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2 Table f Cntents (Click n title t jump t sectin) Overviews: Pre-pubertal (tanner 1,2) Assault Quick Guide Pst-pubertal (tanner 3,4,5) Assault Quick Guide Sectins: Pre-pubertal 1) Acute Assault 2) Sub-acute Assault 3) Nn-acute Assault 4) Onging Assault 5) N Disclsure Pst-pubertal 6) Acute Assault 7) Sub-acute Assault 8) Nn-acute Assault 9) Onging Assault 10) N disclsure Appendices: A) Medicatin Guide B) HIV prphylaxis C) Frensic Evidence Cllectin D) Pht Dcumentatin E) Drug Facilitated Sexual Assault F) Herpes Simplex Testing ST) Sex Trafficking M) Pst-expsure Prphylaxis Medicatin Instructins

3 TANNER 1,2 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 QUESTIONS? CALL CHILD PROTECTION SAM PATIENT PREPUBERTAL GENITAL TANNER 1,2 SOCIAL SERVICE CONSULT NON-SPECULUM EXAM & PHOTOS REFER TO SAM CLINIC ACUTE ASSAULT <72 HRS Obtain evidence kit NPEP HIV if indicated, 1st dse in ED with baseline labs HEP B PEP if indicated N STI testing r serlgy unless symptmatic N STI treatment unless symptmatic. Obtain tests first G t Sectin 1 fr detailed management SUBACUTE ASSAULT 72H-2 WEEKS Hepatitis B PEP if indicated N STI testing r serlgy unless symptmatic N STI treatment unless symptmatic. Obtain tests first G t Sectn 2 fr detailed management NON-ACUTE ASSAULT OVER 2 WEEKS STI testing r serlgy as indicated by disclsure, symptms r time f last cntact N STI treatment unless symptmatic. Obtain tests first G t Sectin 3 fr detailed management ONGOING ABUSE STI testing r serlgy as indicated by disclsure, symptms r timing f last cntact including mst recent and distant event N STI treatment unless symptmatic. Obtain tests first G t Sectin 4 fr detailed management NO DISCLOSURE BUT CONCERNS (Cncerning behavirs, unexplained genital injury r genital infectin) Labs as indicated by symptms N STI treatment unless symptmatic. Obtain tests first G t Sectin 5 fr detailed management

4 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 QUESTIONS? CALL CHILD PROTECTION SAM PATIENT POSTPUBERTAL GENITAL TANNER 3,4,5 SOCIAL SERVICE CONSULT URINE HCG ON ALL FEMALES SPECULUM EXAM (IF SEXUALLY ACTIVE & TOLERATES) & PHOTOS REFER TO SAM CLINIC. IF SEXUALLY ACTIVE & 16Y OR OLDER, REFER TO ADOLESCENT GYN OR PCP ACUTE ASSAULT <72 HRS Obtain evidence kit NPEP HIV if indicated, 1st dse in ED w/baseline labs HEP B PEP if indicated STI prphylaxis Pregnancy prphylaxis if HCG negative G t Sectin 6 fr detailed management SUBACUTE ASSAULT 72H-2 WEEKS Hepatitis B PEP if indicated STI testing with symptms STI empiric treatment G t Sectin 7 fr detailed management NON-ACUTE ASSAULT OVER 2 WEEKS STI &/r serlgy testing Additinal labs as indicated by disclsure, symptms r time f last cntact If symptmatic, treat after btaining testing G t Sectin 8 fr detailed management ONGOING ABUSE STI testing and/r serlgy as indicated by disclsure, symptms r timing f last cntact including mst recent and distant event If symptmatic r mst recent event less than 72 hurs, treat after btaining specimens G t Sectin 9 fr detailed management NO DISCLOSURE BUT CONCERNS STI testing r serlgy as indicated by symptms & timing Cnsider DFSA &/r ETOH G t Sectin 10 fr detailed management

5 1 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Acute (72 hurs r less since last cntact) CHILD AGE: Prepubertal Child (Genital Tanner Scre 1,2) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane r pen skin cntact with ejaculate INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Service will cmplete SAFECARE exam frm ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) Perfrm a Sexual Assault Evidence Cllectin Kit (See Appendix C fr evidence cllectin guidelines) assuring crrect swabs fr genital cntact, ral cntact r anal cntact as well as any area f licking, kissing r ejaculatin. D nt perfrm a pelvic/speculum examinatin n a genital Tanner 1,2 female unless under general anesthesia. Perfrm examinatin using frg-leg, supine and/r knee-chest psitining and labial tractin fr female If assault meets the fllwing criteria, cnsider Nn-Occupatinal Pst Expsure HIV prphylaxis (NPEP): Perpetratr knwn HIV psitive OR Perpetratr knwn t be invlved in HIV high risk behavir (eg., IV substance abuse, receptive anal sexual cntact) OR Perpetratr unknwn but assault included receptive penile t anal cntact OR Multiple perpetratrs OR Expsure f vagina, rectum, eye, muth r ther mucus membrane, nn-intact skin r percutaneus cntact with bld, semen, vaginal secretins, rectal secretins, breast milk r any bdy fluid that is visibly cntaminated with bld AND Patient agrees t take all medicatins fr 28 days AND Patient des nt have histry f allergy t any f the medicatins AND Patient is HIV negative per histry. NPEP shuld be initiated withut waiting fr the results f the HIV test. Refusal t underg baseline testing shuld nt preclude NPEP initiatin If yu anticipate NPEP is indicated and the CGCH ACC Pharmacy is pen, cntact them immediately. They will prcess the discharge rder and have the medicatins available fr the patient upn discharge. Hurs are Mnday-Friday 8:30 am t 4:30 pm LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Order baseline fr HIV prphylaxis nly: CBC (LAB02029) CMP (LAB01669) HIV-1 HIV-2 Antibdy & HIV P24 AG panel, btain cnsent (LAB07228) D nt perfrm rutine surveillance NAAT testing fr gnrrhea and chlamydia Page 1 f 4 SAM 12 AA

6 Female: Only if vaginal discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Male: Only if penile discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site TREATMENT PLAN & MEDICATION ORDERS (See Appendix A fr dsing guidelines): STI empiric treatment is nt indicated in this age grup. Treatment shuld nly be cnsidered if there are clinical signs and symptms cncerning fr STI. If indicated, begin treatment nly after cmpleting necessary testing HIV NPEP if assault meets criteria: Discuss benefits and limitatins f npep HIV prphylaxis medicatins. Dcument victim r family s cnsent r declinatin f medicatin Obtain written cnsent fr HIV testing See Appendix B fr medicatin dsing guidelines and additinal cnsideratins Give first dse f medicatins in ED after administering ndansetrn (Zfran) Area pharmacies are imprving their supply f stck NPEP medicatins but may nt have availability f NPEP meds fr hurs after receiving prescriptin. T address this cncern: If child presents t the ED n Mnday-Friday 8:30 am t 4:30 pm, send a prescriptin t CGCH ACC Pharmacy as sn as yu knw the child will be sent hme n NPEP. The pharmacy will prepare the prescriptins and deliver them t the ED fr pt discharge. Otherwise: 1. Write prescriptin fr 28 day supply f medicatin. Assure crrect administratin frmulatin (liquid r pill frm). 2. Administer the first dse f NPEP while child is in the ED 3. Instruct the caregiver t call their preferred pharmacy befre discharge t determine if they have the medicatin n hand (based n hurs pen). If their pharmacy is nt pen, des nt have the medicatin n hand, r 1 Page 2 f 4 SAM 12 AA

7 the family des nt have a preferred pharmacy, prvide them with the fllwing pharmacy infrmatin: a. Schnucks Specialty Pharmacy i Page Service Drive, Suite 101B, crner f Page & Lindbergh ii. Open Mnday-Friday 9:00 am t 5:30 pm iii. Family delivery services iv. Pediatric frmulatins v. Need insurance inf vi. Can eprescribe b. Walgreens Specialty Pharmacy i Hamptn Ave. ii. NE crner f Hamptn & Chippewa iii. Pharmacy pen 24 hurs iv. Can eprescribe c. Walgreens Specialty Pharmacy i Lindell Blvd ii. Pharmacy pen 24 hurs iii. Can eprescribe 4. Patient s lcal pharmacy may nly carry small supply. Parents shuld take prescriptin immediately t pharmacy f chice. It may take the pharmacy several hurs t lcate sufficient quantity f medicatin. Dcument infrmed cnsent discussin and caregiver s decisin Hepatitis B PEP if n histry f immunizatin r unknwn histry: Prvide VIS Obtain cnsent frm caregiver 1 DISCHARGE PLAN: Discharge instructins t caregiver: Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this child. Include any instructins n pain cntrl & symptm management If applicable, prvide infrmatin n HIV & HBV prphylaxis medicatins. Search Care Ntes Pstexpsure Prphylaxis AND if taking HIV NPEP, search Smart Phrase fr CGNPEPRX (411258). Emphasize imprtance f starting medicatin after discharge withut missing dses. Carefully review and make sure the infrmatin is accurate and specific fr this child Prvide fllw up number fr Child Prtectin Department/SAM Clinic at Instruct caregiver t call SAM clinic ASAP t discuss next steps Fr SSM CGCH patients: If child has been placed n HIV prphylaxis, infrm caregiver that SAM clinic will cntact caregiver weekly t assure medicatin cmpliance Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Encurage parent t speak with their PMD abut beginning HPV series if child is 9 years r lder Instruct caregiver that child will need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C perfrmed ver the next several mnths. Fr SSM CGCH patients: This can be arranged with the SAM clinic r child s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching child s chart and any specific instructins. Page 3 f 4 SAM 12 AA

8 If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Scial Services if child requires assistance with btaining HIV medicatins due t cst r frmulatin PMD fr fllw-up immunizatins Frms cmpleted fr this visit: MO SAFECARE exam frm Sexual Assault Evidence Cllectin kit physical exam frm Cnsent fr HIV testing if indicated Cnsent fr HIV prphylaxis if indicated Cnsent fr HBV if indicated Discharge instructins EPIC dcumentatin 1 Page 4 f 4 SAM 12 AA

9 2 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Subacute (72 hurs t tw weeks since last sexual cntact) CHILD AGE: Prepubertal Child (Genital Tanner Scre 1, 2) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Services will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) D nt perfrm a pelvic/speculum examinatin n a genital Tanner 1,2 female unless under general anesthesia. Perfrm examinatin using frg-leg, supine and/r knee-chest psitining and labial tractin fr female LABORATORY TESTING: (may vary fr nn-ssm rganizatins) D nt perfrm rutine surveillance NAAT testing fr gnrrhea and chlamydia Female: Only if vaginal discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Male: Only if penile discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Page 1 f 2 SAM 12 SA

10 TREATMENT PLAN & MEDICATION ORDERS (See Appendix A fr dsing guidelines): STI empiric treatment is nt indicated in this age grup. Treatment shuld nly be cnsidered if there are clinical signs and symptms cncerning fr STI. If indicated, begin treatment nly after cmpleting necessary testing Prphylaxis fr Hepatitis B if n histry f immunizatin r unknwn histry: Prvide VIS Obtain cnsent frm caregiver DISCHARGE PLAN: Discharge instructins t caregiver: Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this child. Include any instructins n pain cntrl & symptm management Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP t discuss next steps and fllw-up Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Instruct caregiver that child will need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C perfrmed ver the next several mnths. Fr SSM CGCH patients: This can be arranged with the SAM clinic r child s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching child s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Frms cmpleted fr this visit: MO SAFECARE exam frm (if applicable) Cnsent fr HBV if indicated Discharge instructins EPIC dcumentatin 2 Page 2 f 2 SAM 12 SA

11 3 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Nn-Acute (ver tw weeks) since last sexual cntact CHILD AGE: Prepubertal Child (Genital Tanner Scre 1, 2) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Services will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins. (See Appendix D fr guidelines) D nt perfrm a pelvic/speculum examinatin n a genital Tanner 1,2 female unless under general anesthesia. Perfrm examinatin using frg-leg, supine and/r knee-chest psitining and labial tractin fr female LABORATORY TESTING: (may vary fr nn-ssm rganizatins) All tilet trained patients: Chlamydia + GC amplified Prbe SAM (LAB00735) (surce unprepped/dirty urine) using tw yellw Aptima NAAT kits All nn-tilet trained patients: Chlamydia + GC amplified Prbe SAM (LAB00735) (surce vagina/intritus r penis) using tw white Aptima NAAT kits Female: btain specimens as indicated by disclsure r symptms: Penile t vaginal cntact and vaginal discharge/lesins nted n examinatin, rder: Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina using single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Genital t ral cntact r signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Penile t anal cntact r signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last sexual cntact was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Hepatitis C antibdy (LAB01066) Page 1 f 3 SAM 12 NA

12 HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228) RPR (LAB07050) Male: btain specimens as indicated by disclsure r symptms: Vaginal t penile cntact, and penile discharge/lesins nted n examinatin, rder: Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus using single range r white Aptima NAAT swab. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Genital t ral cntact r signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Penile t anal cntact r signs/symptms nted n examinatin, rder Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last sexual cntact was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Hepatitis C antibdy (LAB01066) HIV-1 HIV-2 Antibdy & HIV P24 AG panel. (LAB07228) Obtain cnsent RPR (LAB07050) TREATMENT PLAN & MEDICATION ORDERS (See Appendix A fr dsing schedules): STI empiric treatment is nt indicated in this age grup. Treatment shuld nly be cnsidered if there are clinical signs and symptms cncerning fr STI. If indicated, begin treatment nly after cmpleting necessary testing DISCHARGE PLAN: Discharge instructins t caregiver: Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this child. Include any instructins n pain cntrl & symptm management Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP fr next steps and fllw-up Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Instruct caregiver that child may need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C. Fr SSM CGCH patients: This can be arranged with the SAM clinic r child s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching child s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x Page 2 f 3 SAM 12 NA

13 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Frms cmpleted fr this visit: MO SAFECARE exam frm (if applicable) Discharge instructins EPIC dcumentatin 3 Page 3 f 3 SAM 12 NA

14 4 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Onging (multiple cntacts and time frames) CHILD AGE: Prepubertal Child (Genital Tanner Scre 1, 2) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate Management f children wh are victims f nging sexual abuse is ften difficult. Medical decisin making must take int accunt when the last sexual cntact tk place as well as the verall length f time the abuse has ccurred. INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Services will cmplete SAFECARE exam frm if last sexual cntact was less than 72 hurs ag. If ver 72 hurs since last sexual cntact, Scial Services will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) If the mst recent sexual abuse ccurred within 72 hurs, perfrm a Sexual Assault Evidence Cllectin Kit (see Appendix C fr evidence cllectin guidelines) assuring crrect swabs fr genital cntact, ral cntact r anal cntact as well as any area f licking, kissing r ejaculatin. D nt perfrm a pelvic/speculum examinatin n a genital Tanner 1,2 female unless under general anesthesia. Perfrm examinatin using frg-leg, supine and/r knee-chest psitining and labial tractin fr female If assault meets the fllwing criteria, cnsider Nn-Occupatinal Pst Expsure HIV prphylaxis (NPEP): Perpetratr knwn HIV psitive OR Perpetratr knwn t be invlved in HIV high risk behavir (eg., IV substance abuse, receptive anal sexual cntact) OR Perpetratr unknwn but assault included receptive penile t anal cntact OR Multiple perpetratrs OR Expsure f vagina, rectum, eye, muth r ther mucus membrane, nn-intact skin r percutaneus cntact with bld, semen, vaginal secretins, rectal secretins, breast milk r any bdy fluid that is visibly cntaminated with bld AND Patient agrees t take all medicatins fr 28 days AND Patient des nt have histry f allergy t any f the medicatins AND Patient is HIV negative per histry. NPEP shuld be initiated withut waiting fr the results f the HIV test. Refusal t underg baseline testing shuld nt preclude NPEP initiatin If yu anticipate NPEP is indicated and the CGCH ACC Pharmacy is pen, cntact them immediately. They will prcess the discharge rder and have the medicatins available fr the patient upn discharge. Hurs are Mnday-Friday 8:30 am t 4:30 pm Page 1 f 4 SAM 12 OA

15 LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Order baseline fr HIV prphylaxis nly: CBC (LAB02029) CMP (LAB01669) HIV-1 HIV-2 Antibdy & HIV P24 AG panel LAB(07228), btain cnsent All tilet trained patients: Chlamydia + GC amplified Prbe SAM (LAB00735) (surce urine) using tw yellw Aptima NAAT kits (surce unprepped/dirty urine) All nn-tilet trained patients: Chlamydia + GC amplified Prbe SAM (LAB00735) (surce vagina/intritus r penis) using tw white Aptima NAAT kits Female: btain specimens as indicated by disclsure r signs/symptms: Penile t vaginal cntact r vaginal discharge/lesins nted n examinatin, rder: Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Genital t ral cntact r signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Penile t anal cntact r signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last sexual cntact was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Hepatitis C antibdy (LAB01066) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228) RPR (LAB07050) Male: btain specimens as indicated by disclsure r symptms: Vaginal t penile cntact, r penile discharge/lesins nted n examinatin, rder: Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Genital t ral cntact r signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Penile t anal cntact r signs/symptms nted n examinatin, rder 4 Page 2 f 4 SAM 12 OA

16 4 Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last sexual cntact was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Hepatitis C antibdy (LAB01066) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228). Obtain cnsent RPR (LAB07050) TREATMENT PLAN & MEDICATION ORDERS: (See Appendix A fr dsing schedules) STI empiric treatment is nt indicated in this age grup. Treatment shuld nly be cnsidered if there are clinical signs and symptms cncerning fr STI. If indicated, begin treatment nly after cmpleting necessary testing HIV NPEP if assault meets criteria: Obtain written cnsent fr HIV prphylaxis Obtain written cnsent fr HIV testing See Appendix B fr medicatin dsing guidelines and additinal cnsideratins Give first dse f medicatins in ED after administering ndansetrn (Zfran) Area pharmacies are imprving their supply f stck NPEP medicatins but may nt have availability f NPEP meds fr hurs after receiving prescriptin. T address this cncern: If child presents t the ED n Mnday-Friday 8:30 am t 4:30 pm, send a prescriptin fr npep t CGCH ACC Pharmacy as sn as yu knw the child will be sent hme n npep. The pharmacy will prepare the prescriptins and deliver them t the ED fr pt discharge. Otherwise: 1. Write prescriptin fr 28 day supply f medicatin. Assure crrect administratin frmulatin (liquid r pill frm). 2. Administer the first dse f npep while child is in the ED 3. Instruct the caregiver t call their preferred pharmacy befre discharge t determine if they have the medicatin n hand (based n hurs pen). If their pharmacy is nt pen, des nt have the medicatin n hand, r the family des nt have a preferred pharmacy, prvide them with the fllwing pharmacy infrmatin: a. Schnucks Specialty Pharmacy i Page Service Drive, Suite 101B, crner f Page & Lindbergh ii. Open Mnday-Friday 9:00 am t 5:30 pm iii. Family delivery services iv. Pediatric frmulatins v. Need insurance inf vi. Can eprescribe b. Walgreens Specialty Pharmacy i Hamptn Ave. ii. NE crner f Hamptn & Chippewa iii. Pharmacy pen 24 hurs iv. Can eprescribe c. Walgreens Specialty Pharmacy i Lindell Blvd ii. Pharmacy pen 24 hurs iii. Can eprescribe Page 3 f 4 SAM 12 OA

17 4 4. Patient s lcal pharmacy may nly carry small supply. Parents shuld take prescriptin immediately t pharmacy f chice. It may take the pharmacy several hurs t lcate sufficient quantity f medicatin. Dcument infrmed cnsent discussin and caregiver s decisin Hepatitis B PEP if n histry f immunizatin r unknwn histry: Prvide VIS Obtain cnsent frm caregiver DISCHARGE PLAN: Discharge instructins t caregiver: Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this child. Include any instructins n pain cntrl & symptm management If applicable, prvide infrmatin n HIV & HBV prphylaxis medicatins. Search Care Ntes Pst-expsure Prphylaxis AND if taking HIV NPeP, search Smart Phrase fr CGNPEPRX (411258). Emphasize imprtance f starting medicatin after discharge withut missing dses. Carefully review and make sure the infrmatin is accurate and specific fr this child Prvide fllw up number fr Child Prtectin Department/SAM Clinic at Instruct caregiver t call SAM clinic ASAP t discuss next steps Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Fr SSM CGCH patients: If child has been placed n HIV prphylaxis, infrm caregiver that SAM clinic will cntact caregiver weekly t assure medicatin cmpliance If child received serlgy tday, advise parent that child needs repeat testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C perfrmed. Fr SSM CGCH patients: This can be arranged with the SAM clinic r child s PMD If child received initial dses f HBV vaccine in ED, instruct caregiver t fllw-up with PMD in ne-tw mnths and six mnths fr series cmpletin Encurage parent t speak with their PMD abut beginning HPV series if child is 9 years r lder Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching child s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Scial Services if child requires assistance with btaining HIV medicatins due t cst r frmulatin PMD fr fllw-up immunizatins Frms cmpleted fr this visit: MO SAFECARE exam frm if applicable Sexual Assault Evidence Cllectin kit physical exam frm Cnsent fr HIV testing if indicated Cnsent fr HIV prphylaxis if indicated Cnsent fr HBV if indicated Discharge instructins EPIC dcumentatin Page 4 f 4 SAM 12 OA

18 5 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ABUSE: Parental cncerns withut histry r disclsure CHILD AGE: Prepubertal child (Genital Tanner Scre 1-2) CONTACT HISTORY OR DISCLOSURE: Parental cncerns due t behavirs, symptms (eg., discharge r unexplained injury), r high-risk envirnment withut child disclsure INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Services will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) D nt perfrm a pelvic/speculum examinatin n a genital Tanner 1,2 female unless under general anesthesia. Perfrm examinatin using frg-leg, supine, and/r knee-chest psitining and labial tractin fr female LABORATORY TESTING: (may vary fr nn-ssm rganizatins) In all patients with islated cncerning behavirs (eg., aggressive sexual behavirs, selfstimulating behavirs unrespnsive t distractin), discharge/symptms r unexplained injury, rder Tilet trained patients: Chlamydia + GC amplified Prbe SAM (LAB00735) (surce unprepped/dirty urine) using tw yellw Aptima NAAT kits Nn-tilet trained patients: Chlamydia + GC amplified Prbe SAM (LAB00735) (surce vagina/intritus r penis) using tw white Aptima NAAT kits Female: If vaginal discharge nted n examinatin, rder: Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site If ral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) If anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab(jembec plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin Male: If penile discharge nted n examinatin, rder: Page 1 f 2 SAM 12 NDC

19 Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site If ral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) If anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB00737) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin TREATMENT PLAN & MEDICATION ORDERS: (See Appendix A fr dsing schedules) STI empiric treatment is nt indicated in this age grup. Treatment shuld nly be cnsidered if there are clinical signs and symptms cncerning fr STI. If indicated, begin treatment nly after cmpleting necessary testing DISCHARGE PLAN: Discharge instructins t caregiver: Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this child. Include any instructins n pain cntrl & symptm management Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM fr next steps Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching child s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Frms yu shuld have cmpleted fr this visit: MO SAFECARE exam frm if indicated Discharge instructins EPIC dcumentatin 5 Page 2 f 2 SAM 12 NDC

20 6 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Acute (72 hurs r less since last cntact) CHILD AGE: Pstpubertal Child (Genital Tanner Scre 3, 4, 5) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Service will cmplete SAFECARE exam frm ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) Perfrm a Sexual Assault Evidence Cllectin kit (See Appendix C fr evidence cllectin guidelines) assuring crrect swabs fr genital cntact, ral cntact r anal cntact as well as any areas f licking, kissing r ejaculatin. If female patient is sexually active with a histry f prir pelvic examinatins and able t tlerate a speculum exam, cnsider pelvic exam with speculum t btain endcervical swabs fr DNA up t 7 days after assault If assault meets the fllwing criteria, cnsider Nn-Occupatinal Pst Expsure HIV prphylaxis (NPEP): Perpetratr knwn HIV psitive OR Perpetratr knwn t be invlved in HIV high risk behavir (eg., IV substance abuse, receptive anal sexual cntact) OR Perpetratr unknwn but assault included receptive penile t anal cntact OR Multiple perpetratrs OR Expsure f vagina, rectum, eye, muth, r ther mucus membrane, nn-intact skin r percutaneus cntact with bld, semen, vaginal secretins, rectal secretins, breast milk r any bdy fluid that is visibly cntaminated with bld AND Patient agrees t take all medicatins fr 28 days AND Patient des nt have histry f allergy t any f the medicatins AND Patient is HIV negative per histry. NPEP shuld be initiated withut waiting fr the results f the HIV test. Refusal t underg baseline testing shuld nt preclude NPEP initiatin If yu anticipate NPEP is indicated and the CGCH ACC Pharmacy is pen, cntact them immediately. They will prcess the discharge rder and have the medicatins available fr the patient upn discharge. Hurs are Mnday-Friday 8:30 am t 4:30 pm LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Order baseline fr HIV prphylaxis nly: CBC (LAB02029) CMP (LAB01669) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228), btain cnsent Female: Page 1 f 5 SAM 345 AA

21 6 Male: Urine HCG (LAB07904) During medical interview, btain sexual activity histry, previus STI hx., and date/time f last cnsensual sexual activity. This infrmatin is imprtant if a Sexual Assault Evidence Cllectin kit will be btained r if STI testing is being cnsidered. If the patient is sexually active, presents within 72 hurs and is cncerned they have an STI because f prir symptms, his/her symptms may reflect an STI acquired prir t the assault. Discuss testing with the patient and explain they will be treated regardless f testing t prevent r treat infectin. Allw patient t make testing decisin. If they elect testing, cnsider the fllwing: Vaginal discharge nted n examinatin rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin During medical interview, btain sexual activity histry, previus STI hx., and date/time f last cnsensual sexual activity. This infrmatin is imprtant if a Sexual Assault Evidence Cllectin kit will be btained r if STI testing is being cnsidered. If the patient is sexually active, presents within 72 hurs and is cncerned they have an STI because f prir symptms, his/her symptms may reflect an STI acquired prir t the assault. Discuss testing with the patient and explain they will be treated regardless f testing t prevent r treat infectin. Allw patient t make testing decisin. If they elect testing, cnsider the fllwing: Penile discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable Page 2 f 5 SAM 345 AA

22 If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin 6 TREATMENT PLAN & MEDICATION ORDERS: (See Appendix A fr dsing schedules) Cnfirm negative HCG in female befre rdering meds Pregnancy preventin fr females Obtain written cnsent fr Ella (ulipristal) pregnancy prphylaxis up t five days after assault Hepatitis B PEP if n histry f immunizatin r unknwn histry: Prvide VIS Obtain cnsent frm caregiver Nausea prphylaxis with negative pregnancy test The risk f acquiring an STI as a cnsequence f sexual assault is unknwn but many infectins are preventable with prphylactic antibitics. The Centers fr Disease Cntrl recmmend all victims f sexual assault presenting t the Emergency Department within 72 hurs shuld receive ceftriaxne, azithrmycin and metrnidazle t treat fr: Chlamydia Gnrrhea Trichmnas Symptmatic treatment fr: Herpes Candida HIV NPEP if assault meets criteria: Discuss benefits and limitatins f npep HIV prphylaxis medicatins. Dcument victim r family s cnsent r declinatin f medicatin Obtain written cnsent fr HIV testing See Appendix B fr medicatin dsing guidelines and additinal cnsideratins Page 3 f 5 SAM 345 AA Give first dse f medicatins in ED after administering ndansetrn (Zfran) Area pharmacies are imprving their supply f stck NPEP medicatins but may nt have availability f NPEP meds fr hurs after receiving prescriptin. T address this cncern: If patient presents t the ED n Mnday-Friday 8:30 am t 4:30 pm, send a prescriptin fr npep t CGCH ACC Pharmacy as sn as yu knw the patient will be sent hme n npep. The pharmacy will prepare the prescriptins and deliver them t the ED fr pt discharge. Otherwise: 1. Write prescriptin fr 28 day supply f medicatin. Assure crrect administratin frmulatin (liquid r pill frm). 2. Administer the first dse f npep while patient is in the ED

23 6 3. Instruct the caregiver t call their preferred pharmacy befre discharge t determine if they have the medicatin n hand (based n hurs pen). If their pharmacy is nt pen, des nt have the medicatin n hand, r the family des nt have a preferred pharmacy, prvide them with the fllwing pharmacy infrmatin: a. Schnucks Specialty Pharmacy i Page Service Drive, Suite 101B, crner f Page & Lindbergh ii. Open Mnday-Friday 9:00 am t 5:30 pm iii. Family delivery services iv. Pediatric frmulatins v. Need insurance inf vi. Can eprescribe b. Walgreens Specialty Pharmacy i Hamptn Ave. ii. NE crner f Hamptn & Chippewa iii. Pharmacy pen 24 hurs iv. Can eprescribe c. Walgreens Specialty Pharmacy i Lindell Blvd ii. Pharmacy pen 24 hurs iii. Can eprescribe 4. Patient s lcal pharmacy may nly carry small supply. Parents shuld take prescriptin immediately t pharmacy f chice. It may take the pharmacy several hurs t lcate sufficient quantity f medicatin. Dcument infrmed cnsent discussin and caregiver s decisin DISCHARGE PLAN: Discharge instructins t caregiver: Send hme with prescriptin anti-nausea medicatin and HIV medicatins Search Care Ntes fr Sexual Assault Discharge Care. Carefully review and make sure the infrmatin is accurate and specific fr this patient. Include any instructins n pain cntrl & symptm management If applicable, prvide infrmatin n HIV & HBV prphylaxis medicatins. Search Care Ntes Pst-expsure Prphylaxis AND if taking HIV NPeP, search Smart Phrase fr CGNPEPRX (411258). Emphasize imprtance f starting medicatin after discharge withut missing dses. Carefully review and make sure the infrmatin is accurate and specific fr this patient If applicable, prvide infrmatin n emergency cntraceptin (EC) medicatin. Search Care Ntes fr Emergency Cntraceptin, Ambulatry Care (General Infrmatin) including safe sex precautins t prevent pregnancy and STIs. Carefully review and make sure the infrmatin is accurate and specific fr this patient If applicable, prvide infrmatin n metrnidazle including side effects f medicatin and stress aviding alchl fr at least three days after administratin. Carefully review and make sure the infrmatin is accurate and specific fr this patient Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP fr next steps. If patient is ver 16 and sexually active, refer instead t adlescent medicine clinic. Fr SSM CGCH patients: If patient has been placed n HIV prphylaxis, infrm caregiver that SAM clinic will cntact caregiver weekly t assure medicatin cmpliance Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results If patient received initial dses f HBV and/r HPV vaccines in ED, instruct caregiver t fllw-up with PMD in ne-tw mnths and six mnths fr series cmpletin Page 4 f 5 SAM 345 AA

24 Instruct caregiver that patient will need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C perfrmed ver the next several mnths. Fr SSM CGCH patients: This can be arranged with the apprpriate referral surce r patient s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching patient s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Scial Services if patient requires assistance with btaining HIV medicatins due t cst r frmulatin PMD fr fllw-up immunizatins Frms cmpleted fr this visit: MO SAFECARE exam frm Sexual Assault Evidence Cllectin kit physical exam frm Cnsent fr HBV if indicated Cnsent fr HIV testing if indicated Cnsent fr HIV prphylaxis if indicated Cnsent fr pregnancy prphylaxis if indicated Discharge instructins EPIC dcumentatin 6 Page 5 f 5 SAM 345 AA

25 7 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Subacute Assault (72 hurs-2 weeks) CHILD AGE: Pstpubertal Child (Genital Tanner Scre 3, 4, 5) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Service will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) If female patient is sexually active with a histry f prir pelvic examinatins and able t tlerate a speculum exam, cnsider pelvic exam with speculum t btain endcervical swabs fr DNA up t 7 days after assault LABORATORY TESTING: (may vary fr nn-ssm rganizatins): STI testing may nt be reflective f infectin ccurring during the assault Female: Male: Page 1 f 3 SAM 345 SA Urine HCG (LAB07904) Obtain sexual activity histry & previus STI hx. If sexually active & symptmatic, cnsider testing nly as indicated by histry & symptms fr: Vaginal discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin Obtain sexual activity histry & previus STI hx. If sexually active & symptmatic, cnsider testing nly as indicated by histry & symptms fr:

26 Penile discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin TREATMENT PLAN & MEDICATION ORDERS: (See Appendix A fr dsing schedules) Cnfirm negative HCG in female befre rdering meds STI Treatment Optins: If patient is symptmatic fr STI at time f ED visit, treat empirically fr gnrrhea, chlamydia and trichmnas. If patient is asymptmatic during ED examinatin: they must return tw weeks after assault t SAM clinic r PMD/GYN fr repeat examinatin and STI testing fr gnrrhea, chlamydia and trichmnas. Studies suggest less than 50% f acute sexual assault victims fllw up n testing recmmendatins OR if there are cncerns the patient may nt return fr a tw week fllw-up visit r patient expresses cncern that he/she may have an STI frm a prir cnsensual encunter cnsider empiric treatment fr gnrrhea, chlamydia and trichmnas during the ED visit. Discuss with the patient and allw them t make the decisin emphasizing need fr fllw-up shuld they decline treatment Pregnancy preventin fr females: Obtain written cnsent fr Ella (ulipristal) pregnancy prphylaxis administered up t five days after assault Treat symptmatically fr: Herpes Candida Nausea prphylaxis if empirically treating and negative pregnancy test DISCHARGE PLAN: If indicated, send hme with prescriptin fr anti-nausea medicatin 7 Page 2 f 3 SAM 345 SA

27 Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this patient. Include any instructins n pain cntrl & symptm management If applicable, prvide infrmatin n metrnidazle, including side effects f medicatin and stress aviding alchl fr at least three days after administratin. Carefully review and make sure the infrmatin is accurate and specific fr this patient Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP fr next steps. If patient is ver 16 and sexually active, refer instead t adlescent medicine clinic Instruct caregiver that patient will need fllw up bld testing fr HV and/r syphilis, Hepatitis B, Hepatitis C perfrmed in ver the next several mnths. Fr SSM CGCH patients: This can be arranged with the apprpriate referral surce r patient s PMD Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching patient s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Frms cmpleted fr this visit: MO SAFECARE exam frm if indicated Discharge instructins EPIC dcumentatin 7 Page 3 f 3 SAM 345 SA

28 8 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Nn-Acute Assault (ver tw weeks) CHILD AGE: Pstpubertal Child (Genital Tanner Scre 3, 4, 5) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Service will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) Female exam may include pelvic speculum exam if patient is sexually active and able t tlerate the examinatin LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Female: Urine HCG (LAB07904) Obtain sexual activity histry & previus STI hx. Based n type f assault and/r clinical exam: Penile t vaginal cntact, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Genital t ral/ral t genital cntact, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Penile t anal cntact, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last assault was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Page 1 f 3 SAM 345 NA

29 Hepatitis C antibdy (LAB01066) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228), btain cnsent RPR (LAB07050) 8 Male: Obtain sexual activity histry & previus STI hx. Based n type f assault and/r clinical exam: Genital/ral t penile cntact, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Genital t ral cntact, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Penile t anal cntact, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last assault was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Hepatitis C antibdy (LAB01066) HIV-1 HIV-2 Antibdy & HIV P24 AG panel, btain cnsent (LAB07228) RPR (LAB07050) TREATMENT PLAN & MEDICATION ORDERS (See Appendix A fr dsing schedules): Cnfirm negative HCG in female befre rdering meds STI treatment nly if symptmatic. Administer after testing is cmplete. As per CDC recmmendatins, treat with ceftriaxne, azithrmycin and metrnidazle fr: Chlamydia Gnrrhea Trichmnas Symptmatic treatment as indicated fr: Herpes Candida Nausea prphylaxis if indicated Page 2 f 3 SAM 345 NA

30 8 DISCHARGE PLAN: Send hme with prescriptin anti-nausea medicatin if indicated Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this patient. Include any instructins n pain cntrl & symptm management If applicable, prvide infrmatin n metrnidazle including side effects f medicatin and stress aviding alchl fr at least three days after administratin. Carefully review and make sure the infrmatin is accurate and specific fr this patient Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP fr next steps. If patient is ver 16 and sexually active, refer instead t adlescent medicine clinic. Instruct caregiver that patient will need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C. Fr SSM CGCH patients: This can be arranged with the apprpriate referral surce r patient s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching patient s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Scial Services if patient requires assistance with btaining HIV medicatins due t cst r frmulatin PMD fr fllw-up immunizatins Frms cmpleted fr this visit: MO SAFECARE exam frm Cnsent fr HIV testing if indicated Discharge instructins EPIC dcumentatin Page 3 f 3 SAM 345 NA

31 9 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ASSAULT: Onging abuse (multiple cntacts and time frames) CHILD AGE: Pstpubertal Child (Genital Tanner Scre 3, 4, 5) CONTACT HISTORY OR DISCLOSURE: Genital cntact (eg., penile t vaginal, ral, r anal area); mucus membrane cntact with ejaculate Management f children and adlescents wh are victims f nging sexual abuse is ften difficult. Medical decisin making must take int accunt when the last assault tk place as well as the length f time the abuse the abuse has ccurred. INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Services will cmplete SAFECARE exam frm if last sexual cntact was less than 72 hurs ag. If ver 72 hurs since last sexual cntact, Scial Services will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins (See Appendix D fr guidelines) If the mst recent abuse ccurred within 72 hurs, perfrm a Sexual Assault Evidence Cllectin kit (See Appendix C fr evidence cllectin guidelines) assuring crrect swabs fr genital cntact, ral cntact r anal cntact as well as any area f licking, kissing r ejaculatin. If female patient is sexually active with a histry f prir pelvic examinatins and able t tlerate a speculum exam, cnsider pelvic exam with speculum t btain endcervical swabs fr DNA up t 7 days after assault If assault meets the fllwing criteria, cnsider Nn-Occupatinal Pst Expsure HIV prphylaxis (NPEP): Perpetratr knwn HIV psitive OR Perpetratr knwn t be invlved in HIV high risk behavir (eg., IV substance abuse, receptive anal sexual cntact) OR Perpetratr unknwn but assault included receptive penile t anal cntact OR Multiple perpetratrs OR Expsure f vagina, rectum, eye, muth, r ther mucus membrane, nn-intact skin r percutaneus cntact with bld, semen, vaginal secretins, rectal secretins, breast milk r any bdy fluid that is visibly cntaminated with bld AND Patient agrees t take all medicatins fr 28 days AND Patient des nt have histry f allergy t any f the medicatins AND Patient is HIV negative per histry. NPEP shuld be initiated withut waiting fr the results f the HIV test. Refusal t underg baseline testing shuld nt preclude NPEP initiatin If yu anticipate NPEP is indicated and the CGCH ACC Pharmacy is pen, cntact them immediately. They will prcess the discharge rder and have the medicatins available fr the patient upn discharge. Hurs are Mnday-Friday 8:30 am t 4:30 pm Page 1 f 5 SAM OA 345

32 9 LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Order baseline fr HIV prphylaxis nly: CBC (LAB02020) CMP (LAB01669) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228), btain cnsent Female: Urine HCG (LAB07904) During medical interview, btain sexual activity histry, previus STI hx., and date/time f last cnsensual sexual activity. This infrmatin is imprtant if a Sexual Assault Evidence Cllectin kit will be btained r if STI testing is being cnsidered. If the patient is sexually active, presents within 72 hurs and is cncerned they have an STI because f prir symptms, his/her symptms may reflect an STI acquired prir t the assault. Discuss testing with the patient and explain they will be treated regardless f testing t prevent r treat infectin. Allw patient t make testing decisin. If they elect testing, cnsider the fllwing: Vaginal discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (SAM10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin Male: During medical interview, btain sexual activity histry, previus STI hx., and date/time f last cnsensual sexual activity. This infrmatin is imprtant if a Sexual Assault Evidence Cllectin kit will be btained r if STI testing is being cnsidered. If the patient is sexually active, presents within 72 hurs and is cncerned they have an STI because f prir symptms, his/her symptms may reflect an STI acquired prir t the assault. Discuss testing with the patient and explain they will be treated regardless f testing t prevent r treat infectin. Allw patient t make testing decisin. If they elect testing, cnsider the fllwing: Penile discharge nted n examinatin, rder: Page 2 f 5 SAM OA 345

33 Chlamydia + GC amplified prbe SAM (LAB0073) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin If last sexual cntact was ver six weeks ag, btain serlgy fr: Hepatitis B panel (LAB01077) Hepatitis C antibdy (LAB01066) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228) RPR (LAB07050) 9 TREATMENT PLAN & MEDICATION ORDERS: (See Appendix A fr dsing schedules) Cnfirm negative HCG in female befre rdering meds If mst recent assault ccurred within 5 days and urine HCG is negative, ffer pregnancy preventin fr females: Obtain written cnsent/declinatin fr Ella (ulipristal) pregnancy prphylaxis The risk f acquiring an STI as a cnsequence f sexual assault is unknwn, but many infectins are preventable with prphylactic antibitics. The Centers fr Disease Cntrl recmmend all victims f sexual assault presenting t the Emergency Department within 72 hurs shuld receive ceftriaxne, azithrmycin and metrnidazle t treat fr: Chlamydia Gnrrhea Trichmnas HIV NPEP if the assault meets criteria: Discuss benefits and limitatins f npep HIV prphylaxis medicatins. Dcument victim r family s cnsent r declinatin f medicatin Obtain written cnsent fr HIV testing See Appendix B fr medicatin dsing guidelines and additinal cnsideratins Give first dse f medicatins in ED after administering ndansetrn (Zfran) Area pharmacies are imprving their supply f stck NPEP medicatins but may nt have availability f NPEP meds fr hurs after receiving prescriptin. T address this cncern: Page 3 f 5 SAM OA 345

34 9 If patient presents t the ED n Mnday-Friday 8:30 am t 4:30 pm, send a prescriptin fr npep t CGCH ACC Pharmacy as sn as yu knw the patient will be sent hme n npep. The pharmacy will prepare the prescriptins and deliver them t the ED fr pt discharge. Otherwise: 1. Write prescriptin fr 28 day supply f medicatin. Assure crrect administratin frmulatin (liquid r pill frm). 2. Administer the first dse f npep while patient is in the ED 3. Instruct the caregiver t call their preferred pharmacy befre discharge t determine if they have the medicatin n hand (based n hurs pen). If their pharmacy is nt pen, des nt have the medicatin n hand, r the family des nt have a preferred pharmacy, prvide them with the fllwing pharmacy infrmatin: a. Schnucks Specialty Pharmacy i Page Service Drive, Suite 101B, crner f Page & Lindbergh ii. Open Mnday-Friday 9:00 am t 5:30 pm iii. Family delivery services iv. Pediatric frmulatins v. Need insurance inf vi. Can eprescribe b. Walgreens Specialty Pharmacy i Hamptn Ave. ii. NE crner f Hamptn & Chippewa iii. Pharmacy pen 24 hurs iv. Can eprescribe c. Walgreens Specialty Pharmacy i Lindell Blvd ii. Pharmacy pen 24 hurs iii. Can eprescribe 4. Patient s lcal pharmacy may nly carry small supply. Parents shuld take prescriptin immediately t pharmacy f chice. It may take the pharmacy several hurs t lcate sufficient quantity f medicatin. Dcument infrmed cnsent discussin and caregiver s decisin If mst recent assault ccurred within tw weeks and patient has n r unknwn histry f Hepatitis B immunizatin : Prvide VIS Obtain cnsent frm caregiver DISCHARGE PLAN: Discharge instructins t caregiver: Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin). Carefully review and make sure the infrmatin is accurate and specific fr this patient. Include any instructins n pain cntrl & symptm management If applicable, prvide infrmatin n HIV & HBV prphylaxis medicatins. Search Care Ntes Pst-expsure Prphylaxis AND if taking HIV NPeP, search Smart Phrase fr CGNPEPRX (411258). Emphasize imprtance f starting medicatin after discharge withut missing dses. Carefully review and make sure the infrmatin is accurate and specific fr this patient If applicable, prvide infrmatin n emergency cntraceptin (EC) medicatin. Search Emergency Cntraceptin, Ambulatry Care (General Infrmatin) in Care Ntes instructins n EC, including safe sex precautins t prevent pregnancy and STIs. Carefully review and make sure the infrmatin is accurate and specific fr this patient Page 4 f 5 SAM OA 345

35 If applicable, prvide infrmatin n metrnidazle including side effects f medicatin and stress aviding alchl fr at least three days after administratin. Carefully review and make sure the infrmatin is accurate and specific fr this patient Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP fr next steps. If patient is ver 16 and sexually active, refer instead t adlescent medicine clinic. Fr SSM CGCH patients: Infrm caregiver that ED fllw-up nurse will call with any psitive results Fr SSM CGCH patients: If patient has been placed n HIV prphylaxis, infrm caregiver that SAM clinic will cntact caregiver weekly t assure medicatin cmpliance If patient received initial dses f HBV and/r HPV vaccines in ED, instruct caregiver t fllw-up with PMD in ne-tw mnths and six mnths fr series cmpletin Instruct caregiver that patient will need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C ver the next several mnths. Fr SSM CGCH patients: This can be arranged with the apprpriate referral surce r patient s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching patient s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Scial Services if patient requires assistance with btaining HIV medicatins due t cst r frmulatin PMD fr fllw-up immunizatins Frms cmpleted fr this visit: MO SAFECARE exam frm if applicable Sexual Assault Evidence Cllectin kit physical exam frm if applicable Cnsent fr HBV if indicated Cnsent fr HIV testing if applicable Cnsent fr HIV prphylaxis if applicable Cnsent fr pregnancy prphylaxis if applicable Discharge instructins EPIC dcumentatin 9 Page 5 f 5 SAM OA 345

36 10 SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 TYPE OF ABUSE: Parental r child cncerns withut histry r disclsure CHILD AGE: Pstpubertal child (Genital Tanner Scre 3, 4, 5) CONTACT HISTORY OR DISCLOSURE: Cncerns due t behavirs, symptms (eg., discharge, unexplained injury, mental status changes), r high risk envirnment withut child disclsure r knwledge f event INITIAL STEPS: Medically stabilize and immediately address any urgent/emergent issues (pain, bleeding, etc.) Review Scial Service cnsult. Scial Services will cmplete SAFECARE exam frm nly if SAFECARE prvider is perfrming examinatin ED attending r resident will perfrm examinatin Pht dcument all examinatins. (See Appendix D fr guidelines) If patient presents with cncerns that a sexual assault might have ccurred but is unsure, cnsider Drug Facilitated Sexual Assault (DFSA). If patient believes the assault might have ccurred within 72 hurs: Perfrm a Sexual Assault Evidence Cllectin kit (See Appendix C fr evidence cllectin guidelines) assuring crrect swabs fr genital cntact, ral cntact r anal cntact as well as any areas f licking, kissing r ejaculatin. If female patient is sexually active with a histry f prir pelvic examinatins and able t tlerate a speculum exam, cnsider pelvic exam with speculum t btain endcervical swabs fr DNA up t 7 days after assault Perfrm DFSA &/r ETOH evidence cllectin kit fr evidentiary purpses. (See Appendix E fr guidelines) If assault meets the fllwing criteria, cnsider Nn-Occupatinal Pst Expsure HIV prphylaxis (NPEP): Perpetratr knwn HIV psitive OR Perpetratr knwn t be invlved in HIV high risk behavir (eg., IV substance abuse, receptive anal sexual cntact) OR Perpetratr unknwn but assault included receptive penile t anal cntact OR Multiple perpetratrs OR Expsure f vagina, rectum, eye, muth, r ther mucus membrane, nn-intact skin r percutaneus cntact with bld, semen, vaginal secretins, rectal secretins, breast milk r any bdy fluid that is visibly cntaminated with bld AND Patient agrees t take all medicatins fr 28 days AND Patient des nt have histry f allergy t any f the medicatins AND Patient is HIV negative per histry. NPEP shuld be initiated withut waiting fr the results f the HIV test. Refusal t underg baseline testing shuld nt preclude NPEP initiatin LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Page 1 f 5 SAM 345 NDC

37 10 Lab rders (rder sets may vary fr nn-ssm rganizatins): If patient is symptmatic (nausea, vmiting, headache, mental status changes, btunded) rder txiclgy testing fr treatment purpses as fllws: Urine cmprehensive drug screen (drug screen tx urine panel) (LAB01638) n first available urine. This is a cmprehensive screen and takes apprx. 24 hurs t result ut. In additin, if limited drug panel is indicated fr mre immediate results ALSO rder UDS (LAB01632) Bld ETOH (LAB01215), assure skin prep is betadine nly and n alchl base Order baseline fr HIV prphylaxis nly: CBC (LAB02029) CMP (LAB01669) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228), btain cnsent Female: POC Urine HCG (LAB07924) During medical interview, btain sexual activity histry, previus STI hx., and date/time f last cnsensual sexual activity. This infrmatin is imprtant if a Sexual Assault Evidence Cllectin kit will be btained r if STI testing is being cnsidered. If the patient is sexually active, presents within 72 hurs and is cncerned they have an STI because f prir symptms, his/her symptms may reflect an STI acquired prir t the assault. Discuss testing with the patient and explain they will be treated regardless f testing t prevent r treat infectin. Allw patient t make testing decisin. If they elect testing, cnsider the fllwing: Vaginal discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r vagina). Urine uses tw yellw Aptima NAAT kits. If surce is vaginal, specimen may be btained frm discharge r intritus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce vagina). Specimen may be btained frm intritus r vagina with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin Male: During medical interview, btain sexual activity histry, previus STI hx., and date/time f last cnsensual sexual activity. This infrmatin is imprtant if a Sexual Assault Evidence Cllectin kit will be btained r if STI testing is being cnsidered. If the patient Page 2 f 5 SAM 345 NDC

38 10 is sexually active, presents within 72 hurs and is cncerned they have an STI because f prir symptms, his/her symptms may reflect an STI acquired prir t the assault. Discuss testing with the patient and explain they will be treated regardless f testing t prevent r treat infectin. Allw patient t make testing decisin. If they elect testing, cnsider the fllwing: Penile discharge nted n examinatin, rder: Chlamydia + GC amplified prbe SAM (LAB00735) (surce unprepped/dirty urine r penis). Urine uses tw yellw Aptima NAAT kits. If surce is penis, specimen may be btained frm discharge r interir meatus but must use 2 range r 2 white Aptima NAAT swab kits Trichmnas vaginalis amplified prbe (LAB10667) (surce urethra). Specimen may be btained frm penile discharge r interir meatus with single range r white Aptima NAAT swab kit. Urine is nt acceptable If genital lesins are nted n examinatin and herpes is suspected, rder HSV 1 & 2 PCR lesin (LAB10529) AND Culture HSV w/typing (LAB08458). De-rf vesicle and use a FLOQSwab t btain specimen. Each swab is placed in universal transprt media (red tp media). Cllect ne swab fr HSV 1&2 PCR and ne swab fr Culture HSV w/typing. Fr sampling multiple lesins, use a fresh FLOQSwab fr each site Oral signs/symptms nted n examinatin, rder: Gnrrhea culture (ALB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce ral) Anal signs/symptms nted n examinatin, rder: Gnrrhea culture (LAB04037) using dark green tp mini-tip culture swab (JEMBEC plate) (surce rectal) Chlamydia culture (LAB07337) using dark green tp mini-tip culture swab (red tp viral media) (surce rectal) Chlamydia + GC amplified prbe (LAB00735) is NOT apprved fr rectal specimens in this ppulatin TREATMENT PLAN & MEDICATION ORDERS: (See Appendix A fr dsing schedules) Cnfirm negative HCG in female befre rdering meds Pregnancy preventin fr females Obtain written cnsent fr Ella (ulipristal) pregnancy prphylaxis up t 5 days after assault HIV NPEP if assault meets criteria: Obtain written cnsent fr HIV prphylaxis Obtain written cnsent fr HIV testing See Appendix B fr medicatin dsing guidelines and additinal cnsideratins Give first dse f medicatins in ED after administering ndansetrn (Zfran) Area pharmacies are imprving their supply f stck NPEP medicatins but may nt have availability f NPEP meds fr hurs after receiving prescriptin. T address this cncern: If patient presents t the ED n Mnday-Friday 8:30 am t 4:30 pm, send a prescriptin fr npep t CGCH ACC Pharmacy as sn as yu knw the patient will be sent hme n npep. The pharmacy will prepare the prescriptins and deliver them t the ED fr pt discharge. Otherwise: 1. Write prescriptin fr 28 day supply f medicatin. Assure crrect administratin frmulatin (liquid r pill frm). 2. Administer the first dse f npep while patient is in the ED Page 3 f 5 SAM 345 NDC

39 10 3. Instruct the caregiver t call their preferred pharmacy befre discharge t determine if they have the medicatin n hand (based n hurs pen). If their pharmacy is nt pen, des nt have the medicatin n hand, r the family des nt have a preferred pharmacy, prvide them with the fllwing pharmacy infrmatin: a. Schnucks Specialty Pharmacy i Page Service Drive, Suite 101B, crner f Page & Lindbergh ii. Open Mnday-Friday 9:00 am t 5:30 pm iii. Family delivery services iv. Pediatric frmulatins v. Need insurance inf vi. Can eprescribe b. Walgreens Specialty Pharmacy i Hamptn Ave. ii. NE crner f Hamptn & Chippewa iii. Pharmacy pen 24 hurs iv. Can eprescribe c. Walgreens Specialty Pharmacy i Lindell Blvd ii. Pharmacy pen 24 hurs iii. Can eprescribe Patient s lcal pharmacy may nly carry small supply. Parents shuld take prescriptin immediately t pharmacy f chice. It may take the pharmacy several hurs t lcate sufficient quantity f medicatin. Dcument infrmed cnsent discussin and caregiver s decisin The risk f acquiring an STI as a cnsequence f sexual assault is unknwn but many infectins are preventable with prphylactic antibitics. The Centers fr Disease Cntrl recmmend all victims f sexual assault presenting t the Emergency Department within 72 hurs f last assault shuld receive ceftriaxne, azithrmycin and metrnidazle t treat fr: Chlamydia Gnrrhea Trichmnas Symptmatic treatment fr: Herpes Candida Nausea prphylaxis with negative pregnancy test Hepatitis B PEP if n histry f immunizatin r unknwn histry: Prvide VIS Obtain cnsent frm caregiver DISCHARGE PLAN: Discharge instructins t caregiver: Send hme with prescriptin anti-nausea medicatin and HIV medicatins if applicable Search Care Ntes fr Child Maltreatment Sexual Abuse (General Infrmatin) OR Sexual Assault Discharge Care. Carefully review and make sure the infrmatin is accurate and specific fr this patient. Include any instructins n pain cntrl & symptm management There is currently n Care Nte fr Drug Facilitated Sexual Assault. Emphasize the nline resurces prvided in Sexual Assault Discharge Care t help caregiver btain mre infrmatin Page 4 f 5 SAM 345 NDC

40 10 If applicable, prvide infrmatin n HIV & HBV prphylaxis medicatins. Search Care Ntes Pst-expsure Prphylaxis AND if taking HIV NPeP, search Smart Phrase fr CGNPEPRX (411258). Emphasize imprtance f starting medicatin after discharge withut missing dses. Carefully review and make sure the infrmatin is accurate and specific fr this patient If applicable, prvide infrmatin n emergency cntraceptin (EC) medicatin. Search Care Ntes fr Emergency Cntraceptin, Ambulatry Care (General Infrmatin), including safe sex precautins t prevent pregnancy and STIs. Carefully review and make sure the infrmatin is accurate and specific fr this patient If applicable, prvide infrmatin n metrnidazle including side effects f medicatin and stress aviding alchl fr at least three days after administratin. Prvide fllw up number fr Child Prtectin Department/SAM Clinic Instruct caregiver t call SAM clinic ASAP fr next steps. If patient is ver 16 and sexually active, refer instead t adlescent medicine clinic. Fr SSM CGCH patients: If patient has been placed n HIV prphylaxis, infrm caregiver that SAM clinic will cntact caregiver weekly t assure medicatin cmpliance If patient received initial dses f HBV and/r HPV vaccines in ED, instruct caregiver t fllw-up with PMD in ne-tw mnths and six mnths fr series cmpletin Instruct caregiver that patient will need fllw up bld testing fr HIV and/r syphilis, Hepatitis B, Hepatitis C ver the next several mnths. Fr SSM CGCH patients: This can be arranged with the apprpriate referral surce r patient s PMD Discharge referrals: Fr all SAM patients infrm SAM clinic. EPIC message Thrne, Debrah attaching patient s chart and any specific instructins. If injury r infectin was diagnsed r suspected, ntify the SAM clinic immediately. During business hurs, call t speak w/staff member at x5347 (ASCOM , pager ). After hurs, call SAM clinic vice mail line x5347 & leave a message regarding nature f cncerns. Scial Services if patient requires assistance with btaining HIV medicatins due t cst r frmulatin PMD fr fllw-up immunizatins Frms cmpleted fr this visit: MO SAFECARE exam frm if applicable Sexual Assault Evidence Cllectin kit physical exam frm if applicable Cnsent fr HBV if applicable Cnsent fr HIV testing if applicable Cnsent fr HIV prphylaxis if applicable Cnsent fr pregnancy prphylaxis if applicable Discharge instructins EPIC dcumentatin Page 5 f 5 SAM 345 NDC

41 A SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 APPENDIX A: MEDICATION DOSING SCHEDULE ANTI-NAUSEA: Ondansetrn (Zfran) 4mg p 30 minutes prir t additinal medicatins (cntraindicated in pregnancy) Discharge with prescriptin fr an additinal dse f ndansetrn (Zfran) BV (BACTERIAL VAGINOSIS): Metrnidazle (Flagyl) 500mg p BID x 7 days CANDIDASIS: Flucnazle (Diflucan) 150mg p x1 r 4mg/kg x1 and repeat in ne week (40mg/ml dse) CHLAMYDIA: Less than 45kg: Erythrmycin 50mg/kg/day p divided int fur dses/day fr 14 days (MO Medicaid may nt pay fr erythrmycin, ask scial services t check preferred pharmacy befre discharge). If nt cvered r erythrmycin allergy: Azithrmycin 20mg/kg up t max 1Gm p x1 Greater than 45kg & less than 8 years f age: Azithrmycin (Zithrmax) 1 Gram p x1 in ED Over 8 years f age: Azithrmycin (Zithrmax) 1 Gram p x1 in ED OR Dxycycline 100mg BID p fr 7 days (cntraindicated in pregnancy) GONORRHEA: Children: Uncmplicated vulvvaginitis, cervicitis, urethritis, pharyngitis r prctitis Less than 45 kg Ceftriaxne mg/kg t max 125mg IM Greater than 45 kg Ceftriaxne 250mg IM Dual therapy is nt recmmended in children per CDC recmmendatins. It is recmmended children shuld be tested fr ther STIs Adlescents: Uncmplicated gncccal infectin f cervix, urethra, rectum r pharynx Ceftriaxne 250mg IM AND azithrmycin 1 Gram p Fr knwn cephalsprin allergy r previus penicillin anaphylaxis: N ceftriaxne Azithrmycin 2G which cvers gnrrhea and chlamydia -AND- Gentamycin 5mg/kg (max 240mg) IM nly single dse Instruct patient: N sexual cntact fr seven days & ntify partners N need t test fr cure unless symptms persist r alternate treatment regimen is used Rutine testing in 3 mnths is recmmended fr all sexually active patients Page 1 f 2 SAM Appendix A Med Guidelines

42 A HERPES INITIAL OUTBREAK: Acyclvir (Zvirax) 400mg p TID x 7-10 days Or Valacyclvir (Valtrex) 1G p BID x 7-10 days HEPATITIS B WITH NO/UNKNOWN HISTORY OF IMMUNIZATION (VIS and cnsent): HBIG 0.06ml/kg IM x1 nly if assailant is knwn psitive Hepatitis B and child is unvaccinated Initial dse Hepatitis B vaccine per frmulary availability if vaccine histry is unknwn HIV (cnsent r declinatin frm): See Appendix B fr dsing schedule PREGNANCY PREVENTION (cnsent frm): Ella (ulipristal), 30mg p 1x in ED 30 minutes after administering anti-nausea medicatin. May administer 5 days pst-assault TRICHOMONAS: Tanner 1 r 2: Metrnidazle 15mg/kg/day p dividied int three dses/day fr 7 days Tanner 3,4, r 5: Metrnidazle (Flagyl) 2 Gram p x1 in ED OR Tinizadle (Tindamax) 2 Gram p x1 in ED OR IF ALCOHOL INGESTION IS SUSPECTED Send hme with prescriptin fr metrnidazle r tinizadle POST PUBERTAL PROPHYLACTIC/EMPIRIC TREATMENT GUIDE: If nt pregnant rder: Ondansetrn 4mg p 30 minutes later, and n allergies r cntraindicatins, administer: Ceftriaxne 250 mg IM AND Azithrmycin 1 Gram p AND Metrnidazle 2 Gram p Page 2 f 2 SAM Appendix A Med Guidelines

43 B SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 APPENDIX B: HIV NON-OCCUPATIONAL POST EXPOSURE PROPHYLAXIS (NPEP) AFTER SEXUAL ASSAULT POINTS TO REMEMBER: Transmissin f HIV during sexual assault is rare but pssible. In many cases, the alleged perpetratr HIV status is unknwn and prphylaxis is the nly ptin available t the victim. NPEP efficacy is unknwn. Current thery recmmends beginning NPEP within the first 24 hurs fr best efficacy. Efficacy is thught t diminish significantly if started mre than 72 hurs after expsure. The first dse shuld be administered in the ED t meet this recmmendatin. If yu anticipate NPEP is indicated and the CGCH ACC Pharmacy is pen, cntact them immediately. They will prcess the discharge rder and have the medicatins available fr the patient upn discharge. Hurs are Mnday-Friday 8:30 am t 4:30 pm INCLUSION CRITERIA: NPEP medicatin risks shuld be explained when speaking t the parent r patient abut risks/benefits f NPEP. The medicatin risks include nausea, vmiting, abdminal discmfrt, and elevated liver enzymes. T minimize the risks assciated with the medicatin, ffer NPEP t victims meeting the fllwing criteria: Perpetratr knwn HIV psitive OR Perpetratr knwn t be invlved in HIV high risk behavir (eg., IV substance abuse, receptive anal sexual cntact) OR Perpetratr unknwn but assault included receptive penile t anal cntact OR Multiple perpetratrs OR Expsure f vagina, rectum, eye, muth r ther mucus membrane, nn-intact skin r percutaneus cntact with bld, semen, vaginal secretins, rectal secretins, breast milk r any bdy fluid that is visibly cntaminated with bld AND Patient agrees t take all medicatins fr 28 days AND Patient des nt have histry f allergy t any f the medicatins AND Patient is HIV negative per histry. NPEP shuld be initiated withut waiting fr the results f the HIV test. Refusal t underg baseline testing shuld nt preclude NPEP initiatin CONSENTS: Obtain written cnsent/declinatin fr HIV prphylaxis after explaining risks/benefits Obtain written cnsent fr HIV testing LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Baseline CBC (LAB02029) Page 1 f 3 SAM Appendix B HIV Guidelines

44 B Baseline CMP (LAB01669) HIV-1 HIV-2 Antibdy & HIV P24 AG panel (LAB07228) Urine HCG (LAB07904) (pst discharge labs will be rdered and mnitred by Child Prtectin Department) MEDICATION ORDERS: First dse administered in ED with ndansetrn (Zfran) befre discharge Three dse regimen is recmmended t limit emergence f resistance Dsing: Adults and adlescents age 12 and ver: Truvada (cmbinatin tenfvir DF 300mg/emtricitaine 200mg) p daily (supplied as cmbinatin tablet) AND Isentress (raltegravir) 400mg p BID (supplied as tablet) Adults and adlescents age 12 and ver with elevated creatinine fr age: Please check GFR based n the Schwartz frmula (GFR (ml/min/1.73 m 2 ) = (0.41 Height in cm)/creatinine in mg/dl) & discuss with nephrlgy befre starting NPEP AZT (zidvudine) & 3tc/Epivir (lamivudine) p with dses adjusted t degree f renal functin (supplied as cmpnent separate liquids) AND Isentress (raltegravir) 400mg p BID (supplied as tablet) Children age 4 weeks-11yrs: If child s creatinine is elevated fr age, cnsult nephrlgy befre starting NPEP AZT (zidvudine) (supplied as 10mg/ml ral slutin) Weight Dse 4 t <9 kg 12 mg/kg p BID 9 t <30 kg 9 mg/kg p BID > 30 kg 300 mg p BID Page 2 f 3 SAM Appendix B HIV Guidelines AND 3tc/Epivir (lamivudine) 4mg/kg p BID max 300mg/day (supplied as 10mg/ml ral slutin) AND Isentress (raltegravir) p (supplied as 100mg ral suspensin packets). Raltegravir suspensin administratin instructins: mix entire 100mg pwder packet w/5ml water. Cncentratin is 20mg/ml slutin. Withdraw crrect vlume fr dse and administer within 30 minutes f preparatin Dsing fr raltegravir ral suspensin packets (100mg packet). Weight Dse 3 t <4 kg 20 mg (1 ml) BID 4 t <6 kg 30 mg (1.5 ml) BID 6 t <8 kg 40 mg (2 ml) BID 8 t <11 kg 60 mg (3 ml) BID 11 t <14 kg 80 mg (4 ml) BID 14 t <20 kg 100 mg (5 ml) BID Dsing fr raltegravir chewable tablets (100ng tablet) Weight Dse 14 t <20 kg 100 mg (1 tab) BID 20 t <28 kg 150 mg (1.5 tabs) BID 28 t <40 kg 200 mg (2 tabs) BID > 40 kg 300 mg (3 tabs) BID

45 IMPORTANT MEDICATION CONSIDERATIONS: Area pharmacies are imprving their supply f stck NPEP medicatins but may nt have availability f NPEP meds fr hurs after receiving prescriptin. T address this cncern: If patient presents t the ED n Mnday-Friday 8:30 am t 4:30 pm, send a prescriptin fr npep t CGCH ACC Pharmacy as sn as yu knw the patient will be sent hme n npep. The pharmacy will prepare the prescriptins and deliver them t the ED fr pt discharge. Otherwise: Write prescriptin fr 28 day supply f medicatin. Assure crrect administratin frmulatin (liquid r pill frm). Administer the first dse f npep while patient is in the ED Instruct the caregiver t call their preferred pharmacy befre discharge t determine if they have the medicatin n hand (based n hurs pen). If their pharmacy is nt pen, des nt have the medicatin n hand, r the family des nt have a preferred pharmacy, prvide them with the fllwing pharmacy infrmatin: Schnucks Specialty Pharmacy Page Service Drive, Suite 101B, crner f Page & Lindbergh Open Mnday-Friday 9:00 am t 5:30 pm Family delivery services Pediatric frmulatins Need insurance inf Can eprescribe Walgreens Specialty Pharmacy Hamptn Ave. NE crner f Hamptn & Chippewa Pharmacy pen 24 hurs Can eprescribe Walgreens Specialty Pharmacy Lindell Blvd Pharmacy pen 24 hurs Can eprescribe Patient s lcal pharmacy may nly carry small supply. Parents shuld take prescriptin immediately t pharmacy f chice. It may take the pharmacy several hurs t lcate sufficient quantity f medicatin. Remember t supply family with a prescriptin fr 3-5 days f Zfran (ndansetrn) with refills. If additinal prescriptin is needed, advise them t speak with their physician r Child Prtectin when cntacted fr cnditin check Dcument explanatin f risks, benefits and decisin in EPIC Send EPIC message t Thrne,Debrah (Child Prtectin RN) regarding starting NPEP. Child Prtectin mnitrs cmpliance and symptms weekly and rders pst treatment testing B DISCHARGE PLAN: Refer t the apprpriate management guidelines fr discharge plan Page 3 f 3 SAM Appendix B HIV Guidelines

46 C SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 APPENDIX C: FORENSIC EVIDENCE COLLECTION IN AN ACUTE ASSAULT Several details factr int the decisin t perfrm an evidence cllectin kit. These include but are nt limited t: timing f assault/abuse; age & develpmental level f the initiatr/perpetratr vs. victim age & develpmental level; sexual explrative play vs. aggressin/pwer/cntrl; presence/absence f victim injury; escalating aggressin in initiatr/perpetratr; law enfrcement/children s Divisin (CD) suggestin. Fr example: Current statue in MO requires a family assessment when the initiatr is 14 yrs r yunger. CD autmatically invlves law enfrcement in all referrals. Law enfrcement becmes invlved in any case when the initiatr/perpetratr is 11 yrs r lder. An investigatin might be cnducted after the family assessment has ccurred and may r may nt prceed t prsecutin in juvenile curt. Since statutes vary in IL and MO, cntact the Child Prtectin MD n call fr guidance if cncerns arise regarding the apprpriateness f evidence cllectin in individual cases. INITIAL STEPS: Order all pertinent labs and medicatins befre beginning examinatin if pssible Review the Scial Wrker interview & Nursing Assessment t determine surces f evidence cllectin Assure all supplies and materials are available befre beginning examinatin: Camera with memry card and charged battery Wrking light surce Sufficient swabs, sterile water, and kit supplies Once evidence cllectin begins, pen evidence must be kept in line f sight t maintain chain f custdy. Nursing cannt leave the rm t get additinal supplies during exam Cmplete as much f the evidence cllectin kit s physician reprt as pssible at this time When child arrives t the ED, ask if clthing they are wearing was wrn at time f assault. The crime lab nly wants clthing that might have been tuched by the assailant r cntaminated w/dna secretins. D nt cllect shes r ther articles f clthing unless there is an index f suspicin abut DNA transfer. Nursing will remve and dcument clthing prcessed fr evidence. Each article f clthing is cllected, bagged separately in paper bags, and placed in a larger bag t cntain all articles f clthing befre sealing with evidence tape. Child shuld be in hspital gwn at start f examinatin. Remember, evidence cllectin will be prcessed at the crime lab, nt at Cardinal Glennn. If yu nte discharge r ther cncerns n examinatin and require labratry testing, request apprpriate testing materials fr medical management THE EXAMINATION & ADDITIONAL EVIDENCE COLLECTION: Begin with least invasive prtin f examinatin. Inspect skin frm head t te nting any bites, abrasins, r ther types f injury Phtdcument all injuries nted (see Appendix D fr additinal guidelines) Ask if the child was licked, kissed r bitten. Victims ften d nt vlunteer this infrmatin and need t be questined. The Blue Max Light (ALS) can als aid detectin f dried secretins which might yield DNA. The light is shne n the child s skin in a darkened rm while viewing thrugh the range filter. Any flurescent area shuld be swabbed. Page 1 f 3 SAM FORENSIC

47 Exterir skin surfaces: Swab any area child identifies as being licked, kissed r bitten, labial, external vaginal vestibule, penile glans, penile shaft r areas f flurscence. COLLECT TWO SWABS PER SITE. Misten first swab with single drp f sterile water. Rll swab ver surface using firm pressure (n scrubbing). Repeat prcedure ver same area using dry swab. Use sharpie t mark the wden base f the mist swab. The DNA yield n the first swab is the greatest. Place in dryer. Once dry, the tw swabs will be placed in a cardbard hlder fr that site. Each site will have its wn cardbard hlder C Oral Swabs: THERE SHOULD ALWAYS BE FOUR ORAL SWABS COLLECTED. Obtain ral swab fr reference standard if n genital t ral cntact ccurred. Cllect fur ral swabs fr reference standard swabbing between the cheeks and the teeth. If genital t ral cntact ccurred, nursing may draw bld fr reference standard r ral care may be prvided befre btaining reference standard. Oral swabs fr DNA retrieval shuld be btained between the upper AND the lwer lips AND gums AND under the tngue Buccal swab fr reference standard: Page 2 f 3 SAM FORENSIC

48 C Oral swab fr evidence cllectin: Prceed t genital examinatin Interir (rifice) swabs: COLLECT FOUR SWABS PER SITE if pssible per crime lab s request (4 vaginal, 4 rectal). Current data suggests cllecting frm all sites regardless f current disclsure as pediatric disclsures are usually incmplete r delayed. Mark the first swab s wden base with a sharpie t identify the first swab used. If perfrming a speculum exam, remember t swab the cervical s and under the cervix as well. Evidence may be recvered frm the cervix up t 5 days pst assault. Phtdcument genital exam while maintaining labial tractin in a female. Assistant may need t perfrm phtgraphy Perfrm any medical testing indicated in the curse f the examinatin AFTER THE EXAMINATION IS COMPLETE: IMMEDIATELY speak t yur patient abut what yu did and any medical findings. Prvide reassurance abut their bdily integrity t the best f yur ability. DO NOT refer t the evidence cllectin as a rape kit. This terminlgy can be upsetting and degrading t the victim. Order any additinal testing r treatment as a result f yur bservatins during the examinatin Cmplete dcumentatin and any discharge instructins Page 3 f 3 SAM FORENSIC

49 D SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 APPENDIX D: PHOTO-DOCUMENTATION OBTAIN EQUIPMENT: Digital camera with memry card and charged battery Patient label n index card (in SAM cart). Sign and print yur name under the patient label affixed t the card Phtmacrgraphic ruler (90 degree angle, 3in x 3 in, circles allw cmpensatin fr distrtin that might ccur in blique pht angles) D nt use paper tape ruler in rm Pen r marker OBTAIN CONSENT: SAFE CARE cnsent frm prvides cnsent fr phtdcumentatin f injuries & examinatin. When asking caregiver t sign frm, remember t explain that phtgraphs will be btained Separate cnsent frm fr phtgraphy is nt btained OBTAIN CLEAR PHOTOGRAPHS: Set camera t aut fcus & prtrait mde Assure the fcal pint (red dt in the viewfinder) is a single dt in the center f the viewfinder. The camera will fcus n that spt. If multiple dts are in the viewfinder, change the setting t a single center dt t prevent lss f fcus n the selected subject Prceed as fllws: First pht: signed index card with patient label Secnd pht: Full length pht f child Third pht: child s face Subsequent nn-genital phts: Fur phts f each injury preferred Clse up utilizing phtmacrgraphic ruler Clse up withut ruler Midrange identifying area f injury (i.e., jints abve & belw included) Lng range pht Cntinue until all nn-genital injuries are dcumented Genital phts: Clpscpic phtgraphy is preferred. If unavailable, utilize digital camera. Assistant may need t take phts while crrect labial tractin is perfrmed n females Clse up phts f genitalia with and withut phtmacrgraphic ruler are preferred. Mid & lng range phts are nt necessary Last pht: signed index card with patient label D NOT delete any blurry r pr quality phts On cmpletin f exam, submit memry card t Scial Services fr secure server dwnlad ADDITIONAL INFORMATION: Dcumentatin: EPIC dcumentatin shuld include descriptin f each injury and number f phts btained Page 1 f 2 SAM PHOTOS

50 Caregiver may ask abut distributin f phtgraphs. All phtgraphs are saved t a secure separate server with limited access. They are nt part f the child s medical recrd Nn-genital phtgraphs may be submitted t law enfrcement fr the purpse f investigatin Genital phtgraphs are NOT submitted t investigatrs. They are reviewed by Child Prtectin/SAM prviders and may be used as cmparisn during fllw up examinatins Example f stry bk phtdcumentatin: D Page 2 f 2 SAM PHOTOS

51 E SEXUAL ABUSE MANAGEMENT GUIDELINES 2018 APPENDIX E: DRUG-FACILITATED SEXUAL ASSAULT (DFSA) POINTS TO REMEMBER: Drug facilitated sexual assault (DFSA) is a sexual assault carried ut n a persn after the persn has becme incapacitated due t the influence f drugs, including alchl The mst cmmn drugs used t perpetrate sexual assault include: Alchl (ethanl) (38%) Tetrahydrcannabinl (THC) (18%) Benzdiazepines (8%) Alprazlam Clnazepam Diazepam Flunitrazepam (Rhypnl) Lrazepam Triazlam Gamma-hydrzybutyrate (GHB) 4% Gamma-butyrlactne (GBL) Butanedil (BD) Amphetamines: Methamphetamine MDMA Page 1 f 2 SAM DFSA Ccaine Muscle relaxants: Carisprdl Cyclbenzaprine Meprbamate Antihistamines: Diphenhydramine Chlral hydrate Txiclgy samples shuld be cllected as sn as pssible after DFSA is suspected due t the drug s shrt half-life Testing fr DFSA is a tw-prnged apprach: Bld & urine testing sent t CGCH labratry r reference facility t diagnse & crrectly treat the patient Bld & urine testing sent t the crime lab fr evidentiary purpses including chain f custdy & expert witness testimny Victims may need t repeatedly hear that vluntary use f drugs and/r alchl des nt minimize the seriusness f the assault INCLUSION CRITERIA: Rutine txiclgy testing is nt recmmended In any f the fllwing situatins, cllecting urine and/r bld may be indicated: If a patient s medical cnditin appears t warrant screening fr ptimal care (eg., memry lss, impaired mtr skills, intxicatin) If a patient r accmpanying persn states the patient was r may have been drugged

52 E If the patient suspects drug invlvement because f a lack f recllectin f events LABORATORY TESTING: (may vary fr nn-ssm rganizatins) Urine cmprehensive drug screen (drug screen tx urine panel) (LAB01638) n first available urine. This is a cmprehensive screen and takes apprx. 24 hurs t result ut. In additin, if limited drug panel is indicated fr mre immediate results ALSO rder UDS (LAB01632) Bld ETOH (LAB01215), assure skin prep is betadine nly and n alchl base EVIDENCE COLLECTION: (Utilizing Missuri Highway Patrl kits) Plice may be present fr cllectin f specimen Urine & bld are btained Prcedure perfrmed by nursing Assure skin prep fr bld draw is betadine nly and n alchl base MEDICATION ORDERS & TREATMENT PLAN: As indicated by symptm management and type f ingested substance DISCHARGE PLAN: See apprpriate guideline fr discharge plan. There is currently n Care Ntes entry fr drug facilitated sexual assault available. Page 2 f 2 SAM DFSA

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