Multiple HIV outbreaks among persons who inject drugs (PWID) have occurred in the US since 2015. Emergency departments (EDs), recognized as essential venues for HIV screening, may play a unique role ...in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use (IDU). Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program and estimate the program's contribution to HIV diagnoses among PWID county-wide during the emergence of a regional HIV outbreak.
This was a retrospective study of electronically queried clinical records from an urban, safety-net ED's HIV screening program and publicly available HIV surveillance data for its surrounding county, Hamilton County, Ohio. Outcomes included the change in number of HIV diagnoses and the ED's contribution to case identification county-wide, overall and for PWID during 2014-2018.
During 2014-2018, the annual number of HIV diagnoses made by the ED program increased from 20 to 42 overall, and from 1 to 18 for PWID. We estimated that the ED contributed 18% of HIV diagnoses in the county and 22% of diagnoses among PWID.
The ED program contributed 1 in 5 new HIV diagnoses among PWID county-wide, further illustrating the importance of ED HIV screening programs in identifying undiagnosed HIV infections. In areas experiencing increasing IDU, HIV screening in EDs can provide an early indication of increasing HIV diagnoses among PWID and can substantially contribute to case-finding during an HIV outbreak.
Study objective Opioid abuse and overdose constitute an ongoing health emergency. Many presume opioids have little potential for iatrogenic addiction when used as directed, particularly in short ...courses, as is typical of the emergency department (ED) setting. We preliminarily explore the possibility that initial exposure to opioids by EDs could be related to subsequent opioid misuse. Methods This cross-sectional study surveyed a convenience sample of patients reporting heroin or nonmedical opioid use at an urban, academic ED. We estimated the proportion whose initial exposure to opioids was a legitimate medical prescription and the proportion of those prescriptions that came from an ED. Secondary measurements included the proportion of patients receiving nonopioid substances before initial opioid exposure, the source of opioids between initial exposure and onset of regular nonmedical use, and time from initial prescription to opioid use disorder. Results Of 59 subjects, 35 (59%; 95% confidence interval CI 47% to 71%) reported they were first exposed to opioids by a legitimate medical prescription, and for 10 of 35 (29%; 95% CI 16% to 45%), the prescription came from an ED. Most medically exposed subjects (28/35; 80%; 95% CI 65% to 91%) reported nonopioid substance use or treatment for nonopioid substance use disorders preceding the initial opioid exposure. Emergency providers were a source of opioids between exposure and onset of regular nonmedical use in 11 of 35 cases (31%; 95% CI 18% to 48%). Thirty-one of the 35 medically exposed subjects reported the time of onset of nonmedical use; median time from exposure to onset of nonmedical use was 6 months for use to get high (N=25; interquartile range IQR 2 to 36), 12 months for regular use to get high (N=24; IQR 2 to 36), 18 months for use to avoid withdrawal (N=26; IQR 2 to 38), and 24 months for regular use to avoid withdrawal (N=27; IQR 2 to 48). Eleven subjects (36%; 95% CI 21% to 53%) began nonmedical use within 2 months, and 9 of 11 (82%; 95% CI 53% to 96%) reported nonopioid substance use or treatment for alcohol abuse before initial opioid exposure. Conclusion Although short-term opioid administration by emergency providers is unlikely to cause addiction by itself, ED opioid prescriptions may contribute to the development of addiction in some patients. There is an urgent need for further research to estimate long-term risks of short-course opioid therapy so that the risk of iatrogenic addiction can be appropriately balanced with the benefit of analgesia.
To report per-capita distribution of take-home naloxone to lay bystanders and evaluate changes in opioid overdose mortality in the county over time.
Hamilton County Public Health in southwestern Ohio ...led the program from Oct 2017-Dec 2019. Analyses included all cartons distributed within Hamilton County or in surrounding counties to people who reported a home address within Hamilton County. Per capita distribution was estimated using publicly available census data. Opioid overdose mortality was compared between the period before (Oct 2015-Sep 2017) and during (Oct 2017-Sep 2019) the program.
A total of 10,416 cartons were included for analyses, with a total per capita distribution of 1,275 cartons per 100,000 county residents (average annual rate of 588/100,000). Median monthly opioid overdose mortality in the two years before (28 persons, 95% CI 25-31) and during (26, 95% CI 23-28) the program did not differ significantly.
Massive and rapid naloxone distribution to lay bystanders is feasible. Even large-scale take-home naloxone distribution may not substantially reduce opioid overdose mortality rates.
...each CGZ package was labeled with a sticker identifying its purchase price. ...an educational email was sent to all clinical ED staff at the beginning of the intervention; this email described the ...clinical utility of combat gauze, instructions and limitations regarding use, provided information about its cost, and advised staff of the other intervention elements. ...a multifaceted cost awareness initiative utilizing stocking location changes, informative stickers, and educational communications can reduce ED supply costs.
Pre-exposure prophylaxis (PreP) reduces the rate of HIV transmission in high-risk groups. Emergency departments (EDs) frequently encounter patients at risk for HIV acquisition who are eligible for ...PrEP. ED HIV screening programs have prioritized testing and linkage to care for patients who test positive, but fail to refer HIV-negative patients to PrEP clinicians. Our objective was to estimate referral acceptance to a PrEP clinician among a sample of at-risk ED patients.
This single-center cross-sectional study electronically queried a prospectively acquired dataset of survey responses from a sample of patients presenting to an urban academic ED from March 2019 to February 2020. Patients completed a risk assessment as part of the HIV screening program. PrEP eligibility was based off survey responses in accordance with 2017 CDC PrEP eligibility criteria. Identified PrEP-eligible patients completed a PrEP questionnaire. The primary outcome was the proportion of PrEP-eligible patients who accepted referral to a PrEP clinician during their ED encounter. We secondarily report patient participant characteristics including the proportion of PrEP-eligible patients who were aware of and were knowledgeable about PrEP as a method to prevent transmission of HIV.
In total, 360 patients completed a PrEP questionnaire, of which 287 (80%) were not currently taking PrEP and eligible for PrEP referral. 57% were males, with 41% Black/African American. Of the 287 eligible for PrEP, 61 (21.3%, 95% CI: 16.8–26.5) indicated awareness of PrEP, of which, 49 (80.3%, 95% CI: 67.8–89.0) demonstrated accurate knowledge of PrEP. PrEP referral was offered to 238 (82.9%, 95% CI: 78.0–87.0) patients, of which, 76 (31.9%, 95% CI: 26.1–38.3) accepted.
Approximately one third of PrEP-eligible ED patients accepted PrEP referral during their ED encounter, demonstrating an opportunity for increased PrEP education and intentional referral for eligible patients. Variability in PrEP acceptability by demographic and risk subgroup may be an important consideration in efforts to expand PrEP utilization.
•ED HIV screening programs link HIV-positive patients to care, but fail to refer HIV-negative patients to PrEP.•Approximately one third of PrEP-eligible ED patients accepted PrEP referral during their ED encounter.•This demonstrates an opportunity for increased PrEP education and intentional referral for eligible patients.•Females, MSM, and heterosexual men and women were more likely to accept PrEP referral than males & persons who inject drugs.
Pre-exposure prophylaxis (PrEP) is a highly effective but underutilized method of HIV prevention. Emergency departments (EDs) have access to at-risk populations meeting CDC eligibility criteria for ...PrEP. Characterizing this population could help motivate, develop, and implement ED interventions to promote PrEP uptake.
This cross-sectional study explored the proportion of patients from an urban, academic ED who met CDC 2017 PrEP eligibility criteria using three existing datasets that mimic patient selection strategies for HIV screening: 1) study of consecutively approached ED patients from 2008 to 2009 (analogous to non-targeted screening), 2) patients of the ED's HIV screening program in 2017 (analogous to risk-targeted screening), and 3) electronic health record (EHR) diagnostic codes in 2017 (analogous to EHR selected screening). The primary outcome was the proportion eligible for PrEP referral. Secondary outcomes included proportion by risk group: men who have sex with men (MSM), heterosexual men and women (HMW), and persons who inject drugs (PWID).
The proportion eligible for PrEP was: 568/1970 (28.8%, 95% CI: 26.9–30.9) for consecutively approached patients, 552/3884 (14%, 95% CI: 13–15) for risk-targeted patients, and 605/66287 (0.9%, 95% CI: 0.8–1.0) for EHR diagnoses of all patients. For the two datasets with behavioral risk information, the proportion eligible was: MSM 1–2%, HMW 12–28%, and PWID 1–4%.
A large subgroup of this ED population was eligible for PrEP referral. EDs are a compelling setting for development and implementation of HIV prevention interventions to assist in national efforts to expand PrEP.
•Preexposure prophylaxis (PrEP) is highly effective but underutilized for HIV prevention.•PrEP use is one of the key strategies of the national Ending the HIV Epidemic initiative.•Emergency departments (EDs) have access to at-risk populations eligible for HIV PrEP.•A large subgroup of patients visiting this urban academic ED was eligible for PrEP.•EDs can assist in PrEP uptake by developing and implementing prevention interventions.
Approximately 12.4 million people in the U.S. have latent tuberculosis infection (LTBI), 73% of whom are non-U.S. born. Identification and treatment of LTBI are essential for tuberculosis ...eradication. We evaluated an emergency department (ED) – based LTBI screening and linkage to care program.
We queried electronic records of a clinical prevention program located in a Midwestern, urban, academic ED that serves as the region's safety-net hospital. Program staff approached non-U.S. born ED patients from TB endemic areas. Patients received QuantiFERON-TB Gold Plus (QFT) blood testing and, if positive, were referred to treatment. The primary outcome was the proportion of tested patients newly diagnosed with LTBI. We secondarily report the number of patients linked to care who initiated LTBI treatment.
The program approached 33 patients, of whom 24 (72.7%) were eligible, and 23 (95.8%) were tested. The majority were male (13, 56.5%), median age was 33 years (IQR 27–45), and 13 (56.5%) were from Latin America. Three patients (13.0%, 95% CI 0.03–0.35) were newly diagnosed with LTBI and linked to care; two (66.7%) started LTBI treatment.
In this first report of an ED-based LTBI screening program implemented in a region with low TB prevalence, over 10% of high-risk ED patients tested positive for LTBI and were linked to treatment. Screening populations at risk for LTBI in EDs and linking them to public health treatment services should be prioritized in order to achieve TB elimination in the U.S.
•About 12.4 million people have latent tuberculosis infection (LTBI).•Patients with LTBI represent the main source of new TB cases in the U.S.•73% of patients with LTBI are non-US born.•We conducted an emergency department (ED)-based LTBI screening program.•Over 10% of non-US born ED patients tested positive for LTBI in this screening program.
Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to ...patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician.
This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone.
Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1–33.8). Naloxone provision occurred for 33.6% (95% CI 30.5–36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0–19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4–30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 95% CI 0.011–0.33) for naloxone provision compared to those only referred to outpatient treatment.
A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment “bundle” as a conceptual model for care of ED patients with suspected OUD.
Emergency departments (EDs) are highly valued settings for HIV screening. Most large-volume ED HIV screening programs have attenuated operational barriers by screening only ED patients who already ...have a blood sample available for other clinical reasons. Our objective was to estimate the proportion of HIV positive patients who are missed when an ED excludes patients for whom HIV screening would be the only indication to obtain a blood sample.
This cross-sectional analysis used existing electronic records of patients seen between 2017 and 2019 by an urban, academic ED and its HIV screening program, which includes patients regardless of whether they receive other ED blood testing. The primary outcome was the proportion of patients tested by the screening program who were newly diagnosed with HIV (Sample 1) for whom HIV screening would be the only indication for venipuncture. We secondarily 1) estimate the proportion of ED patients who received venipuncture using a representative sample of consecutively approached participants which prospectively recorded whether patients had blood obtained or intravenous catheter placement during usual ED care (Sample 2) and 2) report patient characteristics including HIV risk factors for those with and without ED venipuncture for both groups.
Of 41 persons newly diagnosed with HIV by the ED screening program (Sample 1), 13 (31.7%, 95%CI 18.6–48.2) did not undergo venipuncture for any reason other than their HIV test. The proportion of ED visits without a venipuncture (Sample 2) was 44.2% (95% CI 41.9–46.6). Patient characteristics were similar for both groups.
Screening only those patients with a blood sample already available or easily obtainable due to usual ED care, misses many opportunities for earlier HIV diagnosis. Innovation in research, policy, and practice is needed to overcome still unaddressed barriers to ED HIV screening when HIV screening is the only indication for collection of a biological sample.
According to data from the Drug Abuse Warning Network, ED referral ranged from 2.6 to 20% of eligible patients 6. A collaborative including the health department, social-service agencies, and ...regional health systems developed a single “hotline” phone number to assist patients with OUD in accessing care. The following terms in the problem list, past medical history, and clinical impression were included in the alert: “opioid abuse”, “overdose of opiate”, “misuse of drugs” including subsections “injection drug user”, “opiate misuse”, “methadone use”, and “narcotic drug user”. ...if a urine drug screen was obtained and was positive for buprenorphine, fentanyl, methadone, opiates, or oxycodone, the EHR alert would activate.
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