Availability of Rapid Human Immunodeficiency Virus Testing in Academic Emergency Departments

Objectives:  The Centers for Disease Control and Prevention (CDC) recommends routine human immunodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. The study objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify factors that influence an ED's adoption of testing, and to describe current HIV testing practices.
Methods:  Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs ( n  = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent ( n  = 102) responded. Most e-mail recipients ( n  = 121) were Emergency Medicine Network (EMNet) investigators; remaining contacts were obtained from residency-related Web sites.
Results:  Most academic EDs ( n  = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIV testing. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32 EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than 10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offer HIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation could link an HIV-positive patient to subspecialty care. The facility characteristic most important to availability of rapid HIV testing was the presence of on-site HIV counselors.
Conclusions:  Most academic EDs now offer rapid HIV testing (57%), but few use it in situations other than occupational exposure. Less than half of academic EDs expect to implement CDC guidelines regarding routine screening within the next few years. The authors identified facility characteristics (e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.     

Risk of human immunodeficiency virus infection for emergency department workers

To evaluate the risk of human immunodeficiency virus (HIV) exposure among emergency department workers (EDWs) and their ability to identify HIV-infected patients, a seroprevalence study was performed in March 1991 in the emergency departments (EDs) of six Italian urban hospitals. At each visit, patients aged 18–65 years were asked to undergo fingerstick blood sampling for anonymous, unlinked HIV testing performed on blood adsorbed filter paper collection cards. Demographic characteristics, known or suspected HIV risk factors, and occupational exposures reported by the EDWs during the patient's visit were recorded. On 9,457 consecutive visits, 9,005 samples (95%) were tested and 65 (0.7%) were HIV positive. ED staff failed to identify 59% of HIV-infected patients. The rate of occupational exposures was 0.13/100 visits. As it is impossible to predict the HIV status of patients attending EDs, adherence to universal precautions and the development of safer devices should be utilized to minimize the risk of blood-borne infections in EDWs.     

HIV testing in US EDs, 1993-2004

Objectives

The aims of the study were to (1) estimate the incidence rates (IRs) of human immunodeficiency virus (HIV) testing among 13-year-old to 64-year-old patients in US emergency departments (EDs); (2) determine ED compliance with Centers for Disease Control and Prevention (CDC) recommendations for HIV testing for patients with nonsexual blood or body fluid exposures, sexually transmitted diseases (STDs), and sexual assaults; and (3) ascertain if HIV testing in EDs varies by patient demographic characteristics.

Methods

The ED visits from the National Hospital Ambulatory Medical Care Survey databases (1993-2004) were analyzed. Visits for nonsexual blood or body fluid exposures, STDs, and sexual assaults were identified using diagnosis and cause codes. Incidence rates for HIV testing were estimated by year. Odds ratios (ORs) with 95% confidence intervals were estimated from multivariable logistic regression models using HIV testing as the outcome and demographic characteristics as covariates.

Results

The average IR of HIV testing for 13-year-old to 64-year-old patients from 1993 to 2004 was 0.31%. Of all patients, 35.1% with nonsexual blood or body fluid exposures, 20.4% with sexual assaults, and 2.6% with STDs were tested for HIV. The HIV testing was more frequent among Hispanics (OR, 1.39 [1.06-1.81]), blacks (OR, 1.52 [1.19-1.94]), patients with Medicaid (OR, 2.35 [1.81-3.03]), Medicare (OR, 1.95 [1.20-3.16]), and self-pay/no charge/other type of insurance (OR, 1.74 [1.35-2.23]), and those visiting EDs in the northeastern United States (OR, 1.57 [1.04-2.38]).

Conclusions

The HIV testing rates are low in US EDs and have changed little for a 12-year period. Compliance with CDC recommendations for HIV testing is poor and not in accordance with risk for infection. Hispanics, blacks, and those without private health care insurance are being tested more frequently than other ED patients.     

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services

ObjectivesRoutine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation.MethodsCross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017–July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care.ResultsThere were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%–8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%–23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services.ConclusionsPatients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.     

Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties

BackgroundRefocused national HIV testing initiatives include a geographic focus.ObjectiveUsing a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example.MethodsRetrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties.ResultsOf the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01).ConclusionsEDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.     

The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program

This study was performed to determine the rate of previously undiagnosed HIV infection among patients presenting to an urban emergency department (ED) and to assess the feasibility of routinely offering voluntary HIV testing in this setting. HIV serostatus was determined anonymously among consecutive acute medicine and trauma ED patients (aged 18-55) who had blood drawn as part of their medical care. Excess serum was aliquoted and coded with an anonymous study code. Before performing HIV testing, the number of persons with previously reported HIV infection was determined by linkage with the state HIV/AIDS reporting registry. Concurrent with the blinded HIV serosurvey, ED patients were offered voluntary HIV testing in a pilot program. Overall, 76 of 2,155 (3.5%) adult ED patients in the blinded survey were HIV-seropositive, 15 of whom (0. 7% of those tested, 20% of those HIV-seropositive) had no infection previously reported to the state HIV/AIDS registry. In the pilot program, six of the 156 (3.8%) individuals who underwent voluntary HIV testing were HIV-seropositive, including three of 53 (5.6%) individuals without prior HIV testing. Of the six HIV-seropositive subjects, one was previously diagnosed, while five of the remaining 155 (3.2%) represented previously undiagnosed infections. Overall, 3. 5% of ED patients from whom blood was obtained for other reasons tested positive for HIV antibody, 20% of whom were previously undiagnosed. Implementation of the voluntary testing program uncovered newly diagnosed infection among 3.2% of those tested. An ED may be an important setting for routinely offering HIV testing, especially for patients who have not been previously tested for HIV.     

A Comparison of HIV Testing in the Emergency Department and Urgent Care

Background: Although national guidelines recommend universal human immunodeficiency virus (HIV) testing, emergency departments (EDs) may choose to limit testing to certain patients, such as those triaged to urgent care (UC). Objective: To compare the results of rapid HIV testing in an urban ED with an affiliated UC. Methods: This was a retrospective analysis of an HIV testing program that included screening, which was initiated by triage nurses, and diagnostic testing, which was initiated by clinicians. Eligible patients were ≥ 12 years old and medically stable. Results: From April 2005 through December 2006, HIV tests were completed in 6196 (8.3%) of the 74,331 ED visits and 3256 (8.8%) of the 37,169 UC visits. Screening accounted for 5009 (80.8%) of the ED tests and 2914 (89.5%) of the UC tests, and diagnostic testing accounted for the remainder. Eighty (1.3%) of the ED tests and 21 (0.6%) of the UC tests were positive (p = 0.0024). Compared with newly diagnosed HIV-positive ED patients, HIV-positive UC patients were less likely to have CD4 counts < 200 cells/μL (adjusted odds ratio 0.19, 95% confidence interval 0.05–0.65). Conclusion: Although the yield of HIV testing is greater among ED patients, UC patients are diagnosed at a less advanced stage of illness.     

HIV post-exposure prophylaxis in the emergency department: An updated assessment and opportunities for HIV prevention identified

ObjectivesResearch suggests nonoccupational post exposure prophylaxis (nPEP) is under prescribed for people seeking treatment within 72 h of human immunodeficiency virus (HIV) exposures in the emergency department (ED). This study is an assessment of ED prescribers' knowledge, attitudes and practices regarding administration of HIV nPEP.MethodsThis was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED participants at work over a 4-month period from 5 hospital-based and 2 freestanding EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants.ResultsThe majority of those surveyed (133/149, 89.3%) believe it is their responsibility to provide HIV nPEP in the ED. Although 91% (138/151) and 87% (132/151) of participants are willing to prescribe nPEP for IV drug use and unprotected sex, respectively, only 40% (61/152) of participants felt they could confidently prescribe the appropriate regimen. Only 25% (37/151) of participants prescribed nPEP in the last year. Participants considered time (27%), connecting patients to follow-up (26%), and cost to patients (23%), as barriers to prescribing nPEP.ConclusionsThis study identified perceived barriers to administration of nPEP and missed opportunities for HIV prevention in the ED. Although most ED prescribers were willing to prescribe nPEP and felt it is their responsibility to do so, the majority of prescribers were not confident in prescribing it. The most commonly cited barriers to prescribing nPEP were time and access to follow-up care.     

Blood or Body Fluid Exposures and HIV Postexposure Prophylaxis Utilization among First Responders

Objectives. To estimate the incidence of first-responder visits to emergency departments (EDs) for blood or body fluid exposures, elucidate any temporal patterns of these visits, and quantify human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) utilization for these exposures. Methods. This was a retrospective study of first responders presenting to Rhode Island EDs for blood or body fluid exposures from 1995 to 2001. Incidence rates for exposures with 95% confidence intervals (CIs) were estimated. Temporal trends for visits were modeled. Factors associated with HIV PEP utilization were identified using logistic regression. Odds ratios (ORs) with 95% CIs were estimated. Results. The average incidence rate of ED visits for blood or body fluid exposures was 23.29 (20.07–26.52) ED visits per 100,000 ambulance runs. The incidence rose between 1995 and 1999 and then decreased. First-responder ED visits were lowest in October and highest in April and were lowest at 7 am and highest at 7 pm. First responders presenting with a percutaneous or blood-to-mucous membrane exposure had a 4.13 (1.82–8.89) greater odds and those exposed to a known HIV-infected source had a 9.03 (1.59–51.26) greater odds of being offered HIV PEP. First responders presenting to a teaching hospital had a 2.21 (1.02–4.77) greater odds of being offered prophylaxis and a 4.20 (1.08–16.32) greater odds of accepting prophylaxis when it was offered. Conclusions. First responders face a risk of blood or body fluid exposure that varies over the course of the day and the year. HIV PEP is more likely to be used if the exposures are percutaneous, or blood-to-mucous membrane, or if the source is known to be HIV-infected. Standardization of protocols across EDs for administering HIV prophylaxis appears to be needed.     

Improved care of acute exacerbation of chronic obstructive pulmonary disease in two academic emergency departments

Background

Although several chronic obstructive pulmonary disease (COPD) practice guidelines have been published, there is sparse data on the actual emergency department (ED) management of acute exacerbation of COPD (AECOPD).

Aims

Our objectives were to examine concordance of ED care of AECOPD in older patients with guideline recommendations and to evaluate whether concordance has improved over time in two academic EDs.

Methods

Data were obtained from two cohort studies on AECOPD performed in two academic EDs during two different time periods, 2000 and 2005–2006. Both studies included ED patients, aged 55 and older, who presented with AECOPD, and cases were confirmed by emergency physicians. Data on ED management and disposition were obtained from chart review for both cohorts.

Results

The analysis included 272 patients: 72 in the 2000 database and 200 in the 2005–2006 database. The mean age of the patients was 72 years; 50% were women and 80% white. In 2005–2006, overall concordance with guideline recommendations was high (for chest radiography, pulse oximetry, bronchodilators, all ≥?90%), except for arterial blood gas testing (7% among the admitted) and discharge medication with systemic corticosteroids (42%). Compared to the 2000 data, the use of systemic corticosteroids in the ED improved from 53 to 77% [absolute improvement: 24%, 95% confidence interval (CI): 11–37%], and the use of antibiotics among the patients with respiratory infection symptoms improved from 56 to 78% (absolute improvement: 22%, 95% CI: 6–38%).

Conclusions

Overall concordance with guideline-recommended care for AECOPD was high in two academic EDs, and some emergency treatments have improved over time.     

The Effect of Financial Incentives on Adherence with Outpatient Human Immunodeficiency Virus Testing Referrals from the Emergency Department

Objectives: Undiagnosed human immunodeficiency virus (HIV) infection is not uncommon among patients who seek care in urban inner‐city emergency departments (EDs). The optimal method for providing appropriate HIV counseling, testing, and referral in this setting is unclear. A previous evaluation of an outpatient referral system for HIV testing among patients seen in the ED demonstrated that only 11% returned to be tested; of those tested, 7% were seropositive. The purpose of this study was to evaluate the effect of a financial incentive on the proportion of referred ED patients who completed outpatient HIV counseling and testing. Methods: This was a quasi‐experiment performed at an urban county teaching hospital. ED patients identified using Centers for Disease Control and Prevention guidelines as being at risk for HIV infection were referred for outpatient HIV counseling and testing at our institution within one week. This study was divided into three study periods. During the first and third periods, no financial incentive was offered for completing HIV counseling and testing. During the second period, a $25 incentive was offered for completing HIV counseling and testing. Results: During the study, 372 patients were referred for HIV counseling and testing. During the control periods, 20 (8%) of 252 patients completed HIV counseling and testing; during the intervention period, 27 (23%) of 120 patients completed HIV counseling and testing (odds ratio, 3.4; 95% confidence interval = 1.8 to 6.3). Of the 47 patients who completed HIV counseling and testing, none (0%; 95% confidence interval = 0% to 8%) tested positive for HIV infection. Conclusions: The use of a modest financial incentive increased the proportion of patients who completed HIV counseling and testing after being referred from the ED. It is unclear whether the use of a financial incentive increases the identification of HIV‐infected patients unaware of their status or if it is cost‐effective.     

Emergency Department Sexually Transmitted Disease and Human Immunodeficiency Virus Screening: Findings from a National Survey

Objectives: To use a previously conducted national physician survey to determine the extent of human immunodeficiency virus (HIV) and sexually transmitted disease (STD) screening by emergency physicians compared with physicians practicing in other settings (primary care offices, hospital ambulatory care clinics, or other).
Methods: From the survey responses, the authors determined the percentage of emergency physicians and physicians not practicing in EDs screening various patient groups for syphilis, gonorrhea, chlamydia, and HIV. Additional data from the survey (for practice location, physician gender, and patient demographics of race and gender) were used in multivariate logistic regressions to determine adjusted odds ratios (ORs).
Results: Of 3,838 survey respondents providing answers to all questions analyzed for this study, 401 (10.5%) practiced in an emergency department. Of the remaining 3,437 physicians, 89% practiced in primary care offices or hospital ambulatory care clinics. Based on unadjusted ORs, emergency physicians were less likely than physicians not practicing in EDs to screen for all STDs and HIV in all patient groups (men, nonpregnant women, and pregnant women), although the differences in screening rates in male patients for chlamydia or gonorrhea were not significant. The adjusted ORs varied from 0.136 (for HIV screening of pregnant women) to 1.177 (for gonorrhea screening of pregnant women). All adjusted ORs that were significant at p < 0.05 were < 1.0.
Conclusions: Although prior research has shown that STD and HIV rates are relatively high in emergency department patients compared with the population as a whole, screening rates are lower than in other settings. Addressing barriers may increase screening rates.     

Airway management practices in emergency medicine residencies

The Core Content for Emergency Medicine (EM) recommends that all emergency physicians be trained to manage the airway, including administering paralytic agents for endotracheal intubation. This study analyzed compliance with the recommendations by reviewing airway management practices at EM residencies. All 96 EM residency directors were sent a 10-item survey characterizing airway management practices at residency-affiliated emergency departments (EDs). The 91 respondents (95%) represented residencies with 120 affiliated hospitals. Paralytic agents routinely were used during intubations in 114 of the EDs (95%). Forty-nine of the EDs (41%) never requested an anesthesiologist for intubations, and 8 EDs (7%) mandated anesthesiology presence during paralytic agent administration. The Department of Anesthesiology never performed quality assurance (QA) evaluations in at least 64 EDs (53%). The Department of Emergency Medicine performed QA checks less than two thirds of the time in at least 44 EDs (36%). The majority of EM residencies are complying with the Core Content recommendations by actively performing intubations using paralytic agents. Anesthesiologists are infrequently consulted in residency-affiliated EDs. Quality assurance of ED intubations is not rigorously monitored by emergency and anesthesiology departments.     

Development and Implementation of a Model to Improve Identification of Patients Infected with HIV Using Diagnostic Rapid Testing in the Emergency Department

Objectives Infection with the human immunodeficiency virus (HIV) continues to expand in nontraditional risk groups, and the prevalence of undiagnosed infection remains relatively high in the patient populations of urban emergency departments (EDs). Unfortunately, HIV testing in this setting remains uncommon. The objectives of this study were 1) to develop a physician‐based diagnostic rapid HIV testing model, 2) to implement this model in a high‐volume urban ED, and 3) to prospectively characterize the patients who were targeted by physicians for testing and determine the proportions who completed rapid HIV counseling, testing, and referral; tested positive for HIV infection; and were successfully linked into medical and preventative care. Methods An interdisciplinary group of investigators developed a model for performing physician‐based diagnostic rapid HIV testing in the ED. This model was then evaluated using a prospective cohort study design. Emergency physicians identified patients at risk for undiagnosed HIV infection using clinical judgment and consensus guidelines. Testing was performed by the hospital's central laboratory, and clinical social workers performed pretest and posttest counseling and provided appropriate medical and preventative care referrals, as defined by the model. Results Over the 30‐month study period, 105,856 patients were evaluated in the ED. Of these, 681 (0.64%; 95% confidence interval [CI] = 0.60% to 0.69%) were identified by physicians and completed rapid HIV counseling, testing, and referral. Of the 681 patients, 15 (2.2%; 95% CI = 1.2% to 3.6%) patients tested positive for HIV infection and 12 (80%; 95% CI = 52% to 96%) were successfully linked into care. Conclusions A physician‐based diagnostic HIV testing model was developed, successfully implemented, and sustained in a high‐volume, urban ED setting. While the use of this model successfully identified patients with undiagnosed HIV infection in the ED, the overall level of testing remained low. Innovative testing programs, such as nontargeted screening, more specific targeted screening, or alternative hybrid methods, are needed to more effectively identify undiagnosed HIV infection in the ED patient population.     

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%).     

Frequent Overcrowding in U.S. Emergency Departments

OBJECTIVE: To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. METHODS: Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five-point Likert scale. RESULTS: Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations < or =250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (+/-SD), causes of overcrowding included high patient acuity (4.3 +/- 0.9), hospital bed shortage (4.2 +/- 1.1), high ED patient volume (3.8 +/- 1.2), radiology and lab delays (3.3 +/- 1.2), and insufficient ED space (3.3 +/- 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding. CONCLUSIONS: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.     

Suspected synthetic cannabinoid receptor agonist intoxication: Does analysis of samples reflect the presence of suspected agents?

BackgroundThere has been a surge in synthetic cannabinoid receptor agonist (SCRA) exposures reported in recent years. The constituents of SCRA preparations are constantly evolving and rarely confirmed. We sought to characterize the constituents of reported SCRA exposures presenting to the emergency department (ED).MethodsPatients who presented to two academic EDs in Washington, DC with reported or suspected SCRA exposure from July 2015–July 2016 were enrolled at the discretion of the treating provider. Blood and/or urine samples were obtained as part of routine clinical care and sent to the DC medical examiner's office for identification of known SCRAs with liquid chromatography-mass spectrometry-mass spectrometry. Standard toxicology screens were additionally performed to determine the presence of other drugs of abuse.Results128 samples were analyzed. Seventy-one (55.5%) were positive for an SCRA. The most common SCRAs detected were AB-fubinaca (28, 39.4%), ADB-fubinaca (15, 21.1%), AB-chminaca 3-methyl-butanoic acid (15, 21.1%), ADB-chminaca (14, 19.7%), and 5-flouro-PB-22 (8, 11.3%). Fifty-seven (44.5%) samples were negative for an SCRA, of which 28 (21.9%) were positive for another substance, most commonly delta-9-tetrahydrocannabinol and phencyclidine. An additional 29 (22.7%) patients had both negative SCRA and toxicology screens.ConclusionsOf patients presenting with reported SCRA intoxication, 55.5% had detectable SCRAs on analytical testing. These results suggest that in a considerable proportion of cases, clinicians are mis-attributing the effects of other drugs or medical conditions to SCRA use. The individual SCRAs detected in our study differed from compounds detected in earlier studies, suggesting there has been a change in constituents.     

Academic Departments of Emergency Medicine: The Effects of Managed Care

Abstract. Objective: To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice. Methods: A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994–1995 and 1995–1996. Results: Forty-seven ADEMs (90.3%) responded. When comparing the 1995–1996 and 1994–1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs. Conclusion: ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.     

Disease surveillance in the ED: Factors leading to the underreporting of gonorrhea

Emergency departments (EDs) are potentially important surveillance sites. This study assessed reporting completeness for gonorrhea by hospital and gender and explored reasons for underreporting. A retrospective review was conducted of ED charts from three hospitals for 2 months. Potential gonorrhea cases were identified by history, physical examination, testing, treatment, and diagnostic practices. Cases were divided into those tested only, those treated with or without testing, and those with positive tests. Reporting completeness was assessed for each. Of 936 cases included, 29.0% were tested without treatment and 71% received treatment. One third of treated patients were not tested, and none of these were reported. Two EDs reported cases themselves and reported 75.9% of confirmed cases. There were significant differences in testing and reporting between hospitals and genders. Underreporting of suspected and confirmed gonorrhea cases was common from these EDs. A major cause was physicians treating without testing for confirmation.     

Informed Consent for Research: Current Practices in Academic Emergency Medicine

Background:  The emergency department (ED) environment presents unique barriers to the process of obtaining informed consent for research.
Objectives:  The objective was to identify commonalities and differences in informed consent practices for research employed in academic EDs.
Methods:  Between July 1, 2006, and June 30, 2007, an online survey was sent to the research directors of 142 academic emergency medicine (EM) residency training programs identified through the Accreditation Council for Graduate Medical Education (ACGME).
Results:  Seventy-one (50%) responded. The average number of simultaneous clinical ED-based research projects reported was 7.3 (95% confidence interval [CI] = 5.53 to 9.07). Almost half (49.3%) of respondents reported that EM residents are responsible for obtaining consent. Twenty-nine (41.4%) participating institutions do not require documentation of an individual resident's knowledge of the specific research protocol and consent procedure before he or she is allowed to obtain consent from research subjects.
Conclusions:  It is common practice in academic EDs for clinical investigators to rely on on-duty health care personnel to obtain research informed consent from potential research subjects. This practice raises questions regarding the sufficiency of the information received by research subjects, and further study is needed to determine the compliance of this consent process with federal guidelines.