HIV screening in emergency departments/process/model
Physician-Initiated Rapid HIV Testing in an Urban Emergency Department: Comparison of Testing Using a Point-of-Care Versus a Laboratory Model

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Study objective

We compare the outcomes of 2 models of physician-initiated rapid HIV testing in an emergency department (ED).

Methods

One-year retrospective cohort comparing 2 6-month models of physician-initiated rapid HIV testing, point-of-care versus laboratory. Patients aged 12 years or older and able to give verbal consent were eligible for physician-initiated rapid HIV testing if their treating physician believed testing was clinically indicated. During the point-of-care phase, nursing staff performed oral fluid testing. During the laboratory phase, the laboratory performed whole-blood testing. The proportion of potentially eligible patients who had physician-initiated rapid HIV testing ordered (order rate), proportion of ordered tests completed (test completion rate), and proportion of potentially eligible patients who completed testing (overall testing rate) during each phase were assessed. ED length of stay and testing times were also compared.

Results

For the point-of-care versus laboratory phase, respectively, there were 24,345 potentially eligible patients versus 26,363; order rate was 3.3% versus 2.4% (P<.001); test completion rate was 75.3% versus 86.8% (P<.001); overall testing rate was 2.5% versus 2.1% (P=.009). Eighteen (3.0%) of the point-of-care-tested patients and 15 (2.7%) of the laboratory-tested patients had reactive tests (P=0.02). The total testing time was greater in the laboratory phase (88 versus 66 minutes; P<.001); however, there was no significant difference in the length of stay between phases (6.2 versus 6.9 hours; P=.15).

Conclusion

Relatively few ED patients undergo physician-initiated rapid HIV testing regardless of whether a point-of-care or laboratory approach is used. Differences exist in most outcome measures when point-of-care and laboratory models are compared, which should be considered when testing is implemented.

Introduction

Implementing universal HIV screening may not be feasible in most emergency departments (EDs). Implementation has proven challenging and penetration of screening within EDs has been relatively low to date.1

Until there is a national strategy to support universal ED-based HIV screening, EDs may choose to implement testing in a more limited fashion. Although not specifically defined in the recent report on standardizing nomenclature for ED-based HIV testing,2 a physician-initiated rapid HIV testing model combines diagnostic testing and targeted screening and is reliant on the discretion of the treating physician: diagnostic testing in patients with signs or symptoms consistent with HIV infection or AIDS and targeted screening in patients perceived to have an increased likelihood of infection.

Several models of delivering ED physician-initiated rapid HIV testing have already been described, including point-of-care testing by native nursing staff,1 point-of-care testing by exogenous testing staff,3 and laboratory testing.4 A presumed advantage of point-of-care testing is faster turnaround times, although this may be offset by testing falling to either the native ED staff or adjunctive exogenous staff. In a laboratory model, incorporation of testing into standard laboratory procedures minimizes the workload on ED staff and eliminates the need for additional personnel. However, laboratory testing may result in longer turnaround times to results and increased ED patient length of stay.4 Accordingly, physicians may be less likely to order laboratory versus point-of-care testing, especially for patients who have no need for other tests.

Most EDs have access to a hospital-based, centralized laboratory, making a laboratory model for physician-initiated rapid HIV testing practical and sustainable. Direct comparison of individual outcomes associated with point-of-care physician-initiated rapid HIV testing versus laboratory physician-initiated rapid HIV testing models is important for guiding decisionmaking about program implementation.

In this study, we sought to compare the outcomes of a physician-initiated, nursing-performed point-of-care rapid HIV testing model with a physician-initiated, laboratory-performed rapid HIV testing model in an urban ED.

Section snippets

Study Design

A retrospective cohort study was conducted from February 2008 through January 2009. Two models for physician-initiated rapid HIV testing were implemented sequentially in 6-month phases: point-of-care testing, followed by laboratory testing. The models were introduced as clinical policy. The study was approved by the hospital institutional review board, with a waiver of written informed consent.

Setting

The Alameda County Medical Center is an urban teaching hospital and regional trauma center with an

Results

The Figure provides a flow chart for the 2 physician-initiated rapid HIV testing phases. For the point-of-care versus laboratory phase, there were 24,345 potentially eligible patients versus 26,363, order rate was 3.3% versus 2.4% (P<.001), test completion rate was 75.3% versus 86.8% (P<.001), and overall testing rate was 2.5% versus 2.1% (P=.009). Similar proportions of patients completing point-of-care and laboratory physician-initiated rapid HIV testing also accepted opt-out HIV screening

Limitations

There are several limitations to the study. First, the outcomes may be influenced by the presence of the coexisting opt-out HIV screening program. The screening program tested approximately 1,000 patients monthly (15% of monthly ED volume), many of whom might have undergone physician-initiated rapid HIV testing if screening were not in place. Because the HIV screening program was ongoing and did not change during both the point-of-care and laboratory study periods, we believe it would have

Discussion

Although ED HIV screening is recommended by the Centers for Disease Control and Prevention and its benefits are well described, implementation of screening may not be possible in many facilities.1, 4, 7, 8, 9, 10 In this study, we implemented and compared 2 models for integrating physician-initiated rapid HIV testing into ED operations: rapid HIV testing on oral fluid specimens, performed point-of-care by nursing staff, and rapid testing on whole-blood specimens, performed by the hospital's

References (14)

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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This study was funded by cooperative agreements from the Centers for Disease Control and Prevention to Dr. White (U18 PS000321).

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Publication of this article was supported by Centers for Disease Control and Prevention, Atlanta, GA.

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