Harbor:Sexual assault

Get SART exam approval

  • Call Harbor Sheriffs
  • Harbor Sheriffs will contact outside Law Enforcement Agency with jurisdiction
  • Law enforcement with jurisdiction will come to Harbor to interview patient and then call:
    • (1)- Forensic Nurse Specialist (SART, available 24/7): (562) 497-0147
    • (2) - Sexual Assault Hotline at SACA (Sexual Assault Crisis Agency): (562) 989-5900
  • Stabilize patient while preserving evidence, and offer STI and HIV prophylaxis below if indicated
  • If patient not stable to be discharged to SART center then inform Law Enforcement Agency to have on-call Sexual Assault Nurse Examiner come to Harbor

Quick Links

Cerner Ordersets

  • Sexual assault order set for Adult and Pediatric in Orchid for all the medications, labs, consults, communication orders

Management

Treat the patient's medical conditions first (may have traumatic injuries), offering prophylactic treatments, while doing your best to preserve any evidence (see below).

Triage Time-Sensitive Actions

  • See Forensic Evidence Preservation section below and counsel patient about each item
  • Order time-sensitive medications if patient does not need to be on strict NPO
  • Consider asking charge nurse to room patient sooner so that the patient does not fall outside the time window for
    • Within 6 hours: If patient had oral trauma within past 6 hours, patient needs be examined/treated by provider, seen by law enforcement, AND get to SART in that time frame for a forensic exam. Must be strict NPO (cannot take oral medications either).
    • Within 72 hours: HIV post-exposure prophylaxis (see HIV PEP section below)
    • Within 120 hours: ulipristal 30 mg PO x1 emergency contraception

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/
  • 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
    • If the sheriffs come in with the patient, they are the ones that handle the SART.

We called dispatch and they kept sending random sheriffs until we figured this out hahaha

    • 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, and Trauma Recovery Center
  • 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)

Prescriptions

  • If patient is NPO for forensic exam, prescribe the following medications. SART is able to give these medications also, but patients sometimes decide not to go while en route and should have the option to still access the medications if they change their mind.
  • Azithromycin 1g PO x1
  • Metronidazole 2g PO x1
  • levonorgestrel 1.5mg PO x1
  • If patient if NPO for the forensic exam AND meets criteria for HIV PEP as above, per protocol as approved by pharmacy and Dr. Bolaris:
    • Prescribe a 2 day supply of Truvada 1 tab PO QDay and raltegravir 400mg PO BID to the Harbor Outpatient Pharmacy, print a paper copy of this prescription and give it to the ED pharmacist who will get the medications to-go for the patient.
      • HIV PEP should be taken ASAP, so as soon as the patient is finished with their forensic exam, they should take the medication. The 2 day supply gives them time to get to the pharmacy and they should be counseled that they must take the full 4 week course.
      • Pharmacy will reconcile the inpatient meds dispensed using an outpatient prescription later.
    • Prescribe the remaining 12 day supply to the Harbor pharmacy (DHS patients) or Bella Vida Pharmacy (OOP patients) NOT their preferred pharmacy (do not readily have HIV medications in stock)

Follow up

  • Follow up with PMD (CCC patient or provide Harbor empanelment information if appropriate)
  • If patient is receiving HIV PEP and does not have a PMD for their 2 week lab check and prescription refill
    • DHS eligible: CCC patient and advise to return to urgent care if no appointment OR give PEP clinic list
    • OOP: give PEP clinic list
  • PEP clinics: http://getprepla.com/pep/get-pep-now/

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.

SART Centers

Antelope Valley Hospital
1600 West Avenue J
Lancaster, CA 93534
(661) 949 5000
Citrus Valley Medical Center-Queen of the Valley
1115 S. Sunset Avenue
West Covina, CA 91790
(626) 962 4011
Community Hospital of Long Beach
1720 Termino Avenue
Long Beach, CA 90804
(562) 498 1000
LAC+USC Medical Center
1200 North State Street
Los Angeles, CA 90033
(323) 409 1000
Pomona Valley Medical Center
1798 North Garey Avenue
Pomona, CA 91767
(909) 865 9500
Presbyterian Intercommunity Hospital
12401 E. Washington Boulevard
Whittier, CA 90602
(562) 698 0811
Providence Little Company of Mary-San Pedro Hospital
1300 West 7th Street
San Pedro, CA 90732
(310) 832 3311
San Gabriel Valley Medical Center
438 W. Las Tunas Drive
San Gabriel, CA 91776
(626) 289 5454
Santa Monica-UCLA Medical Center
1250 16th Street
Santa Monica, CA 90404
(310)3194503(day)(310)3194000(after hrs)

II. Approved for Law Enforcement transport ONLY:

Northridge Hospital: Center for Assault Treatment Services
14531 Gault Street
Van Nuys, CA 91405
(818) 908 8632
Providence Little Company of Mary-Women’s Wellness Center
20911 Earl Street, Suite 440
Torrance, CA 90503
(310) 542 0455

III. Approved for Department of Children and Family Services ONLY:

LAC Harbor-UCLA
Medical Center
1000 W. Carson Street
Torrance, CA 90502
LAC Martin Luther King, MACC
12021 S. Wilmington Avenue, Acute Building 5034
Los Angeles, CA 90059
(310) 668 4321
LAC Olive View-UCLA Medical Center
14445 Olive View Drive
Sylmar, CA 91342
(818) 364 3205
LAC+USC
Medical Center
1200 North State Street
Los Angeles, CA 90033
(323) 409 1000

RAPE CRISIS CENTERS

Peace over Violence
1015 Wilshire Blvd, suite 200, Los Angeles, CA 90017
213 955 9090
Center for the Pacific Asian Family
543 N. Fairfax Ave, suite 108, Los Angeles, CA 90036
323 653 4045
YWCA of Greater LA Sexual Assault Crisis Program
1020 S. Olive Street, suite 700, Los Angeles, CA 90221
213 365 2991
East Los Angeles Women's Center
1255 S. Atlantic Blvd, Los Angeles, CA 90022
323 526 5819
Valley Trauma Center
14653 Gault Street, Van Nuys, CA 91405
818 787 9700
Family Crisis Center:
Los Angeles 213 745 6434
South Bay 310 370 5902
Long Beach 562 388 7652

RAPE HOTLINES

  • National Sexual Assault Hotline: 800 656 HOPE (4673) or visit www.rainn.org
  • Domestic Violence Safety Plan Hotline: 800 978 3600
  • Rainbow Services Hotline (South Bay shelter): 310 547 9343
  • Project Sister Hotline (Claremont) 909 626 4357
  • LA Commission for Assaults against Women: counselor Los Angeles: 213 626 3393, South Bay 310 392 8381
  • Center for Pacific Asian Family (Asian Languages): 323 653 4045
  • Central Los Angeles (TDD): 213 626 3393
  • Los Angeles (TDD): 310 392 8381

See Also

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