Harbor:Sexual assault

Revision as of 22:41, 7 August 2020 by Jfang (talk | contribs) (Added disposition except follow up and prescriptions)

Quick Links

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.
    • Police are responsible for bringing patients to SART center, but may not bring patient home afterwards. Consult social work if patient has transportation needs.
  • 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

Follow Harbor's pediatric-specific protocol: http://pemsource.org/wp-content/uploads/2017/09/Suspected-Child-Abuse-and-Neglect.pdf

  • 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

Disposition

  • If patient being admitted, police to call SART center to send a sexual assault nurse examiner (SANE) to perform forensic exam at the hospital
  • If patient stable for discharge, police to bring patient to closest SART center (San Pedro) AND bring 1) paper bag of patient's belongings and 2) labeled dirty catch urine sample
    • 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 provide post-SART transporation 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)

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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