Harbor:Sexual assault: Difference between revisions
(Updated protocol (except peds section))
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==Background==
==Background==
*See [[Sexual assault]] for general evaluation and management details. Details below are Harbor-specific.
*See [[Sexual assault]] for medical management details. Details below are Harbor-specific processes.
*Harbor non-occupational HIV PEP protocol https://www.wikem.org/wiki/Harbor:Non-Occupational_Exposure
*Harbor non-occupational HIV PEP protocol https://www.wikem.org/wiki/Harbor:Non-Occupational_Exposure
*Harbor SART Protocol https://www.wikem.org/wiki/File:SART_ED_Protocol_Recommendations.pdf
*Harbor SART Protocol https://www.wikem.org/wiki/File:SART_ED_Protocol_Recommendations.pdf
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==Management==
==Management==
*If a survivor presents without law enforcement reporting a sexual assault, perform a medical screening examination according to our hospital's policy and stabilize any injuries or attendant medical conditions.
Treat the patient's medical conditions first (may have traumatic injuries)
**Contact the Harbor-UCLA Sheriff’s Department to notify them of the assault so that they may notify law enforcement WHERE the crime occurred. Please note, LA county Sheriff’s Department and PD may make a courtesy report on behalf of other counties in order to prevent delay in law enforcement arrival and time to SART center. Once a law enforcement officer arrives and authorized a forensic evidentiary examination, instruct the law enforcement officer to make two phone calls.
**(1)- Forensic Nurse Specialist (SART, available 24/7): (562) 497-0147
**(2) - Sexual Assault Hotline at SACA (Sexual Assault Crisis Agency): (562) 989-5900


*The Forensic Nurse Specialist and advocate are ON CALL and must be notified directly by law enforcement. The officer can then discuss ETA to SART in San Pedro (or other closest SART).
===Forensic Evidence Preservation===
The patient may want a forensic exam (to be performed at the SART Center), and providers need to help patients preserve evidence.


*Prior to referral to the San Pedro SART, the patient must be medically cleared and all emergency medical conditions stabilized. The patient should then be discharged from the ED. The police or family can then transport the victim to the SART for forensic evaluation.
*Counsel patient and nursing NOT to wash up, including not washing hands
*Place patient's clothes and belongings in a PAPER bag, NOT the usual plastic bag
**Plastic traps heat and moisture that can degrade evidence
*Collect a DIRTY CATCH urine. Label specimen cup with patient's name, time of collection, and who collected. This specimen will go with the patient to the SART Center for evidence collection
*If the patient has had oral trauma within the past 6 hours, order "NPO no exceptions" (no medications, no ice chips or swabs, no rinsing mouth)


*This is NOT considered an inter-facility transfer under EMTALA since the patient has been discharged from the ED and is being transported as a private re-conveyance. Sexual assault evidentiary examinations are NOT part of medical care or stabilization. They are strictly intended to assist law enforcement in their efforts to prosecute perpetrators of sexual violence.
===Medical Management===
*Order the appropriate labs (see [[Sexual assault]])
**Baseline HIV and other labs will be required if patient meets criteria for HIV post-exposure prophylaxis
*Order the appropriate prophylactic antibiotics, vaccines, and emergency contraceptives (see [[Sexual assault]])


**Age of victim: SART will examine any age victim, however, there is a separate process for Pediatric patients at Harbor-UCLA Medical Center.  
====HIV Post-Exposure Prophylaxis (PEP)====
See [[HIV post-exposure prophylaxis]] for more details
*Order rapid HIV test. If test is positive, consult HIV. If test is negative, HIV does not want to be consulted.
*Indicated if <= 72 hours since exposure AND
**Assailant HIV positive
**Assailant HIV status unknown but patient's mucous membranes or non-intact skin was exposed to blood, semen, vaginal secretions, or bloody body fluids
*In the ED, if the patient is not NPO for the forensic exam, give 1 dose of Truvada and raltegravir ASAP
**Write "HIV post-exposure prophylaxis per CDC guidelines" in the comments so you do not need HIV approval to give the medication
**If patient has renal dysfunction, consult HIV for medication recommendations
*If patient is being discharged, prescribe 2 weeks of Truvada 1 tab PO QDay AND raltegravir 400mg PO BID
**HIV PEP is a 4-week course, but only prescribe a 2 week supply because patients need a lab check at the 2 week mark to determine which medications to continue.
**If patient is DHS eligible, send the prescription to the hospital pharmacy
**If patient is OOP, send the prescription to '''Bella Vida Pharmacy''' NOT the patient's "preferred" pharmacy.
***Most pharmacies do not have HIV medications readily in stock, and the medications could take a week to arrive. HIV PEP is time-sensitive, so they cannot wait that long.
*Follow up for 2 week labs and second prescription
**If DHS eligible, CCC patient for follow up or advise patient to return to UCC or ED if unable to get appointment
**If OOP, either with their PMD or any PEP Center in LA http://getprepla.com/pep/get-pep-now/
*DHS Expected Practice for Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents age ≥13 File:Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents Expected Practice.pdf


===Forensics Logistics===
===Consults===
*If a patient wants a forensic exam or evidence to be collected, please treat the patient medically first, and if otherwise medically clear, keep in mind the following recommendations.
*Hospital sheriffs (MD/DO or RN to call) - physicians, nurses, SW are all mandated reporters by state law
*In addition to the instructions found on the [[Sexual assault]] page, the San Pedro SART has the following policies to preserve forensic evidence
**Within 15 minutes of call, hospital sheriffs will speak to patient to determine appropriate jurisdiction (where the crime occurred) and contact local police
**Place patient's clothes and belongings into a paper back (NOT the usual plastic patient belongings bags)
**Within 30 min to 1 hr of call, police from jurisdiction where assault occurred to come speak to patient
**If patient has had oral trauma within past 6 hours, place patient on strict NPO (no medications, no ice chips or swabs, no rinsing mouth)
***Police from jurisdiction need to close the loop with ED provider regarding disposition plan
**Have nursing call hospital sheriffs. The hospital sheriffs will coordinate to find the correct police department that needs to be contacted to file a report. The hospital sheriffs will not take a report.
***Sheriffs are liaison to outside PD if any issues. If any disagreements, make sure watch commander is involved.
**Specimens that PD will take to SART center with the patient
**Police are responsible for calling the local SART center (has a nurse on call 24/7). Harbor's local SARTs are all reachable at 562-497-0147
***Dirty catch urine. Label specimen cup with patient's name, time of collection, and who collected
***If patient to be discharged, police are responsible for transporting patient to the closest SART center (San Pedro). Give police the paper bag with the patient's belongings and the labeled dirty catch urine sample to bring to the SART center. This is NOT considered an inter-facility transfer under EMTALA since the patient has been discharged from the ED.
 
***Police will bring patient's to the SART, but will not always provide transportation home. '''ASK''' police whether they will provide patients transportation after the SART center. If they do not and the patient does not have the means to call a rideshare or have someone pick them up, consult social work (daytime hours) or ED registration (night time) for a TAP card (bus)
===ED Consults===
***If patient to be admitted, police will call SART center to send a sexual assault nurse examiner (SANE) to perform the forensic exam at the hospital
*Consult to Social Work
*Consult to Social Work
**Also speak to social work about arranging a ride home for the patient. Police will bring patient to the SART center, but some patients have no way to get home from the SART center.
**If the patient does not have transportation home after leaving the SART center, SW can provide the patient with a TAP card during daytime hours. ED registration provides TAP cards after hours.
*Consult to Violence Intervention Team
*Consult to Violence Intervention Team
*If patient meets criteria for [[HIV post-exposure prophylaxis]], give first dose in ED. See below for details. (No longer need to call HIV consult)
*HIV team should not be consulted unless the patient is confirmed positive for HIV or patient cannot take Truvada/raltegravir and needs different medication recommendations
 
===HIV post-exposure prophylaxis===
*Indicated if:
**An exposure occurs to blood, semen, vaginal secretions, rectal secretions, breast milk—or any body fluid visibly contaminated with blood—with non-intact skin, mucosal surface (e.g. vagina, rectum, eye, or mouth) or via percutaneous contact (e.g. by contaminated or shared needle) AND
**The source is known to be HIV+ or is of unknown HIV status AND
**The exposure occurred ≤ 72 hours prior to presentation
**DHS Expected Practice for Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents age ≥13 File:Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents Expected Practice.pdf
 
*If see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional CBC, BMP, LFTs, Hep screen (Hep A IgG, Hep B sAg, sAb, cAb, and Hep C Ab),  needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV, or the National Clinical Consultations Center’s PEPline at (888) 448-4911
*Sexual assault victims that meet criteria should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI testing and prophylaxis.
**First dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's 48 hours of medications to go home with to tie them over until they can get the 28d course needed from a PEP center.
*Can consider offering Plan B contraception if patient is not NPO for evidence collection.
**If not going to SART center:
***STI testing includes: RPR, Chlamydia (CT) and Gonorrhea (GC) Nucleic Acid Amplification Testing (NAAT) testing (urine, pharyngeal, and rectal, or based on site of exposure)
***Give STI prophylaxis: Ceftriaxone 250 mg IM in single dose PLUS azithromycin 1 gram PO in a single dose, PLUS metronidazole 2gm PO in single dose
*For the patient that seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center http://getprepla.com/PEP/Get-PEP-Now/ to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center.  The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure.  Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).


===Pediatric-Specific Modifications===
===Pediatric-Specific Modifications===
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**Pubertal patients will go to SART center after medical evaluation complete, but SCAN team can follow up with patient
**Pubertal patients will go to SART center after medical evaluation complete, but SCAN team can follow up with patient
*Speak to social work about calling DCFS
*Speak to social work about calling DCFS
*SART will examine any age victim, however, there is a separate process for Pediatric patients at Harbor-UCLA Medical Center


===Frequently Asked Questions===
===Frequently Asked Questions===
*What if my patient does not want law enforcement involved or the police decide not to pursue an evidentiary examination?
*What if my patient does not want law enforcement involved or the police decide not to pursue an evidentiary examination?
**If a patient presents to your healthcare facility without law enforcement and discloses at some point that she has been a victim of sexual assault and that she is seeking medical treatment because of that crime, the medical professional IS REQUIRED BY LAW to report this to the appropriate law enforcement agency (Penal Code 11160 & 1162).
**If a patient presents to your healthcare facility without law enforcement and discloses at some point that he/she has been a victim of sexual assault and is seeking medical treatment because of that crime, the medical professional IS REQUIRED BY LAW to report this to the appropriate law enforcement agency (Penal Code 11160 & 1162).
**The patient ALWAYS has the choice to cooperate with the police in giving crime information or simply refuse to cooperate in reporting the crime. Of note, if the patient does not want to report a crime to law enforcement, they are still encouraged to have a SART examination performed and are legally allowed to be privately transferred to SART center for evidence collection.
**The patient ALWAYS has the choice to cooperate with the police in giving crime information or simply refuse to cooperate in reporting the crime. Of note, if the patient does not want to report a crime to law enforcement, they are still encouraged to have a SART examination performed and are legally allowed to be privately transferred to SART center for evidence collection.
**In these cases, it is best to call the on-call forensic nurse specialist on your Spectra or other mobile device, so that they may speak directly with the patient to help coordinate the evidentiary examination.
**In these cases, it is best to call the on-call forensic nurse specialist (SART number 562-497-0147) on your Spectra or other mobile device, so that they may speak directly with the patient to help coordinate the evidentiary examination.
 
*What if my patient requires admission?
** Contact the on-call forensic nurse specialist immediately to coordinate an evidentiary examination on any admitted patient.
 
==Disposition==
*PD from jurisdiction where assault occurred will take patient to SART center
*See "Consult to Social Work" above to arrange a ride home for the patient
*If patient receives HIV PEP, provide a 2 week supply of medications and patient needs follow up appointment in 2 weeks


==See Also==
==See Also==

Revision as of 22:29, 7 August 2020

Background

Coming Soon

  • Sexual assault order set in Orchid for all the medications, labs, consults, communication orders
  • Working on policy with pharmacy for giving NPO patients their prophylactic medications to-go to take at SART center after forensic exam

Management

Treat the patient's medical conditions first (may have traumatic injuries)

Forensic Evidence Preservation

The patient may want a forensic exam (to be performed at the SART Center), and providers need to help patients preserve evidence.

  • Counsel patient and nursing NOT to wash up, including not washing hands
  • Place patient's clothes and belongings in a PAPER bag, NOT the usual plastic bag
    • Plastic traps heat and moisture that can degrade evidence
  • Collect a DIRTY CATCH urine. Label specimen cup with patient's name, time of collection, and who collected. This specimen will go with the patient to the SART Center for evidence collection
  • If the patient has had oral trauma within the past 6 hours, order "NPO no exceptions" (no medications, no ice chips or swabs, no rinsing mouth)

Medical Management

  • Order the appropriate labs (see Sexual assault)
    • Baseline HIV and other labs will be required if patient meets criteria for HIV post-exposure prophylaxis
  • Order the appropriate prophylactic antibiotics, vaccines, and emergency contraceptives (see Sexual assault)

HIV Post-Exposure Prophylaxis (PEP)

See HIV post-exposure prophylaxis for more details

  • Order rapid HIV test. If test is positive, consult HIV. If test is negative, HIV does not want to be consulted.
  • Indicated if <= 72 hours since exposure AND
    • Assailant HIV positive
    • Assailant HIV status unknown but patient's mucous membranes or non-intact skin was exposed to blood, semen, vaginal secretions, or bloody body fluids
  • In the ED, if the patient is not NPO for the forensic exam, give 1 dose of Truvada and raltegravir ASAP
    • Write "HIV post-exposure prophylaxis per CDC guidelines" in the comments so you do not need HIV approval to give the medication
    • If patient has renal dysfunction, consult HIV for medication recommendations
  • If patient is being discharged, prescribe 2 weeks of Truvada 1 tab PO QDay AND raltegravir 400mg PO BID
    • HIV PEP is a 4-week course, but only prescribe a 2 week supply because patients need a lab check at the 2 week mark to determine which medications to continue.
    • If patient is DHS eligible, send the prescription to the hospital pharmacy
    • If patient is OOP, send the prescription to Bella Vida Pharmacy NOT the patient's "preferred" pharmacy.
      • Most pharmacies do not have HIV medications readily in stock, and the medications could take a week to arrive. HIV PEP is time-sensitive, so they cannot wait that long.
  • Follow up for 2 week labs and second prescription
    • If DHS eligible, CCC patient for follow up or advise patient to return to UCC or ED if unable to get appointment
    • If OOP, either with their PMD or any PEP Center in LA http://getprepla.com/pep/get-pep-now/
  • DHS Expected Practice for Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents age ≥13 File:Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents Expected Practice.pdf

Consults

  • Hospital sheriffs (MD/DO or RN to call) - physicians, nurses, SW are all mandated reporters by state law
    • Within 15 minutes of call, hospital sheriffs will speak to patient to determine appropriate jurisdiction (where the crime occurred) and contact local police
    • Within 30 min to 1 hr of call, police from jurisdiction where assault occurred to come speak to patient
      • Police from jurisdiction need to close the loop with ED provider regarding disposition plan
      • Sheriffs are liaison to outside PD if any issues. If any disagreements, make sure watch commander is involved.
    • Police are responsible for calling the local SART center (has a nurse on call 24/7). Harbor's local SARTs are all reachable at 562-497-0147
      • If patient to be discharged, police are responsible for transporting patient to the closest SART center (San Pedro). Give police the paper bag with the patient's belongings and the labeled dirty catch urine sample to bring to the SART center. This is NOT considered an inter-facility transfer under EMTALA since the patient has been discharged from the ED.
      • Police will bring patient's to the SART, but will not always provide transportation home. ASK police whether they will provide patients transportation after the SART center. If they do not and the patient does not have the means to call a rideshare or have someone pick them up, consult social work (daytime hours) or ED registration (night time) for a TAP card (bus)
      • If patient to be admitted, police will call SART center to send a sexual assault nurse examiner (SANE) to perform the forensic exam at the hospital
  • Consult to Social Work
    • If the patient does not have transportation home after leaving the SART center, SW can provide the patient with a TAP card during daytime hours. ED registration provides TAP cards after hours.
  • Consult to Violence Intervention Team
  • HIV team should not be consulted unless the patient is confirmed positive for HIV or patient cannot take Truvada/raltegravir and needs different medication recommendations

Pediatric-Specific Modifications

  • Consult SCAN team
    • Pubertal patients will go to SART center after medical evaluation complete, but SCAN team can follow up with patient
  • Speak to social work about calling DCFS
  • SART will examine any age victim, however, there is a separate process for Pediatric patients at Harbor-UCLA Medical Center

Frequently Asked Questions

  • What if my patient does not want law enforcement involved or the police decide not to pursue an evidentiary examination?
    • If a patient presents to your healthcare facility without law enforcement and discloses at some point that he/she has been a victim of sexual assault and is seeking medical treatment because of that crime, the medical professional IS REQUIRED BY LAW to report this to the appropriate law enforcement agency (Penal Code 11160 & 1162).
    • The patient ALWAYS has the choice to cooperate with the police in giving crime information or simply refuse to cooperate in reporting the crime. Of note, if the patient does not want to report a crime to law enforcement, they are still encouraged to have a SART examination performed and are legally allowed to be privately transferred to SART center for evidence collection.
    • In these cases, it is best to call the on-call forensic nurse specialist (SART number 562-497-0147) on your Spectra or other mobile device, so that they may speak directly with the patient to help coordinate the evidentiary examination.

See Also

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