rapid testing in emergency departments: new jersey sindy m. paul, md, mph, facpm november 8, 2007

Rapid Testing in Emergency Departments: New Jersey

Sindy M. Paul, MD, MPH, FACPM

November 8, 2007

Why is it Important to do Rapid Testing in ED’s?

• For many, only access to health care system• CDC recommendations integrate into care• Patients often won’t return for results of

conventional tests• Negatives receive final results before leave

ED & if appropriate prevention referral• Reactives confirmatory test & referral for

final results (usually HIV or ID clinic)

Why is it Important to do Rapid Testing in ED’s?

• Test results may help in diagnosis and management in ED– Particularly helpful for patients with pneumonia

( a frequent reason to come to EDs)

ED Seroprevalence Data: Urban Teaching Hospital

• Anonymous, unlinked survey

• 10/7/02 – 12/31/02

• Persons > 18 years of age

• 332/3,193 (10.4%) positive

• 11.0% males and 9.6% females positive

• 198/332 (60%) knew they were positive

• 66% females, 55% males knew they were +

HIV Seroprevalence by Age and Gender

0%

5%

10%

15%

20%

Men Women

HIV Seroprevalenceby Race/Ethnicity and Gender

0%

2%

4%

6%

8%

10%

12%

14%

African American Hispanic White

Men Women

Comparison ofKnowledge of HIV Status by Gender

41%

13%

45%

50%

15%

34%

Men Women

Undiagnosed HIV

Diagnosed HIVAntiretroviral use

indicated

Diagnosed HIVNo antiretroviral use

indicated

Rapid Testing in New Jersey EDs

• Major statewide initiative • Goal: expand access to HIV counseling and

testing for high risk persons• CDC and state funding

– RFP included EDs

• Media campaign • State lab regulations requiring a license and

a lab director

New Jersey Models

• Funded by NJDHSS– Counselors– Supplies– Test and control kits

• ED = counseling and testing site• ED = satellite of another counseling and

testing site• Hospital or NJDHSS lab director

Cost Comparison with Non-Rapid Testing

• Counselors same just reassigned to ED

• Rapid test kits less expensive than Orasure because Orasure bundled with warehousing and testing fees from NJDHSS lab

• Volume price negotiated with company

• No cost test kits from CDC very helpful!!

• New expense = lab director

What to do with Cost Savings and Additional State Funds?

• Rapid testing interested all stakeholders resulting in state funding

• Cost savings from lab expenses & state funding media campaign & expansion– 22 Emergency Departments

Caveats to Working with EDs

• All EDs are different

• All hospitals are different

• The approach to each hospital/ED is different

• The key players are different

• Not all ED directors recognize risk of HIV in their catchment area

What is an ED?

• The definition varies – not necessarily the 4 walls of the ED

• Sexual assault area – frequently a separate room not within the 4 walls of the ED

• Adjacent areas i.e. OB “ED”

• Hospital floors if admitted when rapid testing not available in ED

Key Players

• CTS Coordinator

• ID or HIV clinic physician

• ED director

• Hospital lab director

• Hospital administrator

• NJDHSS staff

Identify a Champion within the Hospital and/or ED

• “Right” person varies from hospital to hospital

• CEO

• ID physician

• CTS coordinator

• University President’s Assistant

• ED physician

Helpful Information

• Data on rapid testing in EDs– In your area & other areas– Publications on ED RT in NJ

• Information on which EDs are doing rapid testing with contact information

• The other hospital in town is doing rapid testing in the ED ….

• 9/06 CDC Recommendations

Provide Technical Assistance: Make it as Easy as Possible

• Initial discussions• Meeting at hospital with key players• Tour of “ED”• Demonstration of rapid testing• Who can help

– Statewide lab director (licensing, QA, supplies, template forms)

– NJDHSS staff

Training

• Counseling – No Cost– NJDHSS, ½ Day,

– On request with variable location (could be done at ED)

• Testing – No Cost – Lecture and hands on

– QA, form completion competency testing

– 1 Day in central NJ

– Provided by NJDHSS/RWJ or Hosp. Lab Director

Patient Flow

• Information in waiting area

• Flow varies based on established patient flow in the ED

• Intake staff, then triage nurse, then ED staff

• Just ED staff

• Space for CTS staff– Mobile (cart with supplies)

What if the ED is Undergoing Construction?

• Not an infrequent occurrence• Be flexible – this is temporary• Several models

– CTS staff in ED escort patient to another area for counseling and testing

– CTS staff paged to ED when a patient agrees to have counseling and testing

– Less space, but able to remain in ED

New Issue: Hospital Closures

• The hospital with ED RT may be closing– Impacts resource allocation & access

• Surrounding hospital(s) may be closing– Increased number ED patients at existing RT

EDs– Change in patient flow at ED with RT– ? Need to modify funding for ED with RT due

to increased patient volume

What if a Patient Has a Reactive (Preliminary Positive) Test?

• Same post test counseling as for any reactive rapid test

• Refer patient to ID or HIV clinic for confirmatory results and counseling

• If confirmed positive patient has immediate appointment to start RX at clinic

• If discordant follow discordant protocol and refer to clinic

Improvement in Quality of Care: Case Scenarios

• Case # 1: Pneumocystis Pneumonia – Rapid testing in ED = reactive– Decision which service for admission– Decision on treatment

• Case # 2 Toxoplasmosis– No rapid testing in ED– Large workup including CJD (mad cow)– When non-rapid HIV test done after admit = +

Rapid Testing in New Jersey EDs:

• First ED started rapid testing 3/1/04

• 22 EDs

• 12 counties

• Selection based on prevalence

• Phased in over time

• Time frame to start-up variable– Satellite vs new site

Essex

Sussex

Burlington

Atlantic

Cumberland

Salem

Gloucester

Camden

Cape May

Somerset

Morris

Bergen

Passaic

Warren

Middlesex

Hunterdon

Union

Hudson

Monmouth

Mercer

Ocean

ED Rapid Testing Sites September 1, 2007

Shaded: rapid testing available

New Jersey ED Rapid Testing Data through October 5, 2007

• 17,506 tested• 17,292 (98.78%) received results• 17,069 (97.50%) negative• 421 (2.40%) positive • 314 (74.58%) new positive• 244/314 (77.71%) new +’s got confirmed results• 16 (0.09%) discordant• Non ED statewide RT prevalence 1.7%

New Jersey ED Rapid Testing Data through October 5, 2007

Tested Positive

Male 8,761 (50%) 248 (2.83%)

Female 8,727 (50%) 173 (1.98%)

Black 8,882 (51%) 329 (3.70%)

Hispanic 4,301 (25%) 63 (1.46%)

White 3,679 (21%) 23 (0.63%)

New Jersey ED Rapid Testing Data through October 5, 2007

Age (Years) Tested Positive

13-19 1,637 (9.35%) 5 (0.31%)

20-29 6,481(37.02%) 59 (0.91%)

30-39 4,122 (23.55%) 132 (3.20%)

40-49 3,407 (19.46%) 153 (4.49%)

> 50 1,844 (10.53%) 72 (3.90%)

Lessons Learned for Rapid HIV Testing in New Jersey EDs

• Rapid testing can be done in EDs!

• Higher prevalence than other sites

• Hard to reach at-risk persons not previously diagnosed

• Win-win for hospitals and public health

• One step to integrating HIV testing into patient care