Emily Hopkins

Routine Opt-Out Rapid HIV Screening and Detection of HIV Infection in Emergency Department Patients

CONTEXTnThe Centers for Disease Control and Prevention (CDC) recommends routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. The utility of this approach in EDs remains unknown.nnnOBJECTIVEnTo determine whether nontargeted opt-out rapid HIV screening in the ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing.nnnDESIGN, SETTING, AND PATIENTSnQuasi-experimental equivalent time-samples design in an urban public safety-net hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing.nnnINTERVENTIONSnNontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 15, 2007, and April 15, 2009.nnnMAIN OUTCOME MEASURESnNumber of patients with newly identified HIV infection and the association between nontargeted opt-out rapid HIV screening and identification of HIV infection.nnnRESULTSnIn the opt-out phase, of 28,043 eligible ED patients, 6933 patients (25%) completed HIV testing (6702 patients were screened; 231 patients were diagnostically tested). Ten of 6702 patients (0.15%; 95% CI, 0.07%-0.27%) who did not decline HIV screening in the opt-out phase had new HIV diagnoses, and 5 of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new HIV diagnoses. In the diagnostic phase, of 29,925 eligible patients, 243 (0.8%) completed HIV testing. Of these, 4 patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses. The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and 4 in 29,925 (0.01%; 95% CI, 0.004%-0.03%), respectively. Nontargeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status, and whether diagnostic testing was performed in the opt-out phase. The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/microL (IQR, 17-430) and 13/microL (IQR, 11-15) , respectively (P = .02).nnnCONCLUSIONnNontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease.

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 CDCs 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.

The Current State of Ultrasound Training in Canadian Emergency Medicine Programs: Perspectives From Program Directors

OBJECTIVESnThere is a paucity of data about emergency ultrasound (EUS) training in emergency medicine (EM) residency programs accredited by the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada (CFPC). Historically the progress of EUS in Canada has been different from that in the United States. We describe the current state of EUS training in both Royal College and CFPC-EM programs.nnnMETHODSnAll Royal College EM program directors and all CFPC-EM program directors were invited to participate in a website-based survey. Main outcome measures were characteristics of currently offered EUS training.nnnRESULTSnThe response rate of the survey was 100% (30/30). EUS is part of the formal residency curriculum in 100% (13/13) of Royal College EM programs and in 88% (15/17) of CFPC-EM programs. EM resident rotations in ultrasound (US) are provided by 77% (10/13) of Royal College programs but only 47% (8/17) of CFPC-EM programs. There are specific requirements for numbers of EUS exams to be completed by graduation in 77% (10/13) of Royal College programs and 47% (8/17) of CFPC-EM programs. EM faculty and residents make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology in 100% (13/13) of Royal College programs and 88% (15/17) of CFPC-EM programs. However, 69% (9/13) of Royal College programs and 53% (9/17) of CFPC-EM programs have no formal quality assurance program in place.nnnCONCLUSIONSnEUS training in Canadian EM programs is prevalent, but there are considerable discrepancies among residency programs in scope of training, curricula, determination of proficiency, and quality assurance. These findings suggest variability in both the level and the quality of EUS training in Canada.

Prediction of postinjury multiple-organ failure in the emergency department: development of the Denver Emergency Department Trauma Organ Failure score.

BACKGROUND Multiple-organ failure (MOF) is common among the most seriously injured trauma patients. The ability to easily and accurately identify trauma patients in the emergency department at risk for MOF would be valuable. The aim of this study was to derive and internally validate an instrument to predict the development of MOF in adult trauma patients using clinical and laboratory data available in the emergency department. METHODS We enrolled consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry, a prospectively collected database from an urban Level 1 trauma center. Multivariable logistic regression was used to develop a clinical prediction instrument. The outcome was the development of MOF within 7 days of admission as defined by the Sequential Organ Failure Assessment (SOFA) score. A risk score was created from the final regression model by rounding the regression &bgr; coefficients to the nearest integer. Calibration and discrimination were assessed using 10-fold cross-validation. RESULTS A total of 4,355 patients were included in this study. The median age was 37 years (interquartile range [IQR], 26–51 years), and 72% were male. The median Injury Severity Score (ISS) was 9 (IQR, 4–16), and 78% of the patients had blunt injury mechanisms. MOF occurred in 216 patients (5%; 95% confidence interval, 4–6%). The final risk score included patient age, intubation, systolic blood pressure, hematocrit, blood urea nitrogen, and white blood cell count and ranged from 0 to 9. The prevalence of MOF increased in an approximate exponential fashion as the score increased. The model demonstrated excellent calibration and discrimination (calibration slope, 1.0; c statistic, 0.92). CONCLUSION We derived a simple, internally valid instrument to predict MOF in adults following trauma. The use of this score may allow early identification of patients at risk for MOF and result in more aggressive targeted resuscitation and improved resource allocation. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Payer Status, Race/Ethnicity, and Acceptance of Free Routine Opt-Out Rapid HIV Screening Among Emergency Department Patients

OBJECTIVESnWe estimated associations between payer status, race/ethnicity, and acceptance of nontargeted opt-out rapid HIV screening in the emergency department (ED).nnnMETHODSnWe analyzed data from a prospective clinical trial between 2007 and 2009 at Denver Health. Patients in the ED were offered free HIV testing. Patient demographics and payer status were collected, and we used multivariable logistic regression to estimate associations with HIV testing acceptance.nnnRESULTSnA total of 31,525 patients made 44, 765 unique visits: 40% were White, 37% Hispanic, 14% Black, 1% Asian, and 7% unknown race/ethnicity. Of all visits, 10u2009,237 (23%) agreed to HIV testing; 27% were self-pay, 23% state-sponsored, 18% Medicaid, 13% commercial insurance, 12% Medicare, and 8% another payer source. Compared with commercial insurance patients, self-pay patients (odds ratio [OR]u2009=u20091.63; 95% confidence interval [CI]u2009=u20091.51, 1.75), state-sponsored patients (ORu2009=u20091.64; 95% CIu2009=u20091.52, 1.77), and Medicaid patients (ORu2009=u20091.24; 95% CIu2009=u20091.14, 1.34) had increased odds of accepting testing. Compared with White patients, Black (ORu2009=u20091.29; 95% CIu2009=u20091.21, 1.38) and Hispanic (ORu2009=u20091.17; 95% CIu2009=u20091.11, 1.23) patients had increased odds of accepting testing.nnnCONCLUSIONSnMany ED patients are uninsured or subsidized through government programs and are more likely to consent to free rapid HIV testing.

Programmatic Cost Evaluation of Nontargeted Opt-Out Rapid HIV Screening in the Emergency Department

Background The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial. Methods This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated. Results During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%–0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%–4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were

Ultrasound Guidance for Central Venous Access by Emergency Physicians in Colorado

148,997, whereas total annualized costs for diagnostic HIV testing were

Routine opt-out HIV screening: more evidence in support of alternative approaches?

31,355. The average costs per HIV diagnosis were

Sexual Assault Training in Emergency Medicine Residencies: A Survey of Program Directors

9,932 and

Motor vehicle crash severity estimations by physicians and prehospital personnel

7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of