338 Provider Opinions of Emergency Department HIV Testing Before and After Program Implementation

BackgroundNICE 2016 HIV testing guidelines now include the recommendation to offer HIV testing in Emergency Departments, in areas of high prevalence,1 to everyone who is undergoing blood tests. 23% of...

In the 27 years since HIV was first reported in the United States, an estimated 1.6 million people have been diagnosed with HIV, and more than 525,000 have died as a result of AIDS (Centers for Disease Control and Prevention [CDC], 2005). Currently, approximately 250,000 individuals in the United States are unknowingly infected with HIV, and approximately 40,000 new infections occur each year (CDC, 2006). As the HIV epidemic continues, the populations most deeply affected are racial and ethnic minorities and those who are socially and economically marginalized. These populations currently represent almost 70 percent of new cases of HIV infection (CDC, 2007). In addition to the disproportionate spread of HIV among these populations, access to primary and ongoing medical or preventive care is often a financial or logistical impossibility. Emergency departments (EDs) serve as an important part of this country's medical safety net, and those without access to primary medical care commonly use EDs as their sole source of care. The ED, therefore, is often the only medical venue available to target patients at increased risk of harboring unrecognized HIV infection, to identify those who are infected, and to link them into ongoing care. Successful performance of these services may ultimately affect this epidemic (Rothman, 2004). CDC RECOMMENDATIONS FOR HIV TESTING The CDC first released recommendations for performing HIV testing in health care settings in 1986, and in that document it encouraged voluntary HIV counseling and testing (CDC, 1986). Revised in 1993, the CDC recommendations focused further on the importance of prevention counseling--the process of engaging a patient in a discussion regarding HIV transmission and risk behaviors--and considered counseling a critical integrated component of testing (CDC, 1993). As the recommendations evolved, they continued to specifically advise that counseling be provided by a professional trained in HIV-specific counseling (CDC, 2001) and, until 2006, strongly endorsed the provision of counseling as part of HIV testing. To increase the absolute number of individuals tested for HIV infection and to minimize barriers associated with HIV testing, the CDC again revised its recommendations in September 2006. The most recent guidelines call for the following: incorporating nontargeted opt-out rapid HIV screening (that is, performing rapid HIV testing on all patients unless they specifically decline) into routine medical practice, integrating informed consent for HIV testing into the general medical consent (previously, separate informed consent had been standard), and uncoupling prevention counseling from HIV testing (that is, instead of providing prevention counseling in all cases, prevention counseling is now only recommended for all patients who test positive for HIV infection) (CDC, 2006). STRATEGIES FOR PERFORMING HIV TESTING IN EDS Several distinct methods of performing HIV testing in EDs have been described and evaluated and include the following three: (1) identifying patients at increased risk of HIV infection and referring them from the ED for outpatient HIV counseling and testing; (2) performing conventional (nonrapid) HIV testing in the ED and referring the patients to obtain test results and counseling at an outpatient clinic; and (3) performing rapid HIV testing, in which patients are tested and receive test results during the same ED visit. Adherence rates with the former two methods are low, and therefore, various models of ED-based rapid HIV testing have been developed to determine how to most effectively test patients at risk of HIV infection. Current rapid HIV testing strategies in EDs have been described and include the following: diagnostic testing (that is, performing rapid HIV testing on the basis of a patient's clinical signs or symptoms), targeted screening (that is, performing rapid HIV testing on all patients with specific HIV-related risk characteristics), and nontargeted screening (that is, performing rapid HIV testing on all patients regardless of their risk characteristics) (Rothman, Lyons, & Haukoos, 2007). …

Emergency Department HIV Testing and Counseling: An Ongoing Experience in a Low-Prevalence Area

2009 US Emergency Department HIV Testing Practices

Indicator condition-based and risk-factor guided HIV testing in the emergency department: An effective strategy to increase new diagnoses in Italy.

BackgroundPatient health-related social needs (HRSN) complicate care and drive poor outcomes in emergency department (ED) settings. This study sought to understand what HRSN information is available to ED physicians and staff, and how HRSN-related clinical actions may or may not align with patient expectations.MethodsWe conducted a qualitative study using in-depth semi-structured interviews guided by HRSN literature, the 5 Rights of Clinical Decision Support (CDS) framework, and the Contextual Information Model. We asked ED providers, ED staff, and ED patients from one health system in the mid-Western United Stated about HRSN information availability during an ED encounter, HRSN data collection, and HRSN data use. Interviews were recorded, transcribed, and analyzed using modified thematic approach.ResultsWe conducted 24 interviews (8 per group: ED providers, ED staff, and ED patients) from December 2022 to May 2023. We identified three themes: (1) Availability: ED providers and staff reported that HRSNs information is inconsistently available. The availability of HRSN data is influenced by patient willingness to disclose it during an encounter. (2) Collection: ED providers and staff preferred and predominantly utilized direct conversation with patients to collect HRSNs, despite other methods being available to them (e.g., chart review, screening questionnaires). Patients’ disclosure preferences were based on modality and team member. (3) Use: Patients wanted to be connected to relevant resources to address their HRSNs. Providers and staff altered clinical care to account for or accommodate HRSNs. System-level challenges (e.g., limited resources) limited provider and staff ability to address patients HRSNs.ConclusionsIn the ED, HRSNs information was inconsistently available, collected, or disclosed. Patients and ED providers and staff differed in their perspectives on how HSRNs should be collected and acted upon. Accounting for such difference in clinical and administrative decisions will be critical for patient acceptance and effective usage of HSRN information.

The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic. To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis. This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios. Patients attended 34 Spanish EDs. The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results. The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI). HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests. Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses.

Undiagnosed HIV infection remains the main driver of new HIV cases in Western countries. Emergency Departments (EDs) offer a key opportunity for detection. In 2020, Spanish emergency and infectious diseases societies recommended an opt-in strategy for targeted conditions for HIV testing in EDs. This study evaluates the efficacy of three strategies for targeted HIV testing. Twelve Spanish EDs, selected based on predefined structural criteria, assessed HIV testing from April to June 2024. Hospitals applied: no strategy (control, three EDs), an educational programme (strategy A, three EDs), strategy A plus preconfigured electronic orders (strategy B, three EDs) or strategy B plus electronic alerts in medical records (strategy C, three EDs). The impact on HIV testing was measured overall and by targeted condition, using absolute differences with 95% confidence intervals (CIs). Of the 612 909 ED visits, 210 039 occurred in control hospitals (1232 patients [0.59%] had targeted conditions), 172 806 in hospitals applying strategy A (1497 [0.87%]), 132 835 in strategy B hospitals (1761 [1.33%]) and 97 229 in hospitals applying strategy C (1269 [1.31%]). Testing rates were 0.16%, 0.38%, 1.17% and 2.16% in the control, and strategy A, B and C EDs., respectively. Among patients with targeted conditions, testing reached 13.1%, 22.9%, 30.7% and 78.1%. Compared to no strategy, testing increased by 0.22% (95% CI = 0.18-0.25) with strategy A, 0.79% (95% CI = 0.73-0.86) with B, and 0.98% (95% CI = 0.88-1.09) with C. In targeted conditions, testing rose by 9.8%, 7.8% and 47.5% for strategies A, B and C, respectively. All strategies improved testing in sexually transmitted infections (STI), meningitis/neurological syndromes and community-acquired pneumonia (CAP); strategy C also increased testing in herpes zoster (HZ) and post-exposure prophylaxis. All the strategies evaluated enhanced targeted HIV testing, especially strategy C (electronic alerts), which was associated with the highest testing rates observed, particularly in STI, CAP and HZ.

Background Limited information is available on the extent of Emergency Department (ED) staff knowledge of frailty and frailty screening tools. Educational challenges unique to the ED environment are also little researched. This multi-site staff survey explores frailty knowledge and use of frailty screening tools in Irish emergency departments, as well as detailing educational challenges faced in the ED environment Methods A mixed-methods multi-site survey of twenty-five Irish adult emergency departments, aimed at all grades of ED staff. An anonymous online survey consisting of twenty-five statements across five categories was distributed via staff email at these sites. Five free-text sections were included after each category. Quantitative data were managed and analysed using IBM SPSS Statistics software. Qualitative results were analysed using reflexive thematic analysis Results 181 ED staff (nursing, medical and allied health) across all grades responded to the survey. ED nursing staff made up the largest staff category (n=80, 44%). Less than half of respondents had received training on frailty identification (n=88, 48%,p=0.028), yet the majority felt confident of identifying frailty (n=99, 54%, p=0.007). ED staff aged under 35 years felt nursing staff were the most appropriate group to screen for frailty in ED (N=88, 87%, P=0.017). Most respondents felt overwhelmed by time pressures in ED, which left little opportunity for dedicated teaching (n=77, 45%). A thematic map was created to explore obstacles to frailty screening in ED. Conclusion The opinion of ED staff surveyed was that frailty screening is feasible to undertake in ED but quick, user-friendly frailty screening instruments are lacking. Most ED staff surveyed relied on clinical judgement rather than frailty teaching experience to diagnose frailty syndromes. The provision of inclusive education in ED is challenging. Learning strategies in ED should reflect the demands of the acute care environment and incorporate a flexible, hybrid multi-disciplinary teaching model

New Centers for Disease Control and Prevention (CDC) guidelines recommend routine HIV screening in locations including emergency departments. This study evaluates a novel approach to HIV counseling and testing (C&T) in a high-volume inner-city emergency department in terms of the number of patients who can be recruited, tested, test positive, and are linked to care. This prospective evaluation was conducted for 26 months. Noncritically ill or injured patients presenting to an inner-city emergency department were recruited. Patients used a multimedia program that facilitated data entry and viewed previously evaluated HIV counseling videos. Demographic characteristics, risk factors, and sexual history were collected. Data were collected on the number of patients tested, number of HIV-positive patients identified, and number linked to care. Demographic characteristics of the participants were as follows: 48.7% males, mean age 32.6 +/- 11.3, 34.6% Hispanic, and 37.9 % African American. Of the 7109 eligible patients approached, 6214 (87.4%) agreed to be HIV tested. There were 57 newly diagnosed or confirmed HIV-positive patients, representing a seroprevalence of 0.92%. Of those testing positive, 49 (84.2%) were linked to care and had a mean initial CD4 count of 238 cells/mm(3). In conclusion, a video-assisted rapid HIV program in a busy inner-city hospital emergency department can effectively test a high volume of patients and successfully link HIV-positive individuals to care, while providing high-quality education and prevention messages for all those who test.

BackgroundOn World AIDS Day 2021, the UK Government committed £20 million to expand opt-out HIV testing in EDs in extremely high HIV prevalence (>5/1000) areas as part of their commitment...

Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique) and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. During the baseline period, 321 of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% confidence interval [CI] = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.

Linkage to Care, Antiretroviral Treatment Initiation, and Viral Suppression of Acute HIV-Infected Individuals Identified From an Emergency Department–Based HIV Screening and Linkage-to-Care Program

OBJECTIVE: To determine whether emergency department staff met the needs of the next of kin and close friends ("survivors") of patients dying in an emergency department and to assess the effectiveness of a program to improve care of survivors. DESIGN: Mail survey before and after program implementation. SETTING: Emergency department of a tertiary care, adult teaching hospital. PARTICIPANTS: Two groups of survivors, identified through a review of emergency department records of deaths during two 6-month periods. In the first group, surveyed in 1987, before program implementation, 26 (53%) of 49 responded; in the second group, surveyed in 1990, after program implementation, 40 (70%) of 57 responded. INTERVENTIONS: A structured, multidisciplinary protocol for notifying next of kin of death and supporting the survivors was implemented. An educational program was provided to all emergency department staff. An information pamphlet was created and provided to survivors. MAIN OUTCOME MEASURES: Questionnaire responses regarding the adequacy and timeliness of information provided, the support and actions by emergency department staff and the survivors9 desire to be present during resuscitation efforts. RESULTS: Comparison of responses before and after program implementation showed that adequate information was provided before notification of death in 32% and 83% of cases respectively (p &lt; 0.001), lengthy delays in receiving medical information occurred in 60% and 15% of cases (p &lt; 0.01), adequate medical information concerning the events of death was provided in 53% and 88% (p &lt; 0.05), the presence of emergency department staff was sufficient in 40% and 79% (p &lt; 0.01), survivors spent less than 2 hours in the emergency department in 50% and 81% (p &lt; 0.05), and survivors expressed a desire to be present during resuscitation efforts in 95% and 11% of cases (p &lt; 0.001). CONCLUSION: The grievous experience of learning that a loved one has suddenly and unexpectedly died in the emergency department can be alleviated somewhat by a structured, multidisciplinary approach combined with staff sensitization and education.

BackgroundEmergency Departments (EDs) are important sites for HIV testing. However, there is little guidance on how best to implement HIV testing in the ED. The purpose of this study was to evaluate HIV screening practices of high-risk individuals presenting to an ED in the absence (ED1) and in the presence (ED2) of an established HIV testing program within the same academic hospital.MethodsWe performed a retrospective chart review of all individuals 18 years or older presenting to either ED between January 1, 2016 and December 31, 2018. High-risk of HIV infection was determined by receipt of bacterial sexually transmitted infection (STI) testing for Neisseria gonorrhoeae or Chlamydia trachomatis. The primary outcome was receipt of any HIV test in the ED. Overall proportions of patients tested for HIV at the same time of STI testing were compared between sites by chi-square test. Predictors of HIV testing were analyzed by logistic regression.ResultsDuring the study period, 7,956 individuals received STI testing at ED1 and 10,815 received STI testing at ED2. The majority of individuals receiving STI testing at both sites were female, 81.2% at ED1 and 66.4% at ED2 (P <0.001). Only 4.0% of individuals received HIV testing at ED1 compared with 47.4% at ED2 (P <0.001). Individuals were significantly more likely to receive HIV testing at the time of STI testing in the ED with an HIV testing program (aOR 19.66, 95% CI 17.28–22.37). In the ED without an HIV testing program, individuals were more likely to receive HIV testing if they were male (aOR 3.57, 95% CI 2.78–4.55) and less likely if they were black (aOR 0.57, 95% CI 0.50–0.97). In the ED with an HIV testing program, individuals were more likely to receive HIV testing if they were male (aOR 2.17, 95% CI 1.92–2.44) and more likely if they were black (aOR 1.74, 95% CI 1.37–2.20).ConclusionOverall, the presence of an HIV testing program in the ED significantly increased the probability that individuals would receive an HIV test at the time of bacterial STI testing and mitigated disparities in care. The results of this study will help guide ongoing interventions to improve HIV screening among high-risk individuals in the emergency department.DisclosuresAll authors: No reported disclosures.