Harbor:Sexual assault

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

  • 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.
    • 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).
  • 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.
  • 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.
    • Age of victim: SART will examine any age victim, however, there is a separate process for Pediatric patients at Harbor-UCLA Medical Center.

Forensics Logistics

  • 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.
  • In addition to the instructions found on the Sexual assault page, the San Pedro SART has the following policies to preserve forensic evidence
    • Place patient's clothes and belongings into a paper back (NOT the usual plastic patient belongings bags)
    • 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)
    • 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.
    • Specimens that PD will take to SART center with the patient
      • Dirty catch urine. Label specimen cup with patient's name, time of collection, and who collected

ED Consults

  • 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.
  • 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 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

  • 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

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 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).
    • 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.
  • 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

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