Do you have the time — or the money — to offer HIV screenings?
New CDC guidelines encourage all EDs to offer testing
Offering routine HIV testing to ED patients is something that probably sounds good to an ED manager with a strong sense of his or her public health mission. It also is, however, something more easily thought than done.
Due to the considerable barriers to such programs (for example, cost, lack of staff, and lack of time), only 30-50 EDs in the country have one in place. There is hope, however, that things soon may improve. The Centers for Disease Control and Prevention (CDC) soon will revise its guidelines to ease the burdens for EDs and to encourage all EDs to offer these tests.
Meanwhile, some creative ED managers are finding ways to surmount those barriers. For example, Jackson Memorial Hospital in Miami has just begun offering routine HIV tests free of charge to all patients who are admitted to their ED with a medical problem, and the University of Cincinnati Hospital has had a program in place for years.
Still, they are definitely in the minority. "Most EDs will not do testing for this disease, because the process includes obtaining informed consent, providing counsel, maintaining confidentiality, and ensuring appropriate follow-up," explains James Augustine, MD, FACEP director of clinical operations at Emergency Medicine Physicians in Canton, OH. "Each of those steps is more difficult in the ED than in a clinic or a primary care physician's office, given the time constraints."
In addition, he notes, many of the test results can take days to return, and it's difficult for an ED to get that information back to the patient. "This has improved with the new rapid testing," he concedes, "but it remains challenging for an ED to provide all of the elements necessary."
In addition, note ED managers, providing the necessary counseling staff can be an unbearable financial burden for an ED. "Our policy is we don't do it," says David Vukich, MD, professor and chairman of the department of emergency medicine in the University of Florida College of Medicine, Jacksonville, and chief medical officer for Shands Jacksonville (FL) Hospital System.
For a while, Vukich's facility had partnered with the local public health department and provided a testing program under a grant the department had received. However, when the money ran out, the program ceased. "We want to help, but this is really a [tricky situation],'" he says. Once you start doing it, the requirements for pre- and post-counseling, mandated by the Florida legislature, become attached to it, Vukich says. "There is no continuity of care because there's almost a zero chance you'll see the same doc again," he says. In addition, he notes, it would cost his facility $300,000 to $400,000 to provide such services in-house.
The ED at the University of Cincinnati Hospital does have an ongoing program, says Michael Lyons, MD, a faculty physician in the ED and assistant professor of emergency medicine in the department of emergency medicine at the University of Cincinnati College of Medicine. However, he adds, "We compete every three years for funding from the Ohio health department and have been funded continuously since 1998."
The grant, Lyons says, basically supports the $150,000 per year program, which primarily screens high-risk patients.
EDs need financial help
David Gurr, MD, Jackson Memorial's associate director for emergency services, concedes that his new HIV testing program also will not be possible without outside help; he just doesn't know how much it ultimately will need.
The Miami-Dade Department of Health is paying for the testing kits, which cost $12 each, and a $100,000 grant from Foster City, CA-based Gilead Sciences, which makes HIV medications, is paying staff salaries for the first year. "Currently, we have five workers," he reports. "But we don't really know how many people will say 'yes' to testing."
Gurr's ED sees about 300 adults per day, he says. "We know from other studies that about 40% who are asked will say yes," he says. "If that holds true, we will be overwhelmed." In fact, he notes, he is working to obtain a grant from the CDC.
Lyons concedes that his program, which does not use any health department staff, does not have funding sufficient to its task. "We test between 1,200 and 1,500 patients a year out of the 85,000 patients we see," he says. "I'm sure the number we would like to test would be higher than that."
University of Cincinnati Hospital is not a high-prevalence environment for HIV, Lyons says. "We know we can't test everyone, so we try to maximize testing for those at risk," he says. Patients receive screening based on risk factors, which can include areas such as intravenous drug use to medical issues the physician considers to be consistent with HIV/AIDS, he notes.
Vukich insists, "We want to do this, and if the funding were put in place we would. It's not rocket science; it's what you are funded to do."
A complicated process
While it may not be rocket science, the process does involve several critical steps and follow-through on the part of the ED staff.
"We have posters up in the waiting room and the lobby, advising patients that they may be asked if they want to take an HIV test," Gurr shares. He says a group of state-certified counselors who are employed by the hospital look through the charts to obtain ED patients' names and make sure they are of an appropriate age (ages 13-64, per CDC guidelines). If no one has yet offered them the option of testing, they do so.
"They will go around asking patients if they are willing to be tested and will give counseling before the test if they agree," he explains. Every patient — whether they test positive or negative — then receives post-test counseling. "If they are positive, we have a South Florida AIDS Network on campus, and they will be set up with case a manager who will help them get into a clinic and be put on whatever meds they may need," says Gurr.
The key is that these risk factors are systematically applied, says Lyons, noting that he and another physician provide oversight for the program. "We have a few program coordinators at the level of nurse or highly trained social workers," he says.
Those staff place follow-up phone calls to the patients. "It is resource-intensive," says Lyons. "You can get a number of false-positives in low-prevalence environments." All positive results are given in person; for negative results, the staff have the option of contacting the patient by phone.
During the grant period, Vukich says the public health department sent one of its employees to the ED to provide the blood draws and offers any patients who wanted the test pretest counseling. "That ran for the length of the grant and worked pretty well," he says.
Testing can make a difference
Lyons says his data indicate that these programs can contribute significantly to the battle against AIDS/HIV.
"I think we've had a lot of success," he reports. "Our results show that in our ED, we identified around 10% of all the people identified in the region, and 25% of all those tested from publicly funded test centers."
Could programs like this be replicated in any ED? "If you had someone relatively sophisticated — at least a technician — you could probably do it for a couple hundred thousand a year for salaries, plus lab costs, then a lot of in-kind contributions from the hospital," says Vukich. The total annual cost would be $300,000-$400,000, he estimates.
"Of course, that is volume-dependent," Vukich continues. In a large ED, you'd have to provide testing 24/7, he says. "You might be able to cut your costs by one-third if you only provided testing during the big volume times: from noon to midnight."
For more information on HIV testing in the ED, contact:
- James J. Augustine, MD, FACEP, Director of Clinical Operations, Emergency Medicine Physicians, 4535 Dressler Road, Canton, OH 44718. Phone: (330) 493-4443. E-mail: firstname.lastname@example.org.
- Daniel Gurr, MD, Associate Director for Emergency Services, Jackson Memorial Hospital, Miami. Phone: (305) 291-9305.
- Mike Lyons, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Cincinnati College of Medicine. Phone: (513) 558-8629.
- David Vukich, MD, Professor and Chairman, Department of Emergency Medicine, College of Medicine, University of Florida; Chief Medical Officer, Shands Jacksonville Hospital System, Jacksonville. Phone: (904) 244-4107.