Neal Sikka

Routine HIV Screening in the Emergency Department Using the New US Centers for Disease Control and Prevention Guidelines Results From a High-Prevalence Area

Background:In 2006, the US Centers for Disease Control and Prevention (CDC) released new recommendations for routine HIV testing. Among these were recommendations that emergency departments (EDs) offer routine opt-out HIV screening to their patients. We established a screening program implementing these recommendations at an urban university hospital ED in Washington, DC. We report the results of this program. Methods:During a 3-month period, ED patients being treated for a wide range of conditions were approached by trained HIV screeners and offered point-of-care rapid HIV testing. Patients with positive results were referred to hospital or community resources for confirmatory testing and treatment. Results:During the program period, 14,986 patients were treated in the ED and 4151 (27.6%) were offered HIV screening. The mean patient age was 37.5 years; 48.5% were black, 39.0% were non-Hispanic white, 4.1% were Hispanic, 1.7% were Asian, and 6.7% responded as being other race. A total of 56.1% were female, and most lived within the Washington, DC metropolitan area. Of the patients offered HIV screening, 2476 (59.7%) accepted the test. Of the 26 patients with a preliminary positive screen, 13 were lost to follow-up, 9 were confirmed positive by Western blot, and 4 were confirmed negative by Western blot. Eight of the 9 patients with confirmed HIV infection were successfully linked to follow-up care. Conclusions:The implementation of the CDC recommendations establishing routine opt-out HIV screening programs in EDs is feasible. Further efforts to establish routine ED HIV testing are therefore warranted.

Serious injuries related to the Segway® personal transporter: a case series.

STUDY OBJECTIVE We describe a case series of emergency department (ED) visits for injuries related to the Segway® personal transporter. METHODS This was a retrospective case review using a free-text search feature of an electronic ED medical record to identify patients arriving April 2005 through November 2008. Data were hand extracted from the record, and further information on admitted patients was obtained from the hospital trauma registry. RESULTS Forty-one cases were included. The median age was 50 years, and 30 patients (73.2%) were women. Twenty-nine (70.7%) of the patients resided outside the District of Columbia, Maryland, and Virginia, and 32 (78.1%) arrived between June and September. Seven (17.1%) patients had documented helmet use. Ten (24.4%) were admitted. Four patients (40% of admitted patients) required admission to the ICU. CONCLUSION The severity of trauma in this case series of patients injured by the use of the self-balancing personal transporter is significant. Further investigation into the risks of use, as well as the optimal length and type of training or practice, is warranted. A distinct E-code and Consumer Product Safety Commissions product code is needed to enable further investigation of injury risks for this mode of transportation.

The Use of Mobile Phones for Acute Wound Care: Attitudes and Opinions of Emergency Department Patients

There are a significant number of emergency department (ED) visits for lacerations each year. When individuals experience skin, soft tissue, or laceration symptoms, the decision to go to the ED is not always easy on the basis of the level of severity. For such cases, it may be feasible to use a mobile phone camera to submit images of their wound to a remote medical provider who can review and help guide their care choice decisions. The authors aimed to assess patient attitudes toward the use of mobile phone technology for laceration management. Patients presenting to an urban ED for initial care and follow-up visits for lacerations were prospectively enrolled. A total of 194 patients were enrolled over 8 months. Enrolled patients answered a series of questions about their injury and a survey on attitudes about the acceptability of making management decisions using mobile phone images only. A majority of those surveyed agreed that it was acceptable to send a mobile phone picture to a physician for a recommendation and diagnosis. Patients also reported few concerns regarding privacy and security and believe that this technology could be cost effective and convenient. In this study, the majority of patients had favorable opinions of using mobile phones for laceration care. Mobile phone camera images (a) may provide a useful modality for assessment of some acute wound care needs and (b) may decrease ED visits for a high-volume complaint such as acute wounds.

Are Patients Prepared to Use Telemedicine in Home Peritoneal Dialysis Programs

1. Williams JD, Craig KJ, Topley N, Von ruhland C, Fallon M, Newman Gr, et al. on behalf of the Peritoneal Biopsy Study Group. Morphologic changes in the peritoneal membrane of patients with renal disease. J Am Soc nephrol 2002; 13:470–9. 2. Hendriks PM, Ho-dac-Pannekeet MM, van Gulik TM, Struijk DG, Phoa SS, Sie L, et al. Peritoneal sclerosis in chronic peritoneal dialysis patients: analysis of clinical presentation, risk factors, and peritoneal transport kinetics. Perit Dial Int 1997; 17:136–43. 3. Honda K, Hamada C, Nakayama M, Miyazaki M, Sherif AM, Harada T, et al. Impact of uremia, diabetes, and peritoneal dialysis itself on the pathogenesis of peritoneal sclerosis: a quantitative study of peritoneal membrane morphology. Clin J Am Soc nephrol 2008; 3:720–8. 4. Choi HY, Kim DK, Lee TH, Moon SJ, Han SH, Lee Je, et al. The clinical usefulness of peritoneal dialysis fluids with neutral pH and low glucose degradation product concentration: an open randomized prospective trial. Perit Dial Int 2008; 28:174–82. 5. Working Group Committee for the Preparation of Guidelines for Peritoneal Dialysis, Japanese Society for Dialysis Therapy. 2009 Japanese Society for Dialysis Therapy guidelines for peritoneal dialysis. Ther Apher Dial 2009; 14:489–564. 6. Ayuzawa N, Ishibashi Y, Takazawa Y, Kume H, Fujita T. Peritoneal morphology after long-term peritoneal dialysis with biocompatible fluid: recent clinical practice in Japan. Perit Dial Int 2012; 32:159–67. 7. Tsukamoto M, Ishibashi Y, Takazawa Y, Komemushi Y, Kume H. Normal peritoneal histology after ten years of peritoneal dialysis in a contemporary Japanese patient. Perit Dial Int 2013; 33:463–4. doi:10.3747/pdi.2012.00306

The Use of Mobile Phone Cameras in Guiding Treatment Decisions for Laceration Care

OBJECTIVES Mobile phone technology may be useful in helping to guide medical decisions for lacerations. We examined whether emergency department (ED) provider opinions on which lacerations require repair differed using mobile phone-generated images compared with in-person evaluations. SUBJECTS AND METHODS Patients presenting to an urban ED for initial and follow-up laceration care were prospectively enrolled. Patients took four mobile phone pictures of their laceration and provided a medical history. Cases were reviewed by ED providers who assessed image quality and made a recommendation about whether the laceration needed repair. The same provider then assessed the patient in-person. Concordant decision-making between mobile phone and in-person assessments was calculated as well as the degree of undertriage. RESULTS In total, 94 patients were included over an 8-month period. There was complete agreement in 87% of cases (κ statistic=0.65). Of the 13 patients with discrepant decisions, 6 were due to poor image quality, in 3 the images did not properly represent the problem, in 3 others there were historical findings that altered care, and for 1 the image looked worse than the actual injury in-person. In total, 5 of 94 (5%) of cases would have been undertriaged using only the mobile phone recommendation. Median image quality was 6 out of 10 (with 10 being the best) (interquartile range, 4-8). CONCLUSIONS There are high rates of agreement when providers use mobile phone images to assess lacerations for possible repair in the ED. Image quality is in general good but highly variable and may drive incorrect assessments.

Satisfaction and Improvements in Peritoneal Dialysis Outcomes Associated with Telehealth.

BACKGROUND AND SIGNIFICANCE End stage renal disease (ESRD) affects approximately 660,000 persons in the US each year, representing a significant financial burden to the health care system and affected individuals. Telehealth approaches to care offer an important means of reducing costs as well as increasing autonomy for patients. Understanding patient satisfaction with telehealth provides a key towards eventual scalability. MATERIALS AND METHODS Quarterly surveys were conducted to characterize satisfaction with remote biometric monitoring (RBM) for blood pressure, weight, glucose and peritoneal dialysis (PD)-specific educational online videos for ESRD patients using PD. RESULTS Of 300 participants, 67% participated in the surveys and provided baseline and at least one follow-up assessment. The majority were 45 to 64 years of age (50.5%), Black (64.5%), married or living with significant other (52.0%), and had more than a high school degree (73.0%). RBM was associated with perceived autonomy and confidence in health care activities and decreased negative perceptions of PD care and ESRD. The majority of participants (80.1%) indicated that they were satisfied or completely satisfied with the system. Participants found that the interface increased confidence, reduced frustration, and related perceptions were significantly and positively altered (p<0.05) for each of the separate telehealth components. Educational videos were well utilized with nearly half of the participants (42.5%) reporting that they watched at least one of the videos, and the majority reporting that the videos seen had an overall positive impact on health. DISCUSSION AND CONCLUSIONS Supplementing PD with telehealth has the potential to have a positive impact on patient perceptions of PD care and consequently improve clinical outcomes.

Adoption of Telehealth: Remote Biometric Monitoring Among Peritoneal Dialysis Patients in the United States.

We examined participant uptake and utilization of remote monitoring devices, and the relationship between remote biometric monitoring (RBM) of weight (Wt) and blood pressure (BP) with self-monitoring requirements. Participants on peritoneal dialysis (PD) (n = 269) participated in a Telehealth pilot study of which 253 used remote monitoring of BP and 255 for Wt. Blood pressure and Wt readings were transmitted in real time to a Telehealth call center, which were then forwarded to the PD nurses for real-time review. Uptake of RBM was substantial, with 89.7% accepting RBM, generating 74,266 BP and 52,880 Wt measurements over the study period. We found no significant correlates of RBM uptake with regard to gender, marital, educational, socio-economic or employment status, or baseline experience with computers; frequency of use of BP RBM by Black participants was less than non-Black participants, as was Wt RBM, and participants over 55 years old were more likely to use the Wt RBM than their younger counterparts. Having any review of the breach by a nurse was associated with reduced odds of a subsequent BP breach after adjusting for sex, age, and race. Remote biometric monitoring was associated with adherence to self-monitoring BP and Wt requirements associated with PD. Remote biometric monitoring was feasible, allowing for increased communication between patient and PD clinical staff with real-time patient data for providers to act on to potentially improve adherence and outcomes.

Perspectives from the Kidney Health Initiative on Advancing Technologies to Facilitate Remote Monitoring of Patient Self-Care in RRT

Telehealth and remote monitoring of a patients health status has become more commonplace in the last decade and has been applied to conditions such as heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Conversely, uptake of these technologies to help engender and support home RRTs has lagged. Although studies have looked at the role of telehealth in RRT, they are small and single-centered, and both outcome and cost-effectiveness data are needed to inform future decision making. Furthermore, alignment of payer and government (federal and state) regulations with telehealth procedures is needed along with a better understanding of the viewpoints of the various stakeholders in this process (patients, caregivers, clinicians, payers, dialysis organizations, and government regulators). Despite these barriers, telehealth has great potential to increase the acceptance of home dialysis, and improve outcomes and patient satisfaction while potentially decreasing costs. The Kidney Health Initiative convened a multidisciplinary workgroup to examine the current state of telehealth use in home RRTs as well as outline potential benefits and drawbacks, impediments to implementation, and key unanswered questions.

Telepsychiatric assessment of a mariner expressing suicidal ideation

This case report highlights the successful use of telepsychiatric consultation by secure video chat to remotely assess a mariner expressing suicidal ideation. As a result of this intervention, telemedicine providers initiated psychiatric stabilisation while the mariner was still aboard the vessel, determined that he was safe for repatriation under the care of qualified medical escorts, and facilitated admission to a psychiatric facility near his home in the United States. Mental health emergencies are a significant cause of morbidity and mortality among mariners. Telepsychiatry is a validated method of establishing a psychiatric diagnosis and disposition as well as assessing risk of suicidality and the potential for violent decompensation. It has the potential to be a valuable adjunct to any traditional maritime telemedicine service.

The George Washington University Emergency Medicine Telemedicine and Digital Health Fellowship

Medical schools should integrate health IT and biomedical informatics into their formal curricula. The George Washington University Emergency Medicine Telemedicine and Digital Health Fellowship was designed to train graduate physicians to use telemedicine in their clinical and research work.