Microsoft word - 1.1.doc

Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
Adult Sexual Assault Victims
General Information 1. Patients who are age 18 years or older are to be evaluated in the Adult Emergency 2. Patients age 17 years or less will be evaluated in the Pediatric ED. (See Policies and 3. Patients who are victims of sexual assault are a unique subset of ED patients. These patients present with a profound psychological injury often without outward evidence of physical injury. The health care team needs to manage both the medical and psychological components of the patient's injury with sensitivity and compassion. Identification of Sexual Assault Victims 1. Sexual assault should be evaluated and reported in all cases of sexual assault reported 2. Sexual assault should be considered in every case of unexplained oral, genital or 3. Sexual assault should be considered in every case of unexplained sexually 4. Sexual assault should be considered in incompetent patients (mentally ill or impaired) if history, physical findings or behavioral change suggest such assault has occurred. Notification of Law Enforcement 1. Notify County Police if the patient is not accompanied by a law enforcement officer. a. Harbor-UCLA County Police will contact the appropriate agency. b. Law enforcement need not be in the room during the physical exam unless the patient specifically requests that the law enforcement officer be present. The patient's privacy should be protected.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
Adult Sexual Assault Victims - continued
• Triage: All adult victims of sexual assault should be triaged immediately
(category 1) to the Department of Emergency Medicine (DEM). Patients should be interviewed in a private setting that is conducive to both • Medical Screening Examination (MSE): If emergency medical care is
requested by the patient, or if a request is made on the behalf of the patient, the patinet will receive a medical screening exam and appropriate treatment. • If the patient requests or agrees to an evidentiary examination: Harbor- Medical Center may refer patients reporting sexual assault within the past 96 hours to a local rape treatment and crisis facilty for an evidentiary examination by a nurse examiner. See attachment for contact information of local centers that perform sexual assault examination. Patients will also have access to rape counseling at these centers. a. If the patient arrives accompanied by law enforcement, law enforcement will directly contact the rape treatment facility. b. If the patient arrives unaccompanied by law enforcement, the DEM staff should determine the area where the crime occurred and contact County Police at x3311. County police should contact the law enforcement agency to come to the DEM. c. The patient should be discharged by the Emergency Physician after the MSE and is accompanied by law enforcement to the rape treatment facility. In this case, law enforcement will also contact the d. Should the patient choose to go to the rape treatment facility by private care, the Emergency Staff should contact the rape treatment facility and law enforcement should meet the patient at the Evidence collection:
a. If the patient chooses to have the evidentiary examination performed
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
at the rape treatment facility, the DEM staff should perform the MSE, limiting the physical examination and treatment to only that necessary for any emergency medical condition. The rape treatment facility i. The Rape Kit can be obtained from hospital County Police if the assault occurred in LA County. If the assault occurred outside LA County, local law enforcement should bring its ii. Avoid pelvic examinations unless the patient has a specific emergent complaint. The patient will receive a full culposcopic examination at the rape treatment facility. Multiple examinations are traumatic to the patient and can destroy evidence. iii. If the patient wishes to void prior to transport to the rape treatment facility, the urine and any toilet paper should be collected in a specimen container, labeled with the patient's name, date and time of collection and given to law enforcement to transport with the patient to the rape treatment facility. The patient should be advised NOT to clean her/himself prior to specimen collection. iv. Avoid oral medications if possible. Medication and oral fluids may interfere with or destroy evidence in the oral cavity. Antibiotic, anti-emetics and pregnancy prophylaxis will be provided at the rape treatment facility. If the patient is unstable for discharge and referral to the rape ii. Please contact the Forensic Nurse Specialist (FNS) at (562) 430-6220 if a patient requires admission. We are currently working on a contract to have the FNS come to our facility for iii. The evidentiary examination should be provided at Harbor- UCLA Medical Center by a licensed MD. Any evidence must be collected as outlined by the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
iv. Refer the patient to a rape treatment facility immediately when If the patient refuses transportation or referral to the rape treatment facility, but requests an evidentiary examination at Harbor-UCLA Medical Center: i. County Police and law enforcement should be contacted to provide the Rape Kit and form. The form may also be obtained online at http://www.oes.ca.gov/operational/ ii. Any evidence must be collected as outlined by the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims. See attachment X for instructions on iii. The patient should be encouraged to contact the rape treatment facility for specialized follow-up services. iv. Follow ACEP treatment guidelines for post-exposure prophylaxis for sexually transmitted diseases and pregnancy. If the patient refuses evidentiary examination at the rape treatment facility or Harbor-UCLA Medical Center, but requests medical i. The patient should be advised that the hospital and the physician are required by law to report the assault to law ii. If possible, allow law enforcement to speak with the patient iv. Refer the patient to the rape treatment facility for counseling. The patient should be advised that the hospital and the physician are required by law to report the assault to law enforcement. The patient should be advised that the MSE and the evidentiary examination will be performed at no cost.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
Attachment X Guidelines for Completing Sexual Assault Exam
Obtain Rape kit from Safety Police (LAPD kits only) or from the law enforcement agency bringing in the patient. If the sexual assault occurred within the last 24 hours and the patient has not changed his/her clothes or showered, please let the patient remove his/her clothing and place it in the paper bag provided. This is important so that the examiners sweat is not detected on the clothing, confusing testing of the clothing for ABO antigens. The patient should undress over a sheet of paper provided in the kit. The patient should be consented for the gathering of evidence and the exam before the exam proceeds. The patient must sign the OJCP form 923 in order to document that all of the procedures have been explained. Notwithstanding the gender of the examiner, a chaperon of the same gender as the patient should be present during the genital examination portion of the physical examination. Psychological Support If the patient presents between the hours of 8:00 am and 4:30 pm, notify Social Services that there is a victim of sexual assault in the department and they will send a representative to evaluate and provide emotional support to the patient. (Social Services, pager # (310) 501-0316) 1b. These centers are prepared to receive referrals from Harbor-UCLA Medical Center for outpatient counseling 24 hours a day. (iii) Santa Monica Rape Treatment Center A psychiatric consult may be obtained if it is indicated. Female Sexual Assault Victim Protocol
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
An OB/Gyn resident, Family Practice or an Emergency Medicine resident with a California license may evaluate the patient who is a victim of sexual assault. 1. The history should be taken in detail as can be provided by the patient. a. Document who, what, where, last menstrual period, birth control method used, last voluntary intercourse, if the patient has changed her clothes, douched, or showered, allergies, past medical history and history of previous sexual assault. 2. The physical exam should be complete. Bruising, hematomas, fractures, unusual markings and other physical findings should be recorded. b. Pregnancy test as a minimum. c. Other laboratories or X-rays should be obtained as indicated from the history and physical d. Routine HIV testing from the ED is not recommended. (Attending approval e. Obtain at least 30ml of urine in urine collection container for toxicologic studies by the crime lab. Label the container with patient's name, name of hospital, patient identification number, date and time of evidence collection, name and signature of person collecting the evidence, law enforcement agency name and file number if available, place in plastic bag and give to responding officer. 3. Scheduled follow-up should be arranged with the OB/Gyn or Family Medicine Clinics or with one of the rape crisis centers listed above. 4. Offer treatment for venereal disease and a drug regimen for pregnancy prevention (oral norgestrel and ethinyl estradiol tablets (Ovral), 2 tablets initially and 2 tablets 12 hours later). If the patient has had recent voluntary sexual intercourse there is a very small risk of pregnancy not detected by the pregnancy test. If the patient desires pregnancy prophylaxis, risks to fetus of therapy with Ovral should be explained to the patient. 5. Provide numbers of local rape hotlines and support groups (See above). 6. Be compassionate and supportive to the patient.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05

1.1 Adult Sexual Assault Victims - continued
Male Sexual Assault Victim
1. Escort the patient to a room and notify the charge nurse, the senior resident or the
attending physician on duty if no room is available. Patients should be assured that they are safe and if at all possible the evaluation should take place in a private area of the emergency department. 2. The history should be taken in detail as can be provided by the patient. a. Document who, what, where of the incident, if the patient has changed his clothes or showered, allergies, past medical history and history of previous sexual assault. 3. The physical exam should be complete. a. Bruising, hematomas, fractures, unusual markings and other physical findings b. Other laboratories or X-rays should be obtained as indicated from the history and c. Routine HIV testing from the ED is not recommended but should be obtained on d. Obtain at least 30ml of urine in urine collection container for toxicologic studies by the crime lab. Label the container with patient's name, name of hospital, patient identification number, date and time of evidence collection, name and signature of person collecting the evidence, law enforcement agency name and file number if available, place in plastic bag and give to responding officer. 4. Offer antibiotic prophylaxis for the prevention of sexually transmitted disease. 5. A referral to Family Medicine, General Medicine or Coastal Cluster Clinics (eg., Long Beach Comprehensive) can be made in six weeks for VDRL and medical evaluation. 6. Contact Social Services for additional support to the patient. (See Care Plan for Adult 7. Be compassionate and supportive to the patient.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
ADULT EMERGENCY DEPARTMENT
CARE PLAN FOR ADULT SEXUAL ASSAULT PATIENTS
WHO REFUSE EVIDENTIARY EXAM AT RAPE TREATMENT FACILITY
BUT REQUEST EXAM AT HARBOR-UCLA MEDICAL CENTER
Triage all adult patients who have been sexually assaulted within past 72 hours as "1" and those assaulted greater than 72 hours ago as "2". Bring patient (and police) to Family Room in Adult ED. Notify Charge RN in the Adult ED. List on patient board as "SA." Charge Nurse will: Assign specific nurse (trained in rape exams) to patient Have clerk order entry Social Service consult on HIS. Obtain sexual assault exam kit from Police or County Police and give to assigned nurse. (In the future, a Sexual Assault Nurse Examiner (S.A.N.E.) will be notified at this point to come in and complete evaluation if the patient is not stable for Administrative R3 will assign a licensed resident to perform sexual assault examination within 30 minutes of patient arrival in the Adult ED. DEM Attending will be notified if evaluation is not initiated within 60 minutes of patient's arrival. Assigned nurse will: Provide comfort measures for the patient (eg, water, tissue, phone).
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
Determine if patient wishes to have sexual assault volunteer present. If yes, call: Rape Hotline of Long Beach (Long Beach area): (562) 597-2002 YMCA Sexual Assault Crisis program (Compton area): (310) 764-1403 or (310) 764-1404 Rose Parks Sexual Assault Crisis Center (LA area): (213) 295-4673. Complete page one of OES (Office of Emergency Services) form. Make 20 stamped labels for specimens and prepare for the examination. While wearing gloves, collect the sexual assault patient's clothes, place them in a paper bag, label the bag, and hand them to the police. Document. Inform the resident that the patient is ready for examination. Promptly perform the examination after being informed by the RN that the patient is ready. Verify history if not initially taken by themselves. Complete examination as outlined on OES pages 4-7. Document examination findings on pages 4-7 of OES while in exam room. Complete bottom parts of page 5 (findings, summary findings, and physical examiner) while in exam room. Sign bottom of page 8. Give completed OES to RN. Discuss blood and urine tests, risk of sexually transmitted diseases. Offer option for birth control and STD prophylaxis. As appropriate, order two Ovral po now and two (to go) in 12 hours.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
Order 10mg compazine po prior to exam and one hour before STD prophylaxis given. (Ceftriaxone 125mg IM) + (Metronidazole 2gm po) + (Azithromycin 1gm po or doxycycline 100mg po). Assist resident step by step in examination. Label all specimens collected by resident and place in dry box. Place dry box next to police officer (?Family Room) where all specimens obtained will be drying for 60 minutes. Obtain 30 mL for urine toxicology. Give to police officer (document). Complete page 8 of OES documenting specimens obtained, evidence to crime lab, exam information, and personnel involved. Remove yellow copies of OES; keep for our hospital records. Give completed OES forms to police (not yellow copies). Document. Obtain prepackaged Ovral (2), record lot number on nursing flow sheet, and give to MD. Obtain from RN prepackaged Ovral to go (if patient requested). Give patient prepackaged Ovral to take in 12 hours. Warn risk nausea. Ask patient if they have any questions before leaving the room. Inform the patient that the nurse will give them their final discharge instructions. Complete ED 253 documenting overall examination (refer to the OES for specifics of sexual assault examination). Complete discharge plans on 253 including "return prn, give patient referral to community resources." Refer all patients to Gyn for 2 week follow-up.
Effective: 3/78
1.0 ABUSE Revised: 3/99, 1/05

Last Reviewed: 1/05
Complete discharge instruction forms (using completed 253). Discuss discharge plans with patient, explain side effects of Azithromycin and Ovral (if given), and give community resource sheet(s). Discharge patient. Inform police we have completed the examination. Hand completed nurse assessment sheets, yellow copy OES, and completed 253 into clerk.

Source: http://www.emedharbor.edu/private/policy%20and%20procedure/DEMPP1.1.pdf