Preventive Care in the Emergency Department: Should Emergency Departments Conduct Routine HIV Screening? A Systematic Review

OBJECTIVE: To perform a systematic review of the emergency medicine literature to assess the appropriateness of offering routine HIV screening to patients in the emergency department (ED). METHODS: The systematic review was conducted with the aid of a structured template, a companion explanatory guide, and a grading and methodological scoring system based on published criteria for critical appraisal. Two reviewers conducted independent searches using OvidR, PubMed, MD Consult, and Grateful Med. Relevant abstracts were reviewed; those most pertinent to the stated objective were selected for complete evaluation using the structured template. RESULTS: Fifty-two relevant abstracts were reviewed; of these, nine were selected for detailed evaluation. Seven ED-based prospective cross-sectional seroprevalence studies found HIV rates of 2-17%. Highest rates of infection were seen among patients with behavioral risks such as male homosexual activity and intravenous drug use. Two studies demonstrated feasibility of both standard and rapid HIV testing in the ED, with more than half of the patients approached consenting to testing by either method, consistent with voluntary testing acceptance rates described in other settings. Several cost-benefit analyses lend indirect support for HIV screening in the ED. CONCLUSIONS: Multiple ED-based studies meeting the Centers for Disease Control and Prevention Guideline threshold to recommend routine screening, in conjunction with limited feasibility trials and extrapolation from cost-benefit studies, provide evidence to recommend that EDs offer HIV screening to high-risk patients (i.e., those with identifiable risk factors) or high-risk populations (i.e., those where HIV seroprevelance is at least 1%).     

Estimated Risk for Undiagnosed Diabetes in the Emergency Department: A Multicenter Survey

Background One third of the 21 million Americans with diabetes remain undiagnosed. The emergency department (ED) is a novel setting for diabetes screening.
Objectives To estimate risk factors for undiagnosed diabetes in the ED.
Methods This was a cross sectional survey in five Boston EDs. The authors enrolled consecutive adults without known diabetes over two 24-hour periods at each site. The focus was on diabetes risk factors and estimated risk for diabetes on the basis of American Diabetes Association (ADA) criteria. The authors also examined prior diabetes testing and willingness to participate in ED-based diabetes screening.
Results Six hundred four patients (70% of eligible) were enrolled. On the basis of ADA risk score, 33% (95% confidence interval [CI] = 29% to 37%) were high risk for undiagnosed diabetes, and an additional 42% (95% CI = 38% to 46%) had elevated risk. For example, 58% (95% CI = 54% to 62%) of participants were overweight or obese (body mass index of ≥25). Among these at-risk participants without prior diabetes testing, 73% (95% CI = 66% to 80%) reported amenability to having additional blood drawn for ED diabetes screening, and 98% (95% CI = 96% to 100%) indicated that they would follow up for confirmation of abnormal screening.
Conclusions Many ED patients in the study had risk factors for undiagnosed diabetes. Patient attitudes toward ED-based diabetes screening support further exploration of this important and currently underutilized opportunity for public health intervention.     

Multicenter survey of emergency physician management and referral for hyperglycemia

Background: The Emergency Department (ED), with its high-risk and often disenfranchised patient population, presents a novel opportunity to identify patients as having undiagnosed or uncontrolled diabetes. Objective: To evaluate Emergency Physician opinion on management and referral for incidental hyperglycemia and on ED-based diabetes screening. Methods: We conducted a web-based survey of all attending and resident Emergency Physicians at three academic EDs. We asked for glucose thresholds to treat and refer non-diabetic and diabetic ED patients for hyperglycemia, comparing physicians' ideal and actual practices. We also inquired about interest in and barriers for active ED-based diabetes screening compared to use of blood glucose values obtained during usual ED care. Results: We contacted 185 physicians, and 152 (85%) completed the survey; 75% of respondents reported routine outpatient referral of non-diabetic patients for random glucose values ≥ 200 mg/dL. However, a majority (71%) believed that they should use a lower threshold to refer than they currently use. Nearly all (92%) agreed that Emergency Physicians should inform non-diabetic patients of elevated glucose values; 53% supported and 21% opposed active ED-based screening of asymptomatic patients. The most commonly cited barriers were limited follow-up (69%), insufficient time/resources (51%), and outside scope of practice (36%). Conclusion: Emergency Physicians support improved recognition of and referral for hyperglycemia, based on glucose values collected during usual ED care. We plan to develop tools to interpret random ED glucose values in the context of undiagnosed and uncontrolled diabetes.     

ED length-of-stay and illness severity in dizzy and chest-pain patients

Emergency department (ED) length of stay, illness severity, and patterns of ED-based testing can be used to compare different ED patient populations. To assess the relative significance of ED patients with dizziness and chest pain in emergency medicine practice, the investigators formed a retrospective chart review of 3,864 adults (age ≥16 years) seen at the University of North Carolina Hospitals' ED during May and June of 1991. Patients were eligible if they had any complaint of dizziness (n = 259), nontraumatic chest pain (n = 168), or both (n = 18). ED length of stay and illness severity, as measured by Acute Physiology and Chronic Health Evaluation (APACHE) II score, were not significantly different between the two groups. Dizzy and chest-pain patients were both high users of ED-based testing, but management patterns were different. Chest-pain patients were more likely to undergo electrocardiogram and x-ray testing, whereas dizzy patients more often received testing such as brain computed tomography scanning (10.8% v 3.6%, P = .01). ED patients with dizziness and chest pain were similar with regard to ED length of stay. Given their overall similarities to the chest-pain group, dizzy patients appear to represent a significant population of ED patients and may warrant more clinical study.     

Tuberculosis Exposure Risk in Emergency Medicine Residents

OBJECTIVES: To assess purified protein derivative (PPD) test surveillance and respiratory protection practices of emergency medicine (EM) residents, along with the prevalence of PPD test conversion and the development of active tuberculosis (TB) in EM residents. METHODS: The study instrument was an anonymous, self-reporting, multiple-choice survey administered to U.S. and Canadian EM residents. It was distributed for voluntary completion in conjunction with the American Board of Emergency Medicine's annual in-service examination, which was administered February 25, 1998. RESULTS: A total of 89.3% (n = 2,985) of residents eligible to complete the survey completed at least part of it. The majority of residents are PPD-tested once a year. The prevalence of PPD test conversions in EM residents was between 1.4% (36/2,575) and 2.0% (52/2,575). Of the residents who PPD test-converted, the ED was most often the perceived area of TB source exposure (n = 15). Two residents (0.08%) reported having developed active TB, including chest radiographic findings or clinical infection, which equals a 0.14% (95% CI = 0.005 to 0.31) risk of developing active TB over a three-year residency. Half of all the residents do not routinely wear National Institute for Occupational Safety and Health (NIOSH)-approved particulate filtration respirator (PFR) masks in patient encounters at risk for TB exposure. While more than a third of EM residents have not undergone fit testing for a NIOSH-approved PFR mask, the lack of routine easy availability of such masks is the most common reason they are not routinely worn by EM residents during at-risk encounters for TB transmission. CONCLUSIONS: Most surveillance PPD testing of EM residents is performed at intervals recommended by the CDC. TB control programs at institutions sponsoring EM residencies need to improve both compliance with PFR mask fit testing by EM residents and availability of approved PFR masks in appropriate areas of the ED. Despite poor compliance with personal respiratory protection in ED patient encounters at risk for TB transmission, the risk of an EM resident's developing active TB over a three-year residency is low.     

Feasibility of screening and intervention for alcohol problems among young adults in the ED

This study evaluates the feasibility of screening and brief intervention (SBI) for alcohol problems among young adults (18-39 years) in a rural, university ED. Research staff screened a convenience sample of patients waiting for medical treatment with the Alcohol Use Disorders Identification Test (AUDIT), used motivational interviewing techniques to counsel screen-positive patients (AUDIT >/= 6) during the ED visit, and referred patients to off-site alcohol treatment as appropriate. Patients were interviewed again at 3 months. Eighty-seven percent of age-eligible drinkers (2,067 of 2,371) consented to participate. Forty-three percent (894 of 2,067) screened positive, of which 94% were counseled. Forty percent of those counseled set a goal to decrease or stop drinking and 4% were referred for further treatment. Median times for obtaining consent, screening, and intervention were 4, 4, and 14 minutes, respectively. Project staff reported that 3% of patients screened or counseled were uncooperative. Seventy percent of 519 patients who participated in follow-up interviews agreed the ED is a good place to help patients with alcohol problems. High rates of informed consent and acceptance of counseling confirmed this protocol's acceptability to patients and indicated patients were comfortable divulging alcohol-related risk behavior. The modest times required for the process enhanced acceptability to patients as well as ED staff. The high prevalence of alcohol problems and the broad acceptance of SBI in this sample provide evidence of the ED's promise as a venue for this clinical preventive service.     

Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City

BackgroundPreviously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach.ObjectivesWe examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED.MethodsRetrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion.ResultsThere were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%.ConclusionsNontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.     

Trial study design to test a bilingual digital health tool for alcohol use disorders among Latino emergency department patients

We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.     

Trial study design to test a bilingual digital health tool for alcohol use disorders among Latino emergency department patients

We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.     

Evaluation of the diagnostic utility of a whole-blood interferon-gamma assay for determining the risk of exposure to Mycobacterium tuberculosis in Bacille Calmette-Guerin (BCG)-vaccinated individuals

We evaluated the utility of the "QuantiFERON-TB Gold In-Tube" (QuantiFERON) test that uses tuberculosis (TB)-specific antigens for the diagnosis of latent infection in such individuals. We also examined the correlation between the interferon (IFN)-gamma response to these antigens and the exposure risk to TB by evaluating antigen-specific IFN-gamma release in comparison with IFN-gamma release in response to purified protein derivative (PPD) in 3 groups: medical students, nurses in a TB hospital, and TB patients. All nurses and TB patients responded to PPD, whereas 52% (P < 0.0001) and 79.2% (P = 0.04) responded to QuantiFERON, respectively. In the medical students, only 10.4% responded to QuantiFERON, whereas 85.2% were positive to PPD (P < 0.0001). There was also a significant correlation between the levels of IFN-gamma production and the duration of employment in the group of nurses at the TB hospital, suggesting ongoing exposure in this high-risk group. Thus, these results demonstrate that Mycobacterium tuberculosis-specific IFN-gamma release assay accurately discriminates low- and high-risk healthy subjects and might therefore be a useful diagnostic tool for the diagnosis of latent infection in Bacille Calmette-Guerin (BCG)-vaccinated individuals.     

Multicenter Study of Case Finding in Elderly Emergency Department Patients

Objectives: To assess the feasibility of a brief comprehensive case-finding program for detecting functional, cognitive, and social impairments among elderly ED patients and to estimate the prevalence of unknown, undetected, or untreated impairments elderly patients may have. Methods: A multicenter prospective study conducted at five private and public hospital EDs in five different communities across the country. Patients aged 60 years and older released to their homes during 52 randomly selected evening and weekend shifts between February 1 and April 30, 1993, were eligible for the case-finding program. They were evaluated by medical students who received special training (instructional videotape, supervised examinations, and conference calls) in the administration of a standardized 17-item protocol that included an interview and simple tests of function. The patients' physicians were notified of the screening results and were asked to return a one-month follow-up questionnaire. The physicians answered whether the presumed problem had been confirmed and whether a treatment plan for a new problem had been developed. Results: Patient acceptance of the case-finding program was good; 252 of 338 eligible patients (75%) agreed to participate, and 281 conditions were detected for 242 screened patients (96%). The most frequently reported problems were with: performing the activities of daily living (79%); vision (55%); lack of influenza vaccination (54%); home environment (49%); mental status (46%); general health (41%); falls (40%); and depression (36%). The physicians returned questionnaires for 153 patients (63%); 76 patients (50%) were evaluated at follow-up visits, during which 47 newly identified problems (62%) were confirmed and treatment plans were developed for 25 problems (53%) among 21 patients. A mean time of 17.7 ± 10.2 minutes was required to complete the screen. Conclusions: A brief comprehensive case-finding program for functional, cognitive, and social impairment among elderly ED patients is feasible. The screening uncovered a significant amount of morbidity among older patients visiting EDs.     

Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently Crowded

Objectives: The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high‐risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population. Methods: A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June–August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers’ opinions) and the prevalence of AAA (aortic diameter of ≥3.0 cm) in the study sample. Results: During the 12‐week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening. Conclusions: Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high‐risk patients.     

Screening and Empiric Treatment for Syphilis in an Inner-city Emergency Department

Objective: To examine targeted screening and empiric treatment for syphilis in an urban ED. Methods: Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a university-affiliated, inner-city ED. Emergency patients who perceived that they had high-risk factors for syphilis (i.e., cocaine or heroin use or sexual contact with a user of these substances) were compared with emergency patients denying high risk. All presumed high-risk patients and alternate patients in the group who denied high risk (control group) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR-positive and gave no previous history of syphilis. In addition, serum was submitted to the state laboratory for VDRL and microhemagglutination-Treponema pallidum (MHA-TP) testing. Blinded serologic testing for HIV antibody was performed later on frozen serum. Results: Of 806 patients presenting to the ED, 276 (34%) admitted to high-risk behavior. Of 373 patients tested by RPR in the ED (216 high-risk and 157 control patients), no significant difference was found between the high-risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or positive MHA-TP [47 (22%) vs 25 (16%)]. In the high-risk group, the women were more likely than the men to be MHA-TP-positive (OR = 2.58, 95% CI 1.12–7.98, p = 0.04). Among the women, the MHA-TP was more often positive for the high-risk than for the control patients (34% vs 15%, OR = 2.27, 95% CI 1.12–4.67, p = 0.023). For the high-risk group, seven (3%) new cases of syphilis were managed empirically. vs three (2%) new cases for the control group. HIV antibodies were detected in 16 of 212 (8%) high-risk patients and five of 155 (3%) control subjects (p = 0.13). Conclusion: This inner-city ED population has a high frequency of positive syphilis and HIV serologies, regardless of acknowledged drug use risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphilis to all emergency patients, along with establishment of adequate counseling and follow-up.     

Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.     

Optimizing emergency department care transitions to outpatient settings: A systematic review and meta-analysis

IntroductionSuboptimal transitions from the emergency department (ED) to outpatient settings can result in poor care continuity, and subsequently higher costs to the healthcare system. We aimed to systematically review care transition interventions (CTIs) for adult patients to understand how effective ED-based CTIs are in reducing return visits to the ED and increasing follow-up visits with primary care physicians.MethodsWe searched multiple databases and identified eligible published RCTs of ED-based CTIs affecting outpatient follow-up rates, ED readmission and hospital admission. Two independent authors reviewed titles and abstracts for potential inclusion and selected studies for full review. Study quality was assessed using the Cochrane risk-of-bias tool. ED-based CTIs were classified using a care continuity framework.ResultsOur search generated 28,807 articles; 112 were selected for full-text review. Data were abstracted from 42 articles that met inclusion criteria. Pooling data from 20 studies (n = 8178 patients) found a relative increase in outpatient follow-up with ED-based CTIs compared to routine care (odds ratio 1.79, 95% confidence interval [CI] 1.43, 2.24). However, ED-based CTIs (20 studies, n = 8048 patients) had no significant effect on ED readmissions (odds ratio 1.02, 95% CI 0.87, 1.20]) or hospital admission after ED discharge (13 studies, n = 5742 patients) (odds ratio 0.99, 95% CI 0.86, 1.14) when compared to routine care. Twenty-two studies encompassed CTIs supporting all three functions of care continuity (information, communication and coordination).ConclusionsED-based CTIs do not appear to reduce ED revisit or hospital admission after ED discharge but are effective in increasing follow-up.     

Emergency Department Staff Satisfaction With Rapid Human Immunodeficiency Virus Testing

Objectives: The authors sought to determine staff satisfaction with an emergency department (ED) rapid human immunodeficiency virus (HIV) testing program. Methods: A survey was conducted in an urban ED that has provided rapid HIV testing (routine screening and physician‐initiated testing) since August 2007. From May 1, 2008, to August 31, 2008, the survey was administered to all ED staff involved with HIV testing. The primary outcome was satisfaction, and secondary outcomes were the staff attitudes toward the program. Results: Surveys were administered to 215 of the 217 staff members, and 207 surveys were returned (96% response rate); 201 surveys had complete data available for analysis. The response rate by staffing type was as follows: physicians 64/64 (100%), nurses 124/134 (93%), and registration staff 16/19 (84%). The majority of ED staff (99%; 95% confidence interval [CI] = 95% to 100%) were satisfied with the HIV testing program. Physicians, however, rated the program more favorably than nurses or registration staff. Most staff members agreed that HIV testing improved overall care (93%; 95% CI = 89% to 96%) and felt that HIV testing did not interfere with their ability to provide care (82%; 95% CI = 76% to 87%). The majority of staff perceived that patients were satisfied with the procedures for obtaining consent (73%; 95% CI = 67% to 79%) and with the way HIV testing was performed (83%; 95% CI = 77% to 87%). Conclusions: Emergency department staff satisfaction and overall attitudes with the HIV testing program is high. ED staff does not appear to be a barrier to program implementation. ACADEMIC EMERGENCY MEDICINE 2010; 17:561–565 © 2010 by the Society for Academic Emergency Medicine     

Respiratory Isolation of Patients with Suspected Pulmonary Tuberculosis in an Inner-city Hospital

Objective : To identify clinical factors that predict which patients presenting to the ED with pneumonia will require respiratory isolation for suspected tuberculosis and to evaluate a protocol for rapid identification of patients at risk for pulmonary tuberculosis (PTB). Methods : To identify potential clinical indicators of PTB, a case-control study was performed using patients admitted to an urban teaching hospital with the ED diagnosis of pneumonia (derivation sample). These predictors were then evaluated in a separate prospective observational study of 103 patients admitted to the same institution from July 1994 to February 1995. Adult patients with the admitting diagnosis of pneumonia were admitted to a respiratory isolation bed if they met 1 of the following criteria: 1) HIV-positive or unknown HIV status with a history of injection drug use; 2) chest x-ray consistent with PTB; or 3) pneumonia with 1 of the following: PPD conversion within 2 years, recent exposure to PTB, previous PTB, or hemoptysis. Patients who did not meet isolation criteria were admitted to the medical ward and had a PPD and anergy panel placed. Those who were anergic or PPD-positive were transferred to respiratory isolation. Results : Predictor variables identified during the first study phase were incorporated into the isolation guidelines noted above. Only 36 of 50 (72%) PTB patients were admitted to an isolation bed during this phase. During the second phase, 103 patients were admitted with the ED diagnosis of pneumonia-rule out PTB; 22 patients (22%) were culture-confirmed positive for PTB. The guidelines predicted PTB as follows: sensitivity, 0.96 (95% CI, 0.88–1.0); specificity, 0.14 (95% CI, 0.08–0.24); positive predictive value, 0.23 (95% CI, 0.17–0.35); and negative predictive value, 0.92 (95% CI, 0.77–1.0). The 1 patient who was not isolated was found to be anergic after 48 hours and subsequently isolated. Conclusion : Respiratory isolation guidelines for patients admitted from the ED with pneumonia were developed and validated. These guidelines provide satisfactory guidance for isolation of patients at risk for PTB in a high-PTB-prevalence population.     

Southside medical homes network: linking emergency department patients to community care

BBACKGROUND The 14 neighborhoods surrounding University of Chicago Hospitals (UCH) have both Chicago's highest "ambulatory-care-sensitive condition" hospitalization rates and lack of community-based care. To address these problems, in 2004, the Southside Medical Homes (SMH) Network began linking emergency department (ED) patients with 18 community providers. The ED-based patient navigator (patient advocate) is an integral component of this network, and both their current and developing roles will be discussed. MMETHODS Six navigators worked in the UCH-ED approached eligible patients that are flagged by the ED electronic tracking system. Patients were offered the services provided by primary-care referral and appropriate dental, mental health, and substance abuse facilities. Appointments were scheduled, and pertinent ED medical data was faxed to the outlying sites. Navigator roles were expanding with SMH to include: (1) focus on frequent user/chronic disease populations such as sickle cell disease where advocates will expedite a multidisciplinary clinic referral; (2) navigator training to better inform patients of the specific benefits a "medical home" provides for preventive and psychosocial care; (3) and improving navigator, and secondarily, patient knowledge, of community resources: health-education sites, vocational programs, advocacy agencies, support groups, etc. RRESULTS/CONCLUSIONS Data through 01 July 2007 show a monthly average of 950 ED patients surveyed and 80% of these accepting follow-up referral services. Of those patients with ED-scheduled appointments (43%) in community clinics, network data shows patients returning to their referred providers: 39% of patients have been -> or = times. The navigator role is evolving with the expansion of SMH to include: (1) frequent-user population referrals; (2) preventive health education; and (3) utilization of community resources.     

Design and Implementation of a Controlled Clinical Trial to Evaluate the Effectiveness and Efficiency of Routine Opt-out Rapid Human Immunodeficiency Virus Screening in the Emergency Department

In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.