While use of emergency settings for screening purposes remains controversial, it is hard to ignore the potential opportunities they present for public health intervention. With effective, new treatments now available for hepatitis C — the most common chronic blood-borne infection in the United States — some inner-city EDs are moving on the opportunity to identify the vast numbers of patients who are infected, estimated to be around 3 million, and connect them to care.
Building on earlier work in this area, investigators at Highland Hospital in Oakland, CA, are among the latest to test a hepatitis C screening protocol in the ED, and early reports on this effort reveal a striking public health opportunity.1 Targeting screening toward the 10% of the ED population considered most at risk for hepatitis C, researchers found slightly more than 10% of these patients tested positive for hepatitis C antibodies in the six-month study, and 70% of these patients were confirmed to be chronically infected with the disease. The researchers found that only 24% of the patients who tested positive for hepatitis C were aware that they were infected.2
However, while researchers uncovered a significant need for intervention, they also report coming up against a number of challenges — both in introducing the screening protocol in the ED and in linking the infected patients to appropriate care. Nevertheless, while investigators now have industry funds to support the screening program, they’re hoping to fine-tune the process to the point where it can be self-sustaining. Further, they note some of the roadblocks that have long prevented hepatitis C screening programs from being viable in the emergency setting are now a thing of the past.
Anticipate some staff resistance
The protocol investigators devised involves targeting patients considered at high risk for hepatitis C, such baby boomers, IV drug users, and patients with an unspecified liver disease. Questions about such risks were embedded in the triage process. However, the approach encountered early trouble.
“The nurses were very concerned about privacy and talking about sensitive issues, such as IV drug use, in a non-private setting,” explains Sara Pfeil, BS, the program coordinator of the hepatitis C screening initiative in the Department of Emergency Medicine at Highland Hospital and a co-author of the hepatitis C screening study. “The nurses were afraid of making patients uncomfortable.”
Investigators looked at the issue in some sub-studies and found the nurses’ perceptions of how patients were feeling were more negative than what the patients were actually feeling, Pfeil adds.
However, she notes there was also some pushback from nurses who were concerned about time.
“There is pressure to complete the triage-per-patient [process] at our site in six minutes, and the nurses were concerned that adding additional questions to the screening they already ask in their intake and triage process would slow that down and negatively impact ED flow,” Pfeil explains. “On average, the [hepatitis C screening questions] add 30 seconds to one minute to each triage, which can add up, but not appreciably.”
On the physician side, there was no pushback at all to the screening program, but that doesn’t necessarily mean the introduction of hepatitis C screening programs at other ED facilities would be as readily accepted by physicians.
“We have more than a decade of experience of integrating public health interventions like this,” explains Douglas White, MD, the lead author of the study and director of both HIV and hepatitis C screening in the ED at Highland Hospital. “HIV is what we have the most experience with. We have some of the first physicians in the country to perform large-scale HIV testing, disclosing HIV results and linking HIV patients into care, so being able to layer on hepatitis C testing was not a challenge for the physicians,” he says. “Obviously, it is additional work, and it was new, so additional education needed to happen, but the physicians weren’t a barrier in this roll out.”
Leverage improved testing processes
However, White acknowledges it is generally outside the scope of the mission of most EDs to take on screening when the primary focus is to take on more immediate life-threatening medical illnesses.
“There is that whole concept of changing the culture and thinking about the scope and mission of an inner-city ED,” he says.
Further, White adds that ED administrators interested in developing hepatitis C screening programs should consider the numerous technical challenges involved.
“Integrating screening is impractical in the sense that it takes time and it requires resources in terms of staff,” he says. “You need to dedicate time in order to complete the offering process and the actual testing process, and then you have all the challenges involved with disclosing results while integrating that entire process into standard ED operations when your primary aim is taking care of people with acute medical complaints.”
Along with these challenges, though, White observes that advances in testing have made a big difference in facilitating the screening process in a sustainable manner.
“The hepatitis screening test as well as the HIV screening test that we perform are now fully integrated into the laboratory system and automated so we are no longer performing them at the point of care,” he explains. “They are actually managed completely in house by the laboratory, and the results are automatically populated into our electronic medical record (EMR) system, so that takes a lot of the burden out of the testing process for us.”
Such improvements have enabled the ED to integrate testing into the normal blood draw, which is part of routine practice in the ED, and the results are delivered just like the results of any other lab test, White observes.
“In the past ... some places had dedicated testing staff and it was treated very differently than other ED processes, and now that you can [fully] integrate it into the lab workflow I think has normalized [the testing process],” he says.
Understand the limitations
In the study, while the hepatitis C testing process was greatly streamlined, the time it took to complete laboratory testing proved to be a major obstacle. Investigators report that it typically took between 60 and 90 minutes to receive results back from the lab. While that is not such a long turnaround time for an ED, as many as half the patients who underwent hepatitis screening were already discharged by the time their results came back, and that was a huge issue, according to White.
“If a patient is discharged, you can’t disclose the result. It is that simple,” he explains.
“About a third of our ED patients who get triaged are funneled into the fast-track area, and those patients have an incredibly quick turnaround time,” White notes. “Say these patients accept screening and the test gets ordered and performed … no one in fast track, for the most part, has a 1 or 2 hour visit. They are very short visits, so testing in specific areas of the ED where we know [the visits] are going to be faster, like in the fast track, will always be a barrier to results disclosure.”
This is a challenge that EDs interested in setting up hepatitis screening programs need to be aware of, White stresses.
“You have to know this is a limitation if you choose to screen in settings where patient turnover is fast,” he says. “There needs to be a mechanism in place for contacting these patients.”
The protocol at Highland Hospital did not require investigators to track down patients who received negative results. Instead, investigators focused their efforts on finding patients with positive results so they could arrange for confirmatory testing.
“These antibody tests need to be confirmed in a second blood test to determine what proportion of the patients actually have chronic active hepatitis C, and this is a step that is a barrier and a challenge,” White says.
Pfeil concurs, noting that completing the testing algorithm on patients who were discharged before receiving their initial lab results presented early obstacles.
“We had a huge drop-off where we had a lot of antibody-positive patients who we tried to call back to redirect … using a secondary clinic or going directly to phlebotomy [and then] to the lab with a slip that Dr. White would write to get their confirmatory tests performed,” she says. “That was the first breakdown — bringing people back in who didn’t get their confirmatory tests done at their initial ED visit.”
Use the EMR to your advantage
White observes that staff had to be creative in figuring out ways to get patients back into the system, and one way they did that was by leveraging the department’s EMR.
“A lot of our patients use the ED [repeatedly], so we actually created an alert in our EMR. If a patient came back to the ED who hadn’t had their initial results disclosed or who needed a confirmatory hepatitis C test, the system would alert the provider,” he explains. “We were able to achieve [confirmatory] testing and linkage to care — but not always on that index visit. Sometimes it happened on a patient’s next encounter or even the third encounter in the ED.”
In this case, patient recidivism turned out to be very helpful for a number of antibody-positive patients, Pfeil offers.
“There was quite a large burden of work to try to get those confirmatory test results and to try to get people back into the ED,” she says. “We would call patients and a lot of the phone numbers were non-working numbers, and it was really difficult to track patients down that way. We also had a letter system in place for patients with non-working phone numbers that we integrated into our protocol.”
When tests confirmed a patient had a chronic hepatitis C infection, intervention staff eventually worked out a system where they could schedule the patient to be seen in the hospital’s hepatitis C clinic.
“We have five slots per week [for direct booking] into the clinic, which we did not have originally,” Pfeil notes. “Our hepatitis C clinic is new and up and coming, so we have kind of reached a critical capacity.”
White agrees, noting that the prevalence of hepatitis C is so high that the ED screening program quickly exceeded the capacity of the clinic’s ability to care for these patients.
“There is no doubt about it. Once they opened up slots, we filled them. They are now filled through the beginning of next year with patients waiting to go to the hepatitis C clinic,” he observes.
Fortunately, with hepatitis C most patients do not need to receive immediate treatment.
“It is not an absolute necessity that these patients be treated today or even tomorrow,” White notes. “The majority can be treated at some point in the future, so we do have a little time in terms of getting these patients into care and treatment. That is generally how we look at it.”
Plan ahead, collaborate
While the six-month study at Highland Hospital has concluded, the screening program for hepatitis C is ongoing with funding through Gilead Sciences, the Foster City, CA, biotechnology company responsible for developing Sovaldi and Harvoni, two of the new treatments for hepatitis C.
“We are really trying to refine the model so that it is sustainable, but what is really clear after doing this [for a year and a half] is that the challenges with linkage to care are so great that we don’t recommend taking on a program [like this] without a supplemental workforce to handle [that aspect],” White advises. “Right now, it is too big a challenge to be integrated into most ED processes.”
White adds there may be some systems already in place in some settings that can handle at least part of the workload.
“Look at the healthcare environ-
ment you work in and take advantage of the existing systems,” he says.
White also stresses that a successful program needs to be collaborative.
“Have everyone at the table in the planning, from all ED personnel who are going to be involved to referral systems to the hepatologists who are going to be taking care of the patients and the primary care practitioners (PCPs) who may be the intermediaries,” he says. “Everyone in the system needs to be on board. If you have multiple layers of care providers invested, fewer patients who test positive will fall through the cracks.”
White envisions a push toward the education and training of PCPs to be the referral physicians for hepatitis C patients.
“It may be that a patient doesn’t require ongoing care by a liver specialist in order to receive treatment,” he says. “Expanding the capacity of PCPs to provide treatment will offset some of the work challenges of linkage.”
Pfeil stresses that an effective mechanism for connecting patients with specialty care needs to be in place before screening begins.
“You will be inundated with hepatitis C-positive patients almost immediately, so it is crucial to have a linkage-to-care protocol that you know will work before implementing screening,” she says. “Have personnel on board who can help in that process … and make sure the testing algorithm happens as seamlessly as it can so linkage will be easier on the back end.”
Consider population needs
The EDs most prepared to initiate hepatitis screening programs are those that already have successful HIV screening programs in place, much like the ED at Highland Hospital, White observes.
“It is almost like a parallel process. You are layering on a second screening intervention,” he says. “Programs that have the tools and the experience in place for HIV screening can very easily add on hepatitis C screening.”
However, even in these cases, White adds that there is often a challenge in convincing ED administrators and the people on the front lines responsible for doing the work.
“They are always leery about one more intervention, one more thing to screen,” he says. “There is always a concern of when it will end in terms of adding more work and responsibility to the ED.”
While it is clear the prevalence of hepatitis C in the population is already quite high and threatening to surge even higher, given the exploding problem of IV drug abuse around the country, the patients most likely to benefit from hepatitis screening programs are probably those who frequent safety net hospitals, White says.
“We just don’t have enough cumulative experience doing hepatitis C testing at this point to make recommendations on who should and who shouldn’t adopt screening programs.”
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Galbraith JW, et al. Unrecognized chronic hepatitis C virus infection among baby boomers in the emergency department. Hepatology 2015;61:776-782.
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White D, et al. Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department. Ann Emerg Med 2015. DOI: http://dx.doi.org/10.1016/j.annemergmed.2015.06.023.
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Sara Pfeil, BS, Program Coordinator, Hepatitis C Screening Program, Highland Hospital, Oakland, CA. Email: [email protected].
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Douglas White, MD, Director, Emergency Department HIV and HCV Screening, Highland Hospital, Oakland, CA. Email: [email protected].
