Evaluation of the Centers for Disease Control and Prevention Recommendations for Hepatitis C Virus Testing in an Urban Emergency Department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommends 1-time hepatitis C virus (HCV) testing in the 1945-1965 birth cohort, in addition to targeted risk-based testing. Emergency departments (EDs) are key venues for HCV testing because of the population served and success in HIV screening. We determined the burden of undocumented HCV infection in our ED, providing guidance for implementation of ED-based HCV testing.

METHODS

An 8-week seroprevalence study was conducted in an urban ED in 2013. All patients with excess blood collected for clinical purposes were included. Demographic and clinical information including documented HCV infection was obtained from electronic medical records. HCV antibody testing was performed on excess samples.

RESULTS

Of 4713 patients, 652 (13.8%) were HCV antibody positive. Of these, 204 (31.3%) had undocumented HCV infection. Among patients with undocumented infections, 99 (48.5%) would have been diagnosed based on birth cohort testing, and an additional 54 (26.5%) would be identified by risk-based testing. If our ED adhered to the CDC guidelines, 51 (25.0%) patients with undocumented HCV would not have been tested. Given an estimated 7727 unique ED patients with HCV infection in a 1-year period, birth cohort plus risk-based testing would identify 1815 undocumented infections, and universal testing would identify additional 526 HCV-infected persons.

CONCLUSIONS

Birth cohort-based testing would augment identification of undocumented HCV infections in this ED 2-fold, relative to risk-based testing only. However, our data demonstrate that one-quarter of infections would remain undiagnosed if current CDC birth cohort recommendations were employed, suggesting that in high-risk urban ED settings a practice of universal 1-time testing might be more effective.

Developments in Surge Research Priorities: A Systematic Review of the Literature Following the Academic Emergency Medicine Consensus Conference, 2007-2015

OBJECTIVES

In 2006, Academic Emergency Medicine (AEM) published a special issue summarizing the proceedings of the AEM consensus conference on the "Science of Surge." One major goal of the conference was to establish research priorities in the field of "disasters" surge. For this review, we wished to determine the progress toward the conference's identified research priorities: 1) defining criteria and methods for allocation of scarce resources, 2) identifying effective triage protocols, 3) determining decision-makers and means to evaluate response efficacy, 4) developing communication and information sharing strategies, and 5) identifying methods for evaluating workforce needs.

METHODS

Specific criteria were developed in conjunction with library search experts. PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases were queried for peer-reviewed articles from 2007 to 2015 addressing scientific advances related to the above five research priorities identified by AEM consensus conference. Abstracts and foreign language articles were excluded. Only articles with quantitative data on predefined outcomes were included; consensus panel recommendations on the above priorities were also included for the purposes of this review. Included study designs were randomized controlled trials, prospective, retrospective, qualitative (consensus panel), observational, cohort, case-control, or controlled before-and-after studies. Quality assessment was performed using a standardized tool for quantitative studies.

RESULTS

Of the 2,484 unique articles identified by the search strategy, 313 articles appeared to be related to disaster surge. Following detailed text review, 50 articles with quantitative data and 11 concept papers (consensus conference recommendations) addressed at least one AEM consensus conference surge research priority. Outcomes included validation of the benchmark of 500 beds/million of population for disaster surge capacity, effectiveness of simulation- and Internet-based tools for forecasting of hospital and regional demand during disasters, effectiveness of reverse triage approaches, development of new disaster surge metrics, validation of mass critical care approaches (altered standards of care), use of telemedicine, and predictions of optimal hospital staffing levels for disaster surge events. Simulation tools appeared to provide some of the highest quality research.

CONCLUSION

Disaster simulation studies have arguably revolutionized the study of disaster surge in the intervening years since the 2006 AEM Science of Surge conference, helping to validate some previously known disaster surge benchmarks and to generate new surge metrics. Use of reverse triage approaches and altered standards of care, as well as Internet-based tools such as Google Flu Trends, have also proven effective. However, there remains significant work to be done toward standardizing research methodologies and outcomes, as well as validating disaster surge metrics.

Evaluation of hidden HIV infections in an urban ED with a rapid HIV screening program

BACKGROUND

To investigate the prevalence of undiagnosed HIV infections in an emergency department (ED) with an established screening program.

METHODS

Evaluation of the prevalence and risk factors for HIV from an 8-week (June 24, 2007-August 18, 2007) identity-unlinked HIV serosurvey, conducted at the same time as an ongoing opt-in rapid oral-fluid HIV screening program. Testing facilitators offering 24/7 bedside rapid testing to patients aged 18 to 64 years, with concordant collection of excess sera collected as part of routine clinical procedures. Known HIV positivity was determined by (1) medical record review or self-report from the screening program and/or (2) presence of antiretrovirals in serum specimens.

RESULTS

Among 3207 patients, 1165 (36.3%) patients were offered an HIV test. Among those offered, 567 (48.7%) consented to testing. Concordance identity-unlinked study revealed that the prevalence of undiagnosed infections was as follows: 2.3% in all patients, 1.0% in those offered testing vs 3.0% in those not offered testing (P < .001); and 1.3% in those who declined testing compared with 0.4% in those who were tested (P = .077). Higher median viral loads were observed in those not offered testing (14255 copies/mL; interquartile range, 1147-64354) vs those offered testing (1865 copies/mL; interquartile range, undetectable-21786), but the difference was not statistically significant.

CONCLUSIONS

High undiagnosed HIV prevalence was observed in ED patients who were not offered HIV testing and those who declined testing, compared with those who were tested. This indicates that even with an intensive facilitator-based rapid HIV screening model, significant missed opportunities remain with regard to identifying undiagnosed infections in the ED.

HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department

STUDY OBJECTIVE

The recently released HIV Care Continuum Initiative is a cornerstone of the National AIDS Strategy and a model for improving care for those living with HIV. To our knowledge, there are no studies exploring the entirety of the HIV Care Continuum for patients in the emergency department (ED). We determine gaps in the HIV Care Continuum to identify potential opportunities for improved care for HIV-infected ED patients.

METHODS

A mixed-methods approach was used in 1 inner-city ED in 2007. Data elements were derived from an identity-unlinked HIV seroprevalence study, an ongoing nontargeted HIV screening program, and a structured survey of known HIV-positive ED patients.

RESULTS

Identity-unlinked testing of 3,417 unique ED patients found that 265 (7.8%) were HIV positive. Of patients testing HIV positive, 73% had received a previous diagnosis (based on self-report, chart review, or presence of antiretrovirals in serum), but only 61% were recognized by the clinician as being HIV infected (based on self-report or chart review). Of patients testing positive, 43% were linked to care, 39% were retained in care, 27% were receiving antiretrovirals, 26% were aware of their receiving antiretroviral treatment, 22% were virally suppressed, and only 9% were self-aware of their viral suppression.

CONCLUSION

To our knowledge, this study is the first to quantify gaps in HIV care for an ED patient population, with the HIV Care Continuum as a framework. Our findings identified distinct phases (ie, testing, provider awareness of HIV diagnosis, and linkage to care) in which the greatest opportunities for intervention exist, if appropriate resources were allocated. This schema could serve as a model for other indolent treatable diseases frequently observed in EDs, where continuity of care is critical.

Prevalence and factors associated with herpes simplex virus type 2 infection in patients attending a Baltimore City emergency department

OBJECTIVES

Herpes simplex virus type 2 (HSV-2) is a common sexually transmitted disease, but there is limited data on its epidemiology among urban populations. The urban Emergency Department (ED) is a potential venue for surveillance as it predominantly serves an inner city minority population. We evaluate the seroprevalence and factors associated with HSV-2 infection among patients attending the Johns Hopkins Hospital Adult Emergency Department (JHH ED).

METHODS

An identity unlinked-serosurvey was conducted between 6/2007 and 9/2007 in the JHH ED; sera were tested by the Focus HerpeSelect ELISA. Prevalence risk ratios (PRR) were used to determine factors associated with HSV-2 infection.

RESULTS

Of 3,408 serum samples, 1,853 (54.4%) were seropositive for HSV-2. Females (adjPRR  = 1.47, 95% CI 1.38-1.56), non-Hispanic blacks (adjPRR  = 2.03, 95% CI 1.82-2.27), single (adjPRR  = 1.15, 95% CI 1.07-1.25), divorced (adjPRR  = 1.28, 95% CI 1.15-1.41), and unemployed patients (adjPRR  = 1.13, 95% CI 1.05-1.21) had significantly higher rates of HSV-2 infection. Though certain zip codes had significantly higher seroprevalence of HSV-2, this effect was completely attenuated when controlling for age and gender.

CONCLUSIONS

Seroprevalence of HSV-2 in the JHH ED was higher than U.S. national estimates; however, factors associated with HSV-2 infection were similar. The high seroprevalence of HSV-2 in this urban ED highlights the need for targeted testing and treatment. Cross-sectional serosurveys in the urban ED may help to examine the epidemiology of HSV-2.

Emergency Physicians' Adherence to Center for Disease Control and Prevention Guidance During the 2009 Influenza A H1N1 Pandemic

INTRODUCTION

Little is known regarding compliance with management guidelines for epidemic influenza in adult emergency department (ED) settings during the 2009 novel influenza A (H1N1) epidemic, especially in relation to the Centers for Disease Control and Prevention (CDC) guidance.

METHODS

We investigated all patients with a clinical diagnosis of influenza at an inner-city tertiary academic adult ED with an annual census of approximately 60,000 visits from May 2008 to December 2009. We aimed to determine patterns of presentation and management for adult patients with an ED diagnosis of influenza during the H1N1 pandemic, using seasonal influenza (pre-H1N1) as reference and to determine the ED provider's adherence to American College of Emergency Physicians and CDC guidance during the 2009 H1N1 influenza pandemic. Adherence to key elements of CDC 2009 H1N1 guidance was defined as (1) the proportion of admitted patients who were recommended to receive testing or treatment who actually received testing for influenza or treatment with antivirals; and (2) the proportion of high-risk patients who were supposed to be treated who actually were treated with antivirals.

RESULTS

Among 339 patients with clinically diagnosed influenza, 88% occurred during the H1N1 pandemic. Patients were similarly managed during both phases. Median length of visit (pre-H1N1: 385 min, H1N1: 355 min, P > 0.05) and admission rates (pre-H1N1: 8%, H1N1: 11%, P > 0.05) were similar between the 2 groups. 28% of patients in the pre-H1N1 group and 16% of patients in the H1N1 group were prescribed antibiotics during their ED visits (P > 0.05). There were 34 admitted patients during the pandemic;, 30 (88%) of them received influenza testing in the ED, and 22 (65%) were prescribed antivirals in the ED. Noticeably, 19 (56%) of the 34 admitted patients, including 6 with a positive influenza test, received antibiotic treatment during their ED stay.

CONCLUSION

During the recent H1N1 pandemic, most admitted patients received ED diagnostic testing corresponding to the current recommended guidance. Antibiotic treatment for ED patients admitted with suspected influenza is not uncommon. However, less than 70% of admitted patients and less than 50% of high-risk patients were treated with antivirals during their ED visit, indicating a specific call for closer adherence to guidelines in future influenza pandemics.

Hospital-based shootings in the United States: 2000 to 2011

STUDY OBJECTIVE

Workplace violence in health care settings is a frequent occurrence. Emergency departments (EDs) are considered particularly vulnerable. Gunfire in hospitals is of particular concern; however, information about such workplace violence is limited. Therefore, we characterize US hospital-based shootings from 2000 to 2011.

METHODS

Using LexisNexis, Google, Netscape, PubMed, and ScienceDirect, we searched reports for acute care hospital shooting events in the United States for 2000 through 2011. All hospital-based shootings with at least 1 injured victim were analyzed.

RESULTS

Of 9,360 search "hits," 154 hospital-related shootings were identified, 91 (59%) inside the hospital and 63 (41%) outside on hospital grounds. Shootings occurred in 40 states, with 235 injured or dead victims. Perpetrators were overwhelmingly men (91%) but represented all adult age groups. The ED environs were the most common site (29%), followed by the parking lot (23%) and patient rooms (19%). Most events involved a determined shooter with a strong motive as defined by grudge (27%), suicide (21%), "euthanizing" an ill relative (14%), and prisoner escape (11%). Ambient society violence (9%) and mentally unstable patients (4%) were comparatively infrequent. The most common victim was the perpetrator (45%). Hospital employees composed 20% of victims; physician (3%) and nurse (5%) victims were relatively infrequent. Event characteristics that distinguished the ED from other sites included younger perpetrator, more likely in custody, and unlikely to have a personal relationship with the victim (ill relative, grudge, coworker). In 23% of shootings within the ED, the weapon was a security officer's gun taken by the perpetrator. Case fatality inside the hospital was much lower in the ED setting (19%) than other sites (73%).

CONCLUSION

Although it is likely that not every hospital-based shooting was identified, such events are relatively rare compared with other forms of workplace violence. The unpredictable nature of this type of event represents a significant challenge to hospital security and effective deterrence practices because most perpetrators proved determined and a significant number of shootings occur outside the hospital building.

Factors associated with no or delayed linkage to care in newly diagnosed human immunodeficiency virus (HIV)-1-infected patients identified by emergency department-based rapid HIV screening programs in two urban EDs

OBJECTIVES

The objective was to describe the proportions of successful linkage to care (LTC) and identify factors associated with LTC among newly diagnosed human immunodeficiency virus (HIV)-positive patients, from two urban emergency department (ED) rapid HIV screening programs.

METHODS

This was a retrospective analysis of programmatic data from two established urban ED rapid HIV screening programs between November 2005 and October 2009. Trained HIV program assistants interviewed all patients tested to gather risk behavior data using a structured data collection instrument. Reactive results were confirmed by Western blot testing. Patients were provided with scheduled appointments at HIV specialty clinics at the institutions where they tested positive within 30 days of their ED visit. "Successful" LTC was defined as attendance at the HIV outpatient clinic within 30 days after HIV diagnosis, in accordance with the ED National HIV Testing Consortium metric. "Any" LTC was defined as attendance at the outpatient HIV clinic within 1 year of initial HIV diagnosis. Multivariate logistic regression was performed to determine factors associated with any LTC or successful LTC.

RESULTS

Of the 15,640 tests administered, 108 (0.7%) were newly identified HIV-positive cases. Nearly half (47.2%) of the patients had been previously tested for HIV. Successful LTC occurred in 54% of cases; any LTC occurred in 83% of cases. In multivariate analysis, having public medical insurance and being self-pay were negatively associated with successful LTC (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.12 to 0.96; OR = 0.34, 95% CI = 0.13 to 0.89, respectively); being female and having previously tested for HIV was negatively associated with any LTC (OR = 0.30, 95% CI = 0.10 to 0.93; OR = 0.23, 95% CI = 0.07 to 0.77, respectively).

CONCLUSIONS

In spite of dedicated resources for arranging LTC in the ED HIV testing programs, nearly 50% of patients did not have successful LTC (i.e., LTC occurred at >30 days), although >80% of patients were LTC within 1 year of initial diagnosis. Further evaluation of the barriers associated with successful LTC for those with public insurance and self-pay is warranted.

Is inadequate human immunodeficiency virus care associated with increased ED and hospital utilization? A prospective study in human immunodeficiency virus-positive ED patients

BACKGROUND

There is a lack of data on the effect(s) of suboptimal human immunodeficiency virus (HIV) care on subsequent health care utilization among emergency department (ED) patients with HIV. Findings on their ED and inpatient care utilization patterns will provide information on service provision for those who have suboptimal access to HIV-related care.

METHODS

A pilot prospective study was conducted on HIV-positive patients in an ED. At enrollment, participants were interviewed regarding health care utilization. Participants were followed up for 1 year, during which time data on ED visits and hospitalizations were obtained from their patient records. Inadequate HIV care (IHC) was defined according to Infectious Diseases Society of America recommendations as less than 3 scheduled clinic visits for HIV care in the year before enrollment. Cox regression models were used to evaluate whether IHC was associated with increased hazard of health care utilization.

RESULTS

Of 107 subjects, 36% were found to have IHC. Inadequate HIV care did not predict more frequent ED visits but was significantly associated with fewer hospitalizations (adjusted incidence rate ratio, 0.61 [95% CI: 0.43-0.86]). Inadequate HIV care did not significantly increase the hazard for earlier ED visit or hospitalization. However, further stratification analysis found that IHC increased the hazard of hospitalization for subjects without comorbid diseases (adjusted hazard ratio, 2.50 [95% CI: 1.10-5.68]).

CONCLUSIONS

In our setting, IHC does not appear to be associated with earlier or more frequent ED visits but may lead to earlier hospitalization, particularly among those without other chronic diseases.

Use of a high resolution melting (HRM) assay to compare gag, pol, and env diversity in adults with different stages of HIV infection

BACKGROUND

Cross-sectional assessment of HIV incidence relies on laboratory methods to discriminate between recent and non-recent HIV infection. Because HIV diversifies over time in infected individuals, HIV diversity may serve as a biomarker for assessing HIV incidence. We used a high resolution melting (HRM) diversity assay to compare HIV diversity in adults with different stages of HIV infection. This assay provides a single numeric HRM score that reflects the level of genetic diversity of HIV in a sample from an infected individual.

METHODS

HIV diversity was measured in 203 adults: 20 with acute HIV infection (RNA positive, antibody negative), 116 with recent HIV infection (tested a median of 189 days after a previous negative HIV test, range 14-540 days), and 67 with non-recent HIV infection (HIV infected >2 years). HRM scores were generated for two regions in gag, one region in pol, and three regions in env.

RESULTS

Median HRM scores were higher in non-recent infection than in recent infection for all six regions tested. In multivariate models, higher HRM scores in three of the six regions were independently associated with non-recent HIV infection.

CONCLUSIONS

The HRM diversity assay provides a simple, scalable method for measuring HIV diversity. HRM scores, which reflect the genetic diversity in a viral population, may be useful biomarkers for evaluation of HIV incidence, particularly if multiple regions of the HIV genome are examined.

Outcomes and cost analysis of 3 operational models for rapid HIV testing services in an academic inner-city emergency department

OBJECTIVE

We compare the outcomes and costs of alternative staffing models for an emergency department (ED) rapid HIV testing program.

METHODS

A rapid oral-fluid HIV testing program was instituted in an inner-city ED in 2005. Three staffing models were compared during 24.5 months: indigenous medical staff only, exogenous staff only, or exogenous staff plus medical staff (hybrid). Personnel obtained written consent and provided brief pretest counseling, obtained kits, collected specimens, returned specimens to the ED satellite laboratory, and performed posttest counseling and referral to care. Cost analysis was performed to estimate cost per patient tested and cost per patient linked to care.

RESULTS

Overall, 44 of 2,958 (1.5%) patients tested received confirmed positive results and 30 (68%) were linked to care. The exogenous staff only model yielded the highest number tested per month (587), and indigenous medical staff only yielded the lowest (57). Significantly higher positivity rates were found in both indigenous medical staff only (2.2%) and hybrid (2.0%) models versus the exogenous staff only model (0.6%) (prevalence rate ratio: 3.7 [95% confidence interval {CI}1.5 to 9.3] versus 3.4 [95% CI 1.5 to 7.8], respectively). All patients with confirmed positive results were linked to care in the indigenous medical staff only model but only approximately 60% were linked to care in the 2 other models (linked to care rate ratio versus exogenous staff only: 1.8 [95% CI 1.1 to 4.4]; versus hybrid: 1.7 [95% CI 1.2 to 2.5]). The indigenous medical staff only model had the highest cost ($109) per patient tested, followed by the hybrid ($87) and the exogenous staff only ($39). However, the indigenous medical staff only model had the lowest cost ($4,937) per patient linked to care, followed by the hybrid ($7,213) and exogenous staff only ($11,454).

CONCLUSION

The exogenous staff only model tested the most patients at the least cost per patient tested. The indigenous medical staff only model identified the fewest patients with unrecognized HIV infection and had the highest cost per patient tested but the lowest cost per patient linked to care.

A randomized controlled trial of the effect of service delivery information on patient satisfaction in an emergency department fast track

OBJECTIVES

The objective was to determine the effect on patient satisfaction of providing patients with predicted service completion times.

METHODS

A randomized controlled trial was conducted in an urban, community teaching hospital. Emergency department (ED) patients triaged to fast track on weekdays between October 26, 2009, and December 30, 2009, from 9 am to 5 pm were eligible. Patients were randomized to: 1) usual care (n = 342), 2) provided ED process information (n = 336), or 3) provided ED process information plus predicted service delivery times (n = 333). Patients in group 3 were given an "average" and "upper range" estimate of their waiting room times and treatment times. The average and upper range predictions were calculated from quantile regression models that estimated the 50th and 90th percentiles of the waiting room time and treatment time distributions for fast track patients at the study site based on 2.5 years of historical data. Trained research assistants administered the interventions after triage. Patients completed a brief survey at discharge that measured their satisfaction with overall care, the quality of the information they received, and the timeliness of care. Satisfaction ratings of very good versus good, fair, poor, and very poor were modeled using logistic regression as a function of study group; actual service delivery times; and other patient, clinical, and temporal covariates. The study also modeled satisfaction ratings of fair, poor, and very poor compared to good and very good ratings as a function of the same covariates.

RESULTS

Survey completion rates and patient, clinical, and temporal characteristics were similar by study group. Median waiting room time was 70 minutes (interquartile range [IQR] = 40 to 114 minutes), and median treatment time was 52 minutes (IQR = 31 to 81 minutes). Neither intervention affected any of the satisfaction outcomes. Satisfaction was significantly associated with actual waiting room time, individual providers, and patient age. Every 10-minute increase in waiting room time corresponded with an 8% decrease (odds ratio [OR] = 0.92; 95% confidence interval [CI] = 0.89 to 0.95) in the odds of reporting very good satisfaction with overall care. The odds of reporting very good satisfaction with care were lower for several triage nurses and fast track nurses, compared to the triage nurse and fast track nurse who treated the most study patients. Each 10-minute increase in waiting room time was also associated with a 10% increase in the odds of reporting very poor, poor, or fair satisfaction with overall care (OR = 1.10; 95% CI = 1.06 to 1.14). The odds of reporting very poor, poor, or fair satisfaction with overall care also varied significantly among the triage nurses, fast track doctors, and fast track nurses. The odds of reporting very poor, poor, or fair satisfaction with overall care were significantly lower among patients aged 35 years and older compared to patients aged 18 to 34 years.

CONCLUSIONS

Satisfaction with overall care was influenced by waiting room time and the clinicians who treated them and not by service completion time estimates provided at triage.

Understanding estimated worker absenteeism rates during an influenza pandemic

OBJECTIVES

Published employee absenteeism estimates during an influenza pandemic range from 10 to 40 percent. The purpose of this study was to estimate daily employee absenteeism through the duration of an influenza pandemic and to determine the relative impact of key variables used to derive the estimates.

DESIGN

Using the Centers for Disease Control and Prevention's FluWorkLoss program, the authors estimated the number of absent employees on any given day over the course of a simulated 8-week pandemic wave by using varying attack rates. Employee data from a university with a large academic health system were used. Sensitivity of the program outputs to variation in predictor (inputs) values was assessed. Finally, the authors examined and documented the algorithmic sequence of the program.

RESULTS

Using a 35 percent attack rate, a total of 47,270 workdays (or 3.4 percent of all available workdays) would be lost over the course of an 8-week pandemic among a population of 35,026 employees. The highest (peak) daily absenteeism estimate was 5.8 percent (minimum 4.8 percent; maximum 7.4 percent). Sensitivity analysis revealed that varying days missed for nonhospitalized illness had the greatest potential effect on peak absence rate (3.1 to 17.2 percent). Peak absence with 15 and 25 percent attack rates were 2.5 percent and 4.2 percent, respectively.

CONCLUSIONS

The impact of an influenza pandemic on employee availability may be less than originally thought, even with a high attack rate. These data are generalizable and are not specific to institutions of higher education or medical centers. Thus, these findings provide realistic and useful estimates for influenza pandemic planning for most organizations.

Facilitating hospital emergency preparedness: introduction of a model memorandum of understanding

Effective emergency response among hospitals and other health care providers stems from multiple factors depending on the nature of the emergency. While local emergencies can test hospital acute care facilities, prolonged national emergencies, such as the 2009 H1N1 outbreak, raise significant challenges. These events involve sustained surges of patients over longer periods and spanning entire regions. They require significant and sustained coordination of personnel, services, and supplies among hospitals and other providers to ensure adequate patient care across regions. Some hospitals, however, may lack structural principles to help coordinate care and guide critical allocation decisions. This article discusses a model Memorandum of Understanding (MOU) that sets forth essential principles on how to allocate scarce resources among providers across regions. The model seeks to align regional hospitals through advance agreements on procedures of mutual aid that reflect modern principles of emergency preparedness and changing legal norms in declared emergencies.

An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers

OBJECTIVES

The objective was to perform an epidemiologic study of emergency department (ED) medical malpractice claims using data maintained by the Physician Insurers Association of America (PIAA), a trade association whose participating malpractice insurance carriers collectively insure over 60% of practicing physicians in the United States.

METHODS

All closed malpractice claims in the PIAA database between 1985 and 2007, where an event in an ED was alleged to have caused injury to a patient 18 years of age or older, were retrospectively reviewed. Study outcomes were the frequency of claims and average indemnity payments associated with specific errors identified by the malpractice insurer, as well as associated health conditions, primary specialty groups, and injury severity. Indemnity payments include money paid to claimants as a result of settlement or court adjudication, and this financial obligation to compensate a claimant constitutes the insured's financial liability. These payments do not include the expenses associated with resolving a claim, such as attorneys' fees. The study examined claims by adjudicatory outcome, associated financial liability, and expenses of litigation. Adjudicatory outcome refers to the legal disposition of a claim as it makes its way into and through the court system and includes resolution of claims by formal verdict as well as by settlement. The study also investigated how the number of claims, average indemnity payments, paid-to-close ratios (the percentage of closed claims that resolved with a payment to the plaintiff), and litigation expenses have trended over the 23-year study period.

RESULTS

The authors identified 11,529 claims arising from an event originating in an ED, representing over $664 million in total liability over the 23-year study period. Emergency physicians (EPs) were the primary defendants in 19% of ED claims. The largest sources of error, as identified by the individual malpractice insurer, included errors in diagnosis (37%), followed by improper performance of a procedure (17%). In 18% of claims, no error could be identified by the insurer. Acute myocardial infarction (AMI; 5%), fractures (6%), and appendicitis (2%) were the health conditions associated with the highest number of claims. Over two-thirds of claims (70%) closed without payment to the claimant. Most claims that paid out did so through settlement (29%). Only 7% of claims were resolved by verdict, and 85% of those were in favor of the clinician. Over time, the average indemnity payments and expenses of litigation, adjusted for inflation, more than doubled, while both the total number of claims and number of paid claims decreased.

CONCLUSIONS

Emergency physicians were the primary defendants in a relatively small proportion of ED claims. The disease processes associated with the highest numbers of claims included AMI, appendicitis, and fractures. The largest share of overall indemnity was attributed to errors in the diagnostic process. The financial liability of medical malpractice in the ED is substantial, yet the vast majority of claims resolve in favor of the clinician. Efforts to mitigate risk in the ED should include the diverse clinical specialties who work in this complex environment, with attention to those health conditions and potential errors with the highest risk.

Antiviral prescriptions to U.S. ambulatory care visits with a diagnosis of influenza before and after high level of adamantane resistance 2005-06 season

Background

Rapid emergence of influenza A viruses resistance to anti-influenza drugs has been observed in the past five years. Our objective was to compare antiviral prescription patterns of ambulatory care providers to patients with a diagnosis of influenza before and after the 2005–2006 influenza season, which was temporally concordant with the emergence of adamantane resistance. We also determined providers' adherence to Centers for Disease Control and Prevention (CDC) 2006 interim treatment guidelines for influenza after the dissemination of guidelines.

Methodology/Principal Findings

We conducted a multi-year cross-sectional analysis using 2002–2006 data from the national representative ambulatory care surveys, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Our main outcome measure was prescription of any anti-influenza pharmaceutical medication, including amantadine, rimantadine, oseltamivir, and zanamivir. Analyses were performed using procedures taking into account the multi-stage survey design and weighted sampling probabilities of the data source. Overall, there were 941 visits to U.S. ambulatory care providers for which the diagnosis of influenza was made, representing 12,140,727 visits nationally. Antiviral drugs were prescribed in 21.7% of visits. Even though prescription rates were not significantly different by influenza season (2001–02: 26.4%; 2002–03: 11.2%; 2003–04: 16.5%; 2004–05: 18.0%; 2005–06: 35.8%; 2006–07: 46.5%, p = 0.061), significantly higher prescription rates were observed in the high adamantane resistance period (18.7% versus 37.0%, p = 0.023), and after the announcement of the 2006 guidelines (18.5% versus 38.8%, p = 0.032). Use of adamantanes decreased over time, in that they were commonly used during influenza seasons 2001–03 (60.1%), but used much less frequently during seasons 2003–05 (31.9%), and used rarely after high adamantane resistance emerged (2.2%) (p<0.001). Adherence to 2006 guidelines was 97.7%. After March 2006, no prescriptions for adamantanes were given to patients with a diagnosis of influenza.

Conclusions/Significance

In this nationally representative study of U.S. ambulatory care visits, we found a complete absence of the use of adamantanes in all ambulatory care settings after March 2006, closely corresponding to release of the 2006 CDC interim guidelines. Adherence to such practice is an essential element for control and prevention of influenza, especially during the era of emergence of resistance to anti-viral drugs.

Emergency medicine resident attitudes and perceptions of HIV testing before and after a focused training program and testing implementation

OBJECTIVES

The objectives were to determine attitudes and perceptions (A&P) of emergency medicine (EM) residents toward emergency department (ED) routine provider-driven rapid HIV testing services and the impact of both a focused training program (FTP) and implementation of HIV testing on A&P.

METHODS

A three-phase, consecutive, anonymous, identity-unlinked survey was conducted pre-FTP, post-FTP, and 6 months postimplementation. The survey was designed to assess residents' A&P using a five-point Likert scale. A preimplementation FTP provided both the rationale for the HIV testing program and the planned operational details of the intervention. The HIV testing program used only indigenous ED staff to deliver HIV testing as part of standard-of-care in an academic ED. The impact of the FTP and implementation on A&P were analyzed by multivariate regression analysis using generalized estimating equations to control for repeated measurements in the same individuals. A "favorable" A&P was operationally defined as a mean score of >3.5, "neutral" as mean score of 2.5 to 3.5, and "unfavorable" as mean score of <2.5.

RESULTS

Thirty of 36 residents (83.3%) participated in all three phases. Areas of favorable A&P found in phase I and sustained through phases II and III included "ED serving as a testing venue" (score range = 3.7-4.1) and "emergency medicine physicians offering the test" (score range = 3.9-4.1). Areas of unfavorable and neutral A&P identified in phase I were all operational barriers and included required paperwork (score = 3.2), inadequate staff support (score = 2.2), counseling and referral requirements (score range = 2.2-3.1), and time requirements (score = 2.9). Following the FTP, significant increases in favorable A&P were observed with regard to impact of the intervention on modification of patient risk behaviors, decrease in rates of HIV transmission, availability of support staff, and self-confidence in counseling and referral (p < 0.05). At 6 months postimplementation, all A&P except for time requirements and lack of support staff scored favorably or neutral. During the study period, 388 patients were consented for and received HIV testing; six (1.5%) were newly confirmed HIV positive.

CONCLUSIONS

Emergency medicine residents conceptually supported HIV testing services. Most A&P were favorably influenced by both the FTP and the implementation. All areas of negative A&P involved operational requirements, which may have influenced the low overall uptake of HIV testing during the study period.