A Cross-Sectional Review of HIV Screening in High-Acuity Emergency Department Patients: A Missed Opportunity

Overview

Journal West J Emerg Med

Specialty Emergency Medicine

Date 2024 Sep 25

PMID 39319814

Authors

Jacqueline J Mahal

Fernando Gonzalez

Deirdre Kokasko

Ahava Muskat

Affiliations

Soon will be listed here.

Abstract

Introduction: Emergency department (ED) patients requiring immediate treatment often bypass a triage process that includes HIV screening. In this study we aimed to investigate the potential missed opportunity to screen these patients for HIV.

Methods: We conducted this cross-sectional study in a municipal ED over a six-week period between June-August 2019. The patient population in this study arrived in the ED as a pre-notification from prehospital services or designated by the ambulance or walk-in triage nurse as requiring immediate medical attention. Medical student researchers collected demographic data and categorized patients into three clinical groups (trauma, medical, psychiatric). They documented the patient's eligibility for HIV screening as determined by a physician and confirmed that the patient met criteria of clear mental status, controlled pain, stable vital signs, and ability to contribute to a medical history and physical examination. The student researchers did this at initial presentation and then again during the patient's ED stay of up to eight hours. The study outcomes measured the percentage of total patients within each clinical group (trauma, medical, psychiatric) able to engage in the HIV screening process upon arrival and during an eight-hour ED stay.

Results: On average, 700 patients per month are announced on arrival via overhead page, indicating that they require immediate medical attention. During the six-week study, 205 patients (approximately 20% of total) were enrolled: 114 trauma; 56 medical; and 35 psychiatric presentations. The average patient age was 53; 60% of patients were male. Niney-eight (48%) patients were eligible for HIV screening within an eight-hour ED stay; 63 (31%) were able to be screened upon initial presentation and 35 (17%) in the first eight hours of their ED visit. Within medical and trauma subgroups, there was no significant difference in the proportion (36%) of patients that could be screened upon presentation. Among the psychiatric presentations, only five (14%) were able to be screened during their hospital stay.

Conclusion: Triage protocols for high-acuity medico-surgical patients resulted in a missed opportunity to screen 48% of patients for HIV. Acute psychiatric patients represented a particular missed opportunity. We advocate for universal HIV screening, facilitated through electronic best practice advisories and a modified triage tailored to higher acuity patients. Implementing these changes would ensure that HIV screening is not overlooked in high-acuity ED patients, leading to early detection and timely interventions.

References

Haukoos J, Hopkins E, Byyny R . Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Ann Emerg Med. 2008; 51(3):303-9, 309.e1. DOI: 10.1016/j.annemergmed.2007.10.028. View

Pisculli M, Reichmann W, Losina E, Donnell-Fink L, Arbelaez C, Katz J . Factors associated with refusal of rapid HIV testing in an emergency department. AIDS Behav. 2010; 15(4):734-42. PMC: 3082047. DOI: 10.1007/s10461-010-9837-2. View

Lin J, Baghikar S, Mauntel-Medici C, Heinert S, Patel D . Patient and System Factors Related to Missed Opportunities for Screening in an Electronic Medical Record-driven, Opt-out HIV Screening Program in the Emergency Department. Acad Emerg Med. 2017; 24(11):1358-1368. DOI: 10.1111/acem.13277. View

Kecojevic A, Lindsell C, Lyons M, Holtgrave D, Torres G, Heffelfinger J . Public health and clinical impact of increasing emergency department-based HIV testing: perspectives from the 2007 conference of the National Emergency Department HIV Testing Consortium. Ann Emerg Med. 2011; 58(1 Suppl 1):S151-9.e1. DOI: 10.1016/j.annemergmed.2011.03.040. View

Escudero D, Bahamon M, Panakos P, Hercz D, Seage 3rd G, Merchant R . How to best conduct universal HIV screening in emergency departments is far from settled. J Am Coll Emerg Physicians Open. 2021; 2(1):e12352. PMC: 7812459. DOI: 10.1002/emp2.12352. View

White D, Scribner A, Vahidnia F, Dideum P, Gordon D, Frazee B . HIV screening in an urban emergency department: comparison of screening using an opt-in versus an opt-out approach. Ann Emerg Med. 2011; 58(1 Suppl 1):S89-95. DOI: 10.1016/j.annemergmed.2011.03.032. View

Remien R, Stirratt M, Nguyen N, Robbins R, Pala A, Mellins C . Mental health and HIV/AIDS: the need for an integrated response. AIDS. 2019; 33(9):1411-1420. PMC: 6635049. DOI: 10.1097/QAD.0000000000002227. View

Zachariasse J, van der Hagen V, Seiger N, Mackway-Jones K, van Veen M, Moll H . Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open. 2019; 9(5):e026471. PMC: 6549628. DOI: 10.1136/bmjopen-2018-026471. View

Haukoos J, Lyons M, Rothman R, White D, Hopkins E, Bucossi M . Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial. JAMA Netw Open. 2021; 4(7):e2117763. PMC: 8314142. DOI: 10.1001/jamanetworkopen.2021.17763. View

10.

Branson B, Handsfield H, Lampe M, Janssen R, Taylor A, Lyss S . Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006; 55(RR-14):1-17. View

11.

Collins P, Velloza J, Concepcion T, Oseso L, Chwastiak L, Kemp C . Intervening for HIV prevention and mental health: a review of global literature. J Int AIDS Soc. 2021; 24 Suppl 2:e25710. PMC: 8222838. DOI: 10.1002/jia2.25710. View

12.

Stanford K, Eller D, Schmitt J, McNulty M, Spiegel T . High Rate of HIV Among Trauma Patients Participating in Routine Emergency Department Screening. AIDS Behav. 2023; 27(11):3669-3677. PMC: 10208187. DOI: 10.1007/s10461-023-04083-3. View

13.

Tan R, Hugli O, Cavassini M, Darling K . Non-targeted HIV testing in the emergency department: not just how but where. Expert Rev Anti Infect Ther. 2018; 16(12):893-905. DOI: 10.1080/14787210.2018.1545575. View

14.

Joska J, Kaliski S, Benatar S . Patients with severe mental illness: a new approach to testing for HIV. S Afr Med J. 2008; 98(3):213-7. View

15.

St-Jean M, Tafessu H, Closson K, Patterson T, Lavergne M, Elefante J . The syndemic effect of HIV/HCV co-infection and mental health disorders on acute care hospitalization rate among people living with HIV/AIDS: a population-based retrospective cohort study. Can J Public Health. 2019; 110(6):779-791. PMC: 6964491. DOI: 10.17269/s41997-019-00253-w. View

16.

Mistry B, Stewart de Ramirez S, Kelen G, Schmitz P, Balhara K, Levin S . Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment. Ann Emerg Med. 2017; 71(5):581-587.e3. DOI: 10.1016/j.annemergmed.2017.09.036. View

17.

Lyss S, Branson B, Kroc K, Couture E, Newman D, Weinstein R . Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007; 44(4):435-42. DOI: 10.1097/QAI.0b013e31802f83d0. View

18.

McHugh M, Tanabe P, McClelland M, Khare R . More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States. Acad Emerg Med. 2012; 19(1):106-9. DOI: 10.1111/j.1553-2712.2011.01240.x. View

19.

White D, Scribner A, Schulden J, Branson B, Heffelfinger J . Results of a rapid HIV screening and diagnostic testing program in an urban emergency department. Ann Emerg Med. 2008; 54(1):56-64. DOI: 10.1016/j.annemergmed.2008.09.027. View

20.

Mijch A, Burgess P, Judd F, Grech P, Komiti A, Hoy J . Increased health care utilization and increased antiretroviral use in HIV-infected individuals with mental health disorders. HIV Med. 2006; 7(4):205-12. DOI: 10.1111/j.1468-1293.2006.00359.x. View