having to take additional courses. And no, that doesn't take the place of a forensic nurse or that whole forensic team. Like, ideally, we definitely want that to happen, best practice. But we also realize that sometimes that can't happen in certain communities. So we want to make sure that, again, we have appropriate resources. Yeah, that's right. We wrote this for any clinician who might be seeing patients who've experienced intimate partner violence. So we wrote it with a very broad lens in this particular case. And then considering, again, more in the medical forensic exam process, of course, we have a section on photography, talking about types of equipment, the types of photos taken, and additional considerations. And then sample or evidence collection, we use both of those terms together. And a collection flowchart, handling considerations, the supplies and instructions that would be needed for collection, including checklist, and then chain of custody. Again, with the idea that not everybody who may end up collecting samples from a patient who's experienced IPV has necessarily done that in previous clinical work. I think that was the photography section. We did take a few, we took a little bit further, just knowing that in some of the previous protocols, things were kind of vague. And providing TA, we've gotten lots of TA around photography specifically. So we tried to add in a little bit more basic knowledge around the photography and what needs to be a part of it. I think that's right. And then lastly, of course, as part of this process, there's the entire section on discharge and follow-up, including specifically for medical and mental health services, for victim services, and then other types of community connections that patients may need to make for themselves in order to keep themselves safe, in order to move forward, whatever they may need for themselves or for their loved ones. So that's the last section in the medical forensic exam process. And then the last section within the protocol, before we get to the glossary and the appendix, is the judicial response and medical testimony. And so within it, there are common legal terms, overview of testimony at trial, receiving and responding to a subpoena, the expectations of clinicians at trial, and then subpoenas for medical records, with, again, some more updated details that I think are a little bit different since the SAFE protocol. So that piece has been updated, but again, written for a broader audience of clinicians who may not have ever had this particular information before. Anything more on that, Angelita? No, I think you've covered it. Okay, I'm going to turn it back over to you to talk about the glossary and the appendix. Yeah, so we keep talking about the online TA Enhanced version and the PDF version. So the PDF version does have an appendix, and within that appendix, there's a glossary, but there's also some downloadable forms. Some of the same ones you may see in the TA Enhanced, but there are some specific ones that were created specifically for this protocol. So things like the chain of custody, a sample chain of custody is there. The QAQI template is there. So there's multiple different things that are actually there within the PDF that you can download. But again, we'll talk about the TA Enhanced piece in a second. That does offer a little bit more. Any of the flowcharts that you see within the actual document are also a part of the PDF so that they're downloadable so that you can have them as a resource to print out if you wanted to put them in your office or your exam rooms. Hi, Angelita. I'm just going to jump in because there is a question in the Q&A. Does the protocol address evidence destruction, especially in IPV strangulation if evidence is collected and then the patient changes their mind in the exam room? Are there recommendations about whether it is appropriate for a nurse to destroy evidence? I realize jurisdictions may vary, but wondering if there's a general thought to this and if it's within a nurse's scope. Let's just start with that, Jen. So there is not a recommendation in the protocol related to evidence destruction. I can tell you that we have not tackled that particular aspect of it. And I, boy, that is a conversation that could take up, I feel like, an entire webinar in and of itself. So I would say that, like I said, we have not tackled it. There are different recommendations and certainly different ways in which jurisdictions have handled it. Angelita, do you, before we go any further, do you want to weigh in on this one? Yeah, I think that from the perspective of ISN, you know, when it comes to holding of evidence, and I understand that just specifically if the patient changes their mind, right, in the middle of the exam, if they're changing their mind, I think that maybe it may be a conversation that you would be having with the patient at that point about what they're thinking, right? Because the reality is, it's going to be their choice and their option. And if they're not going to report and they're telling you they no longer want the exam, that's something that we have to actually document in their chart. And I think that it's also going to be a conversation to have amongst your multidisciplinary team as to what they want to do in those instances because there's so many different layers to that. I don't want to go too far into it, but even in situations where people are collecting things and they're collecting evidence, in particular to IPV, because it's best practice maybe in their community, but their crime lab hasn't gotten to the point where they're actually testing it, right? So there's so many different layers to that. I think that would be a conversation for you to definitely have starting at the level of your multidisciplinary team to say what would they like to see happen. I understand we want to give the patient the option to be able to come back and change their mind if they choose to, but one of the things that also applies here is the best practice recommendations for evidence collection kits. I know that's specific to sexual assault kits, but it's still evidence in general and it's not recommended for healthcare to hold evidence in the first place. So I think I would take those things with you to your multidisciplinary team and have a good conversation about what that would look like for your community and then take that back to your facility, whoever the leadership team is in your facility, and then have further discussion on what your policy should be. Yeah, I guess I would also say there's a really big difference between exam programs that are storing kits and then you have a patient who has decided not to report like you have in the state of Michigan where Michigan is required to hold their own kits, right? If they're non-reporting, Michigan doesn't turn over their kits. Michigan holds their own and should then, if those patients don't report, should the nurses be responsible or should the healthcare facility be responsible for destroying that evidence? That's a different conversation, I think, than you're in mid-swab and the patient's like, never mind, I'm not interested in this anymore, I don't think I want this. Those are different scenarios, I think. And so I agree with Angelita, this is a much more nuanced conversation. And there are a lot of layers depending on whether or not law enforcement's ever going to pick it up if the patient doesn't want to cooperate with an investigation or whether or not there's someone who's going to, well, I'll just leave it at that. I think that it bears a lot more conversation at the community level and there's not a simple response for it. But I'm not a huge fan of healthcare facilities being responsible for destroying evidence, but I'm not sure that this particular, like, a patient changing their mind mid-exam rises to the level of that. So I think it's a much more nuanced conversation. But bottom line is, no, the protocol doesn't address it, but you do give me some things to think about for a different protocol that we're writing, and so thank you for that. Kaylin, we hope that somehow we address the answer somewhat a little bit for you. So I have another question that's come in who says their law enforcement has been giving them pushback on collection of forensic evidence on known offenders and refusing to pick up the evidence even when the patient has consented to the release. As this is not a state requirement to collect on IPV cases, what is the recommendation on known offenders in IPV cases when it's not sexual assault? I need to look at the question. So when it comes to sample collection, I mean, I think it depends on what the sample collection is, right? Are we talking about strangulation? Is that what we're talking about, where you're talking about actually touch DNA? Okay, thanks, Kaylin. So, you know, again, the question is, does your lab run touch DNA? If your lab's not going to run it, then, you know, there may not be any point to collecting it. You can potentially collect and hold it and document that it was collected. If you have a place to hold it, if you want to get in the business of that, and if somebody decides they know that it exists somewhere and someone wants to run it eventually should the case move forward, it's available. It's not going to go anywhere. I suppose that's a possibility. At the end of the day, obviously, a good medical forensic exam with all of the documentation, you know, is certainly incredibly useful in and of itself. I think, you know, you are constrained by the realities of your jurisdiction and what they are and are not willing to do. It may be a conversation for your multidisciplinary team, for the larger statewide conversations that I know take place in your particular state sometimes. But at the end of the day, the only thing you can do is document what you are willing potentially to do that you have done, potentially holding it, if you have the ability to store it, if that's a thing that you decide to do. But if you know that your crime lab is not going to run it, then there's no point in getting it, right? That's the challenge. So is it that your law enforcement won't pick it up, but your crime lab would run it, or that you're willing to do it, but nobody else wants to process it, if you don't mind me asking? Your lab will run it. Yeah, I mean, so certainly, I mean, so obviously that is a conversation either for your multidisciplinary team, since the lab is willing to, and maybe the lab gets involved in that conversation, especially if they would like to be able to have that evidence. And maybe you've already tried that, because I'm just spitballing here. But at the end of the day, the other question is whether or not you have prosecutors who are interested in having that evidence available, because maybe that's another thing that would be the tipping point. If your prosecutors are like, no, it wouldn't really be helpful to us, then that's that. So I think there are a couple of different ways that you could approach it. Okay, I'm thinking. Okay, I'm thinking that's it. Okay. And Caitlin, hit me up offline if there's more conversation you want to have with it. Okay, so now we're going to talk about the TA Enhanced version just a little bit more so you guys have a better understanding of what else is included. So, of course, this is going to be accessible across all devices. So, what I mean by that is regardless if you click into it on your computer or desktop or if you do a laptop or a tablet or a phone, the actual program will actually auto fit. So, you should still be able to actually utilize it the same exact way regardless of what electric device that you're on, electronic device you're utilizing. Once you're in there, you will notice that there is all these things and more. So, there's Interactive Table of Contents, there's Graphics and Content, there's Markowitz. Sorry, I'm so used to calling Jen Markowitz. We put in a lot of hours. There are sections that we consider the Read More section. So, I'll show you in a second, but in those sections, there's actually additional research literature that may be useful to you guys. A lot of us actually look for this stuff and can't figure out where to find it. So, that has actually been inserted into multiple sections. And then there's downloadable resources. So, in addition to what's already available to you through the PDF version, there's additional downloadable resources that you can access through the TA Enhanced. And then you already heard that there are example images for things such as injuries and also like sample images for photography section. So, here's an example of what I mean by the Interactive Table of Contents. You can collapse the Table of Contents if you wanted to have a fuller version of the protocol to look at, or you can uncollapse it just by hitting on the tab in the upper left-hand corner. There's multiple different types of interactive graphics throughout the whole entire protocol. So, we already talked about the Table of Contents. You can click through the Table of Contents without having to scroll. But within the actual document itself, there's different versions and different types. So, there's different areas where you can do a left-to-right screen scroll and go see the content from left to right. There's tab sections. And then there are pop-out sections where everything is listed where you would click on the plus or the minus to minimize or maximize the screen. There's diagrams such as this particular one. This one is under the health consequences. This you would be able to click on the different areas of the bodies to see exactly how IPV may actually affect the body in that particular area. This is the read more section that I talked about. So, these, all of the articles that are linked out to will send you to an actual link where you'll have more information about the article. I think that we link to sites where they were freely accessible articles. So, you'll be able to just go to that site to get through those articles. All of the actual links within the protocol, like if we're citing something, you could link, you could actually click on that citation to actually see what the full article is. You won't have access to the article, but you'll be able to have the citation for the article fully. All of those things are available. And then I talked about downloadable resources. So, here are a few examples. The actual glossary itself is downloadable. We created a resource list that can be used as a template for any clinician, any clinical setting, or really, you'll be able to pull the resources from your particular community and insert them and hang that somewhere or have it in a book somewhere that's accessible. There is a guide for interpretation services that's also inserted in here, along with many, many other downloadable resources. This is an example of our example. I say example way too many times there, but here are some example images. So, we talked about definitions for injury. Here are some of the examples where we have, we also have physical assessment images so that we give examples of things such as fatigue EI and what that would look like. When it comes to documentation, we have sample documentation forms, including body maps that are also included in the downloadable forms. So, how do you actually access the protocol? The PDF version and the interactive version are both available freely accessible on SafeTA. So, you go to SafeTA.org. This is the page that you will see initially to the right-hand column of the menu bar. You'll see that there is a protocols. Once you hover over that, you'll get the drop-down box. If you go to National IPV Protocol and click on that, you will then get this screen. So, once you're on this screen, if you want to download the PDF version of the protocol, you would click on to the download here and if you wanted to actually interact through the TA enhanced version, you would click on that screen and then it will take you into the actual interactive version of the protocol. So, before we jump into case scenarios, I just want to make sure that no questions have come up that we need to address or anything at this point. Okay. No other questions. Great. Jen, did you have anything else you wanted to say about that before we jump into this? Good. So, in this section, we just kind of wanted to be able to share a few case scenarios of what it could be like, what things look like before the IPV protocol and talk about how it could look differently if the IPV protocol was pretty much in existence. So, in this particular scenario, this patient is going to be presenting to a large ED within a hospital setting. So, there is a SANE team for this particular hospital, but that particular program does not provide a response for IPV patients. So, they strictly only see sexual assault patients. The patient is triaged in the normal ED, but they are put in a room where there's privacy and the patient is evaluated by the ED physician as well as the ED nursing staff. So, specifics about the patient. The patient is a 23-year-old African-American identified as female. She has a complaint of a headache and neck pain, and she discloses that she's had multiple episodes of IPV within the last 24 hours. She stated that the assault also included being slapped in the face and the head. She said that she was pushed and shook by her partner, by the shoulders, and that she was also strangled. So, in this particular scenario, the nurse had some concern about the strangulation piece of it and asked for a strangulation assessment. The physician refused to do an additional assessment, stating that there was no need for that. The physician also said that he was not going to order a head CT because there was no loss of consciousness and the patient wasn't actually punched in the head. He did give the patient medication for a mild headache. He medicated it with Tylenol and pretty much was ready to dismiss her. The nurse actually asked for social work to come in and speak with the patient related to IPV and to make sure there was safety planning in place, but the ED doc declined that. So, at discharge, the ED nurse actually provided the patient with some very IPV-specific resources, as well as information for a different ED, should she choose to go after this discharge because of her situation and to get further assessment by a forensic nurse. So, in this particular scenario, it would have been helpful for this nurse to be able to, if nothing else, because clearly this physician didn't feel like they wanted to hear their voice, be able to say, well, you know, there is a protocol in place that helps us to guide the care of this patient. So, we would have been able to bring the protocol in for this physician, especially the interactive version, to be able to point out some really quickly, some places that here's some best practice for this particular, here's why. So, this would have been a good opportunity to have the protocol in place for this particular patient. Okay. Here's a slightly, a slightly better case scenario in terms of patient outcomes, at least. So, we have a patient who presents to a hospital emergency department that does collaborate with an in-house forensic nursing program that responds to all types of interpersonal violence. And at triage, the patient reports that they're there because last night they got into a fight with their spouse, and their co-worker told them to go get checked out because they sounded bad. After the standard triage process, the patient is placed in one of the rooms used by the forensic nursing program. Since they're stable, the forensic nurse on duty is alerted that a patient, not a patent, a patient is waiting for the nurse, my typo. It's a 32-year-old patient, reports they are multiracial, presents with a raspy voice, a headache, and neck pain, discloses IPV about 15 to 18 hours prior, not the first incident, but the first incident for which they have sought treatment. The assault included punches to the side of the head and a strangulation assault without loss of consciousness. So, the forensic nurse discussed the patient's options for working with law enforcement, and the patient declined. A review of systems and history included negative for loss of consciousness, negative for vomiting and memory loss, about three beers last night before the assault, denies any painful swallowing or difficulty breathing. Head-to-toe exam was pretty unremarkable, so no neurological deficits, some tenderness with palpation, not surprisingly to the left side of the head, and also some tenderness to the anterior neck, a little bit of redness to the right side of the neck, and a little bit of pain moving that neck around, but no limitations, and otherwise looks pretty good. A consult with the emergency department physician to discuss imaging, and the imaging that was obtained was a non-contrast head CT that was actually ordered, and some pain management was addressed. So, documentation was completed by the forensic nurse and the consulting physicians, and photographs were obtained with the physician, with the patient's consent. Patient was discharged with instructions about strangulation, emergent signs and symptoms, and to return to the emergency department if any arise. Social work was present at the end of the exam to discuss safety planning, and connect the patient with local community advocacy program. The patient was unclear as to whether they would be returning home after discharge, and the forensic nurse reviewed accessing medical record and photographs with the patient should they need it in the future. So, all in all, a pretty decent response. There are certainly a few things here that could be potentially shored up, but overall, a fairly decent response. The question is, will that always be the response? It depends on if the forensic nurse is always available. Certainly, that response is predicated on the fact that you've got a well-educated forensic nurse. One of the things that we hope that a protocol provides is a level of consistency and response that we know that all patients deserve, and so I think that's one of the aims of creating protocols like this, making sure the patients don't lock into a quality, thorough, and consistent exam, depending on who's working that particular instance when they show up for whatever type of health care they're seeking. Great point. Totally agree. So, for the final scenario, pretty similar to the last scenario that we just heard, patient, again, is presenting to an ED setting. In this particular ED, they have a forensic nursing team that actually is in-house, so they're able to respond to all forms of interpersonal violence. The patient was triaged, and they disclosed that there was an altercation with the partner while riding in the car coming home from the bar just prior to coming to the ED, and the patient was placed in a private exam room, and the forensic nurse was notified that the patient would need consultation. The patient is a 28-year-old Caucasian identifying as female. She has a complaint of facial pain, braid around the right jaw, right wrist pain and swelling, oh, that should say right shoulder, another little typo, sorry for you guys, right shoulder pain and headache. Patient discloses that the IPV incident happened just prior to arrival and states that there have been other incidents, but this particular incident was the worst case yet. She states that she was assaulted, and it included slapping and grabbing of the jaws, being punched to the right side of the head and face, twisting of the right hand and right wrist, and then she was pulled from the car by her hair and pushed to the ground on the right shoulder and then dragged by her hair. The patient does consent to the medical forensic exam with photo documentation. The forensic nurse discusses options for reporting to law enforcement, but the patient does decline at the time of the exam. During the review of systems and the history, the patient denies any loss of consciousness, denies loss of memory, and denies strangulation. She states that she was out with her partner and had two drinks of vodka and cranberry juice prior to leaving the bar. During the car ride, they started arguing and her partner started hitting her in the head and punching her. During the head to toe exam, there was no neurological deficits. There was some pain, redness and swelling noticed to the right side of her head, her eye and her jaw. She had complaint of pain to the right jaw with opening her mouth and she had some alopecia noted to the right side of her scalp, some redness and some pain and palpation to the right side of her scalp as well. Linear abrasions were noted to the right shoulder, the right wrist and right hand were swollen and painful with limited range of motion to the wrist. The physician did order a head CT and facial and maxillary films were obtained. Films of the right hand and right wrist were obtained and that patient was medicated for pain once the head CT results were back. Ortho was consulted for the right risk due to a fracture. They did apply ice until ortho arrived and the patient also and also to the face for her facial pain and swelling. Safety planning was done for this patient by the forensic nurse. Patient recognized the infrequency of the patient recognized the increase in frequency of the severe and severity of her IPV incident with her partner and she stated that she did not feel safe returning home with her partner for that night. IPV specific resources were shared, IPV advocacy program referral was provided to the patient and the patient was admitted for 24-hour observation with the social work consult placed for the morning to address additional needs for shelter. Documentation was completed, photos were obtained and both the nurse, the physician and the consulting physician all documented appropriately in the chart and then also they also shared with the patient how to access medical records and photos if she needed them. So again a better outcome but I definitely have to reiterate exactly what Jen said. It really is about making sure that you understand how your facility is set up so if you have a forensic nursing team is that forensic nursing team 24-7 or not in this particular instance this program was 24-7 and they also had a staff on 24 hours a day so it was much easier for the patient to be seen by the forensic nurse right away. It's not set up that way in every single scenario. We had a good ED physician who was actually working really well and with the patient as well as the forensic nurse there was no pushback in this particular scenario. It would have been nice maybe to have social work be able to come but we all know that social work varies depending on where you're at so it's helpful that the forensic nurse had history or education on safety planning with the patient and making a plan for that night with the health care facility. Sometimes they're not able to do that but this was another situation where they were fortunate to be able to do that. So again thankfully another good outcome but always things that you can actually reach out to the actual protocol and see is there anything else we can do in this situation? Am I missing anything? Jen do you have any other thoughts on any of the scenarios? No. Okay let's see. So yep so at the end of the day this was really I think our driving sort of the the mantra behind everything that we really were doing with the protocol here and what I've already really alluded to when we were talking about my scenario which is that every patient experiencing IPV deserves access to a medical forensic examination right. Every clinician that has a concern for or disclosure from a patient who's experiencing IPV should have access to the needed resources to provide the appropriate care to their patients regardless of the clinical setting. So all of our scenarios were hospital-based but we tried to write this protocol in a way that would address a variety of scenarios whether it's you know a community clinic, whether it's campus-based, whether you know we really tried to think about the pre-hospital folks and obviously not everything would apply to pre-hospital but we really tried to think about those folks as well. So really thinking as expansively as possible about all of the places where our patients show up right and that's really what we want and how we wrote this protocol to be able to address those patients wherever they present. So that's what we hope will happen with this protocol. We hope that it will be helpful to clinicians wherever we work in all of the places where we work. So with that I will open up for any additional questions that you all may have if any. We are leaving space for that. Marnie while we wait to see if questions come did you have anything else that you wanted to say? Not that I can think of. Just again to thank you both for all of your work on this. I'm very happy with how this protocol turned out and I really hope that it will make a difference for victims. Thanks. Yeah I think that both Jen and I are really happy with it as well. I know that I I know that I consistently keep looking at it and sending people to it. Yeah well it doesn't look like we have any it doesn't look like we have any additional questions. Oh someone has a question about being forensic nurse. So I'm going to just share my contact slide with you guys. You feel free especially the person that put in how to become a forensic nurse you can reach out to me and I can definitely provide you with some information and some guidance on how to become a forensic nurse. CEs are being offered. Stephanie will be dropping the evaluation in the chat shortly and also it would also come to you once you close out of this webinar. And I don't think there's any other questions that I'm seeing. So if there are no other questions we'll be hanging around for a few more minutes but if there's no other questions then we just want to thank you guys for being here. Thank you all for your participation. Thank you for your time and if you have any feedback once you have an opportunity to actually go through the protocol and look at both versions please don't hesitate to send it our way. We're always interested in hearing people's thoughts about it or if you have any questions that come up after you reviewed it we would definitely be more than willing to address those things. Definitely thank you. Just as a reminder this was a product of our Safe TA project. I already directed you guys on how to get to Safe TA but if you have any additional questions or you need additional resources there are two ways that you can request TA assistance. If you go to SafeTA.org at the bottom of the right hand of the screen there's a little tab you can click on to submit a form or there's a telephone number that you can call. That telephone number is 1-877-879-7278 and you will have a forensic nurse to respond to you regardless which way you reach out to us. We do have upcoming webinars so here are the next two upcoming webinars for the month of September. We would love for you to join us for those webinars. You can go to SafeTA.org. You can either click on calendar events or at the top of the page on the webinars tab there is upcoming webinars you can click to register there as well. With that being said I just want to say thank you one more time to Jen and Marnie for being here and presenting with me today and for all the work that you've done to get this protocol up and going and continuing to do this with me as we get it out to the world. So thank you both for being here. Thank you.

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