ED crafts own HIV test program
Selected by CDC to create model
The leaders at San Francisco General Hospital were more than happy to participate in a nationwide Centers for Disease Control and Prevention (CDC) program that offers routine rapid HIV testing to all ED patients, but they believed strongly that universal testing was not practical. In the process of working with the CDC, they developed a model they thought was appropriate for their ED, while at the same time achieving impressive results.
In fact, as the testing program unfolded, they continued to revise the program. The data dramatically show the wisdom of their approach: At the start of the program in February 2007, they were testing about 150 patients a month. Now, they are testing about 500.
"The CDC put out recommendations that you should to try to do testing of everyone from age 15 to 65, but that requires an enormous burden on the ED and enormous cost to the lab," notes Beth Kaplan, MD, clinical professor of emergency medicine at the University of California, San Francisco, and director of the HIV testing program. "I went to quite a few CDC meetings, and we were selected as an ED that would try a type of model that might be sustainable and practical." That selection meant using a model that would not require extra money, require additional staff, or "clog up" the ED, she says.
"A lot of evidence from other programs that do more across-the-board screening indicates it is extremely expensive and has a lower yield," Kaplan says. "Our program shows that with targeted testing, you have a high yield of positives, and the ED is not burdened in any way."
Eric Isaacs, MD, the ED medical director, says, "I am concerned it has a small impact on flow, but the turnaround for the test is rapid enough that if you are ordering other labs, it really does not take extra time."
By reviewing initial results, Kaplan explains, she was able to adjust indicators and include a wider swath of patients. "I looked back at the first 37 patients we found positive to see what they had in common with each other and used those indicators," she shares. So, for example, one of the main indicators was drug use, but not specifically IV drug use. It turns out that 35% of the patients who tested positive used methamphetamine, 37% used "crack" or cocaine, but only 19% used IV drugs. Fever was a major physical finding.
"We could have identified 85% of [the positives] if we had looked just at drug use or fever." says Kaplan.
In addition, she decided to expand testing to include all admitted patients, and she received more funding from the CDC to make that expansion possible.
Kaplan is pleased that so many individuals who were not receiving any HIV care are now being treated thanks to the program. "In March alone, we found 10 new patients and five patients who had positive test results documented in their chart but were not engaged in care at all," she says. "That's 15 new patients with HIV who were not receiving care and who are now."
Rapid HIV testing can impact initial treatment A rapid HIV testing program in the ED cannot only help identify more HIV-positive patients, but it can significantly affect how those patients' symptoms are treated, says Beth Kaplan, MD, clinical professor of emergency medicine at the University of California, San Francisco, and director of the HIV testing program at San Francisco General. "The diagnosis tends to affect how we treat the patient," she observes. "Chronic diarrhea would be treated one way if the test is negative; another if it is positive." The same would be true for dysphasia, difficulty in swallowing, shortness of breath, and even fever, Kaplan says. "If you make a different diagnosis, you have a different disposition," she explains. Eric Isaacs, MD, the ED medical director, says, "Previously, we would have just treated these patients symptomatically or assumed they would get better. With a positive result comes additional testing, which ensures closer follow-up, like treating the patient for pneumocystosis when we may have originally though they had ambulatory pneumonia." |
