Ed_rtc_treatment_protocol_revised_6_09

Sexual Assault Guidelines
SFGH Emergency Department
Physicians, Residents, Nurse Practitioners, and Physician Assistants

When a Trauma Recovery / Rape Treatment Center (TRC/RTC) medical provider is unavailable the
following is offered as a guideline in the care of sexual assault clients.
Upon arrival, determine whether patient is interested in making a police report and having forensic evidence
collected. Evidence is collected up to 72 hours post assault. Do not assume a patient arriving with police wants
the police involved.
Please page the RTC backup administrator and relay the patient's name and contact information. The RTC
backup administrator pager can be located at the bottom of the RTC schedule. During regular business hours
(Monday through Friday 8am-5pm) a TRC/RTC mental health provider is available for the patient and can come
to the ED for crisis counseling. Triage / Nursing will start the process of clearing room 6 of zone 3 for the patient.
In the interim, all attempts should be made to place the patient and family in a quiet and private waiting area. In
the event room 6 is unavailable, all attempts should be made to place the patient in a private room.
Legally, a sexual assault client has the right to have a support person in the room during the exam process. In
addition, should the patient request an advocate, please page the RTC backup administrator to facilitate the arrival
of an advocate.
If the patient is interested in forensic evidence collection, call the police, treat the patient medically, and inform
the patient they will have a forensic exam upon availability of the TRC/RTC provider. The client may wait for
the provider or be discharged after medical clearance with instructions to return at a specific time. Encourage the
client to avoid showering and to bring in any clothing associated with the assault.
If the client is not interested in police involvement, treat them medically and make a mandated report after the
client leaves the hospital. In addition, please give the patient the number for the Trauma Recovery Center (437-
3000) to schedule a follow-up appointment. For any questions or problems, please page the RTC backup
administrator.

Police Involvement:
• If patient presents with police, please speak to the patient in private to confirm they would like to have police involved. Be sure they understand they do have a choice regarding police involvement.
• If patient is without an officer and requests police involvement, call SFPD Dispatch at 553-0123 and have • If the patient does not want police involvement, complete an 11160 Mandatory Report (see DV pack for o Call 553-0123 after client has left ED o Report there was a sexual assault but patient does not want police involvement o Complete written report and include in ED record for clerk to mail to SFPD History and assessment:
• Ask client to describe the event (what occurred, where, when, any identifying information about perpetrator, sexual assault acts involved, weapons involved) • Ask client specifically about anal, vaginal, and oral involvement for each perpetrator. • Ask about any physical injury • Assess support systems • Ask about current safety Provided by the Trauma Recovery/Rape Treatment Center Please call 415-437-3000 if you have questions Revised 6_2_2009 Physical Examination:
• Do a full physical exam, allow client to have accompanying support person if requested • Consider possible injury based on acts described by client
Documentation:
• Carefully document incident, acts and assailant in patient's own words • Document information about anal, vaginal, and oral involvement • Carefully document any findings on physical exam with both words and drawings. Documenting areas of tenderness as a physical exam finding is important as patient may not have bruising immediately after the assault. • Document pain/tenderness as well as objective findings on body map (in DV packet) • Obtain client permission and take photographs when appropriate (5-lens Polaroid)
Treatment: Sexually Transmitted Infection (STI), Pregnancy, and HIV prophylaxis
• If ‹ 3 weeks post-assault, offer STI prophylaxis
• If › than 3 week, offer STI screening
• Offer pregnancy prophylaxis if at risk for pregnancy per history
• Offer HIV prophylaxis if at risk for HIV per history, and if assault occurred ≤ 72 hours
STI Prophylaxis Protocol: (meds are in Sur-med in Zone 3)
o Azithromycin: 1 gram PO now
o Cefpodoxime (Vantin): 400mg PO now
o Flagyl: 2 grams PO now (no alcohol 24 hours prior or post treatment)

Pregnancy Prophylaxis Protocol:
• Send urine pregnancy • If urine pregnancy is negative Plan B may be offered up to 96 hours post assault: o Plan B (Norgestril): 2 pills PO now

HIV Prophylaxis Protocol:
• Make risk assessment based on sexual assault event • Offer only if assault ≤ 72 hours ago • Obtain a HIV rapid test for baseline o If positive: do not give HIV prophylaxis (refer to Ward 86, drop in hours)
o If negative: offer Combivir (AZT/3TC) 1 bid x 28 days
• Zone 3 has Combivir in 10 -day supply packs: please give patient first dose from pack and give them the rest of the take-home pack (document combivir as medication in LCR) • Patient will follow-up at TRC/RTC within 3-5 days for remaining Combivir • Recommend repeat HIV screening at 3, 6, and 12 months post-assault Provided by the Trauma Recovery/Rape Treatment Center Please call 415-437-3000 if you have questions Revised 6_2_2009 Drug Facilitated Sexual Assault (DFSA):
• If a patient suspects that he/she may have been drugged (for example, due to a loss of memory or consciousness surrounding the alleged or suspected assault), and he/she wishes to have forensic evidence collected, a non-sterile urine specimen should be collected as soon as possible and refrigerated until the arrival of the RTC examiner. This specimen will be sent to the crime lab for testing by the RTC provider. This specimen will need to labeled with the following information: o Patient's name o Time and date specimen was collected o Name of provider collecting the specimen • Most often, a urine toxicology screening test processed at SFGH will not yield any information about whether a patient was drugged with any of the common "date-rape" drugs. The hospital laboratory is not looking for these drugs, and is not sensitive enough to provide this information. If a patient wants information about possible drug involvement, a urine specimen can be sent to the San Francisco Crime Lab for analysis. However, this requires SFPD involvement, forensic evidence collection, and can take 6-8 months or longer to be processed.
Make Referrals for Sexual Assault Services:

• Call Trauma Recovery/ Rape Treatment Center @ 415- 437-3000 and leave message with patient's name, MRN, DOB and phone. RTC will call patient to arrange follow-up appointment for medical care, therapy and case management. • Please page the RTC manager / Back up administrator pager or Dr. Laurie Richer, Medical Director of RTC for any questions or assistance. The back up administrator pager can be found at the bottom of the RTC schedule. Provided by the Trauma Recovery/Rape Treatment Center Please call 415-437-3000 if you have questions Revised 6_2_2009

Source: http://sfghed.ucsf.edu/PatCare/ED_RTC_Treatment_Protocol_revised_6_09.pdf