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A Comparison of Patient Satisfaction with Emergency Department Opt-In and Opt-Out Rapid HIV Screening  [PDF]
Douglas A. E. White,Alicia N. Scribner,Maria E. Martin,Stacy Tsai
AIDS Research and Treatment , 2012, DOI: 10.1155/2012/904916
Abstract: Study objective. To compare patient satisfaction with emergency department (ED) opt-in and opt-out HIV screening. Methods. We conducted a survey in an urban ED that provided rapid HIV screening using opt-in (February 1, 2007–July 31, 2007) and opt-out (August 1, 2007–January 31, 2008) approaches. We surveyed a convenience sample of patients that completed screening in each phase. The primary outcome was patient satisfaction with HIV screening. Results. There were 207 and 188 completed surveys during the opt-in and opt-out phases, respectively. The majority of patients were satisfied with both opt-in screening (95%, 95% confidence interval [CI] = 92–98) and opt-out screening (94%, 95% CI = 89–97). Satisfaction ratings were similar between opt-in and opt-out phases even after adjusting for age, gender, race/ethnicity, and test result (adjusted odds ratio 1.3, 95% CI = 0.5–3.1). Conclusions. Emergency department patient satisfaction with opt-in and opt-out HIV screening is similarly high. 1. Introduction 1.1. Background In 2006 the Centers for Disease Control and Prevention (CDC) published revised recommendations for HIV testing in health-care settings, which included emergency departments (EDs) [1]. Prior to these recommendations, the standard approach included opt-in HIV screening (in which patients are offered an HIV test and assent is required), separate written consent, and pre- and posttest counseling. The revised recommendations include using an opt-out approach to screening and removing requirements for test counseling and separate written informed consent as strategies to reduce barriers to testing and to make testing a routine part of care. With opt-out HIV screening, patients are notified that HIV testing will be performed unless they decline and consent for testing is integrated into the general ED consent process. Pretest counseling and risk assessment are not recommended, and written informational materials can replace posttest counseling and risk reduction strategies for patients that test negative. Access to clinical care and support services continue to be essential for patients with positive HIV test results [1]. The CDC recommends an opt-out approach for several reasons. By integrating opt-out screening into general consent, the screening process is streamlined and routinized. Patients may perceive the process to be less stigmatizing because they do not feel “singled out” for testing [1, 2]. It is hoped that adopting opt-out screening methodologies will increase screening rates. This is supported by the finding that, in some clinical
Programmatic Cost Evaluation of Nontargeted Opt-Out Rapid HIV Screening in the Emergency Department  [PDF]
Jason S. Haukoos, Jonathan D. Campbell, Amy A. Conroy, Emily Hopkins, Meggan M. Bucossi, Comilla Sasson, Alia A. Al-Tayyib, Mark W. Thrun, For the Denver ED HIV Opt-Out Study Group
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0081565
Abstract: Background The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial. Methods This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated. Results During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%–0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%–4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection. Conclusions Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.
Early Glycemic Control in Critically Ill Emergency Department Patients: Pilot Trial  [cached]
Cohen, Jason,Goedecke, Eric,Cyrkler, Jennifer E,Mangolds, Virginia B
Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health , 2010,
Abstract: Objective: Glycemic control in the critically ill intensive care unit (ICU) patient has been shown to improve morbidity and mortality. We sought to investigate the effect of early glycemic control in critically ill emergency department (ED) patients in a small pilot trial.Methods: Adult non-trauma, non-pregnant ED patients presenting to a university tertiary referral center and identified as critically ill were eligible for enrollment on a convenience basis. Critical illness was determined upon assignment for ICU admission. Patients were randomized to either ED standard care or glycemic control. Glycemic control involved use of an insulin drip to maintain blood glucose levels between 80-140 mg/dL. Glycemic control continued until ED discharge. Standard patients were managed at ED attending physician discretion. We assessed severity of illness by calculation of APACHE II score. The primary endpoint was in-hospital mortality. Secondary endpoints included vasopressor requirement, hospital length of stay, and mechanical ventilation requirement.Results: Fifty patients were randomized, 24 to the glycemic group and 26 to the standard care cohort. Four of the 24 patients (17%) in the treatment arm did not receive insulin despite protocol requirements. While receiving insulin, three of 24 patients (13%) had an episode of hypoglycemia. By chance, the patients in the treatment group had a trend toward higher acuity by APACHE II scores. Patient mortality and morbidity were similar despite the acuity difference.Conclusion: There was no difference in morbidity and mortality between the two groups. The benefit of glycemic control may be subject to source of illness and to degree of glycemic control, or have no effect. Such questions bear future investigation. [West J Emerg Med. 2010; 11(1):20-23].
The effect of the development of an emergency transfer system on the travel time to tertiary care centres in Japan
Makiko Miwa, Hiroyuki Kawaguchi, Hideaki Arima, Kazuo Kawahara
International Journal of Health Geographics , 2006, DOI: 10.1186/1476-072x-5-25
Abstract: The mean travel time was 57 min, the range was 83 min, and the standard deviation was 20.4. As a result of multiple regression analysis, average coverage area per tertiary care centre, kilometres of highway road per square kilometre, and population were selected as variables with impact on the average travel time. Based on results from linear regression analysis, benchmarks for the emergency transfer system that would effectively reduce travel time to the mean value of 57 min were identified: 26% pavement ratio of roads (percentage of paved road to general roads), and three tertiary care centres and 108 ambulances.Regional gaps in the travel time to tertiary care centres were identified in Japan. The systems we should focus on to reducing travel time were identified. Further reduction of travel time to tertiary care centres can be effectively achieved by improving these specific systems. Linear regression analysis showed that a 26% pavement ratio and three tertiary care centres are beneficial to prefectures with an average time longer than the mean score, to achieve a reduction of travel time. Measures for reducing travel time need to be considered in policy-making to re-evaluate the current locations of tertiary care centres to provide equality of access to emergency medicine.In Japan, the emergency medical system has been provided systematically as a result of the Medical Care Law enacted in 1985, to ensure that "anyone can receive appropriate emergency medical care anytime, anywhere". The actual framework and infrastructure of emergency medical care have been developed through Medical Care Planning, which is ruled by Medical Care Law to establish the provision of the health care system in Japan. Medical Care Planning specifically states the requirement of, "securing and maintaining the emergency medical care system" [1]. In accordance with the framework provided by Medical Care Planning, the emergency medical system in Japan is categorized into three levels: prim
Misconception of emergency contraception among tertiary school students in Akwa Ibom state, South-South, Nigeria
AM Abasiattai, AJ Umoiyoho, EA Bassey, SJ Etuk, EJ Udoma
Nigerian Journal of Clinical Practice , 2007,
Abstract: Objective: To assess the degree of awareness and use of emergency contraception among tertiary school students in Akwa Ibom State, Nigeria. Design: A self-administered questionnaire survey. Setting: The Akwa Ibom State Polytechnic, Ikot Osurua, located on the outskirts of Ikot Ekpene local government area between 1st April 2002 and 31st April 2002. Subjects: 1,000 randomly selected female students of the Akwa Ibom State polytechnic, Ikot Osurua Results: The students were aged between 16 and 43 years. Five hundred and eighty-nine (68.5%) of the respondents had heard of products that could be used as emergency contraceptives. However, only 49 (5.7%) of the respondents had practised some form of emergency contraception, which was most commonly practised by those between 16 and 25 years (71.4%). Menstrogen (30.6%), gynaecosid (24.5%), and quinine (14.3%) were the most common medications used for emergency contraception. Patent medicine dealers (40.9%) and friends/course mates (29.7%) were the most common sources of knowledge about emergency contraception. Conclusion: This study shows that awareness and use of emergency contraception by our youths is low. Community enlightenment about emergency contraception using specifically designed programmes, the formation of reproductive health clubs in our tertiary institutions and training of peer group educators in all our communities are advocated. Patent medicine dealers in our communities should have basic training in modern contraceptive methods and periodic evaluation should be carried out to assess their knowledge and practice of emergency contraception.
The Global Burden of Road Injury: Its Relevance to the Emergency Physician  [PDF]
Sharon Chekijian,Melinda Paul,Vanessa P. Kohl,David M. Walker,Anthony J. Tomassoni,David C. Cone,Federico E. Vaca
Emergency Medicine International , 2014, DOI: 10.1155/2014/139219
Abstract: Background. Road traffic crash fatalities in the United States are at the lowest level since 1950. The reduction in crash injury burden is attributed to several factors: public education and prevention programs, traffic safety policies and enforcement, improvements in vehicle design, and prehospital services coupled with emergency and acute trauma care. Globally, the disease burden of road traffic injuries is rising. In 1990, road traffic injuries ranked ninth in the ten leading causes of the global burden of disease. By 2030, estimates show that road traffic injuries will be the fifth leading causes of death in the world. Historically, emergency medicine has played a pivotal role in contributing to the success of the local, regional, and national traffic safety activities focused on crash and injury prevention. Objective. We report on the projected trend of the global burden of road traffic injuries and fatalities and describe ongoing global initiatives to reduce road traffic morbidity and mortality. Discussion. We present key domains where emergency medicine can contribute through international collaboration to address global road traffic-related morbidity and mortality. Conclusion. International collaborative programs and research offer important opportunities for emergency medicine physicians to make a meaningful impact on the global burden of disease. 1. Introduction Deaths caused by road traffic injuries (RTI) in the United States are at their lowest number since 1950, with a nearly 10 percent decline in such fatalities between 2000 and 2009 alone [1]. Though the National Highway Traffic Safety Administration (NHSTA) cites several factors in the reduction of road traffic fatalities, including economy, unemployment, and improvements in vehicle design, success can be attributed to the attention focused on prehospital services and emergency medicine (EM) in the last half century, as well as the attention paid to injury prevention efforts within the field of EM itself. The passage of the 1966 Traffic and Motor Vehicle Safety and Highway Safety Acts set unprecedented federal safety standards for motor vehicles and state highway safety programs [2]. In establishing such standards at federal and state levels, road safety compliance became a greater and more tangible priority. The next few decades saw an increase in federal funding, which was applied toward mass media awareness campaigns and research grants, as well as driving while intoxicated (DWI) regulations, and seatbelt and drinking-age laws [2]. With the increase in federal funding and the sense of
Clinic-epidemiological analysis of an otorhinolaryngology emergency unit care in a tertiary hospital
Furtado, Paula Lobo;Nakanishi, Marcio;Rezende, Gustavo Lara;Granjeiro, Ronaldo Campos;Oliveira, Taciana Sarmento de;
Brazilian Journal of Otorhinolaryngology , 2011, DOI: 10.1590/S1808-86942011000400004
Abstract: emergencies are common in our otorhinolaringology specialty. however, the clinical and epidemiological features are not very well known. objectives: to evaluate the clinical and epidemiological profiles of otorhinolaryngological disorders in an emergency unit of a tertiary hospital, and to determine the appropriateness of the level of health care for a tertiary hospital. materials and methods: an analytical study using data records of an otorhinolaryngological emergency unit at a tertiary hospital in the federal district for a year, full time, and no screening. the age, sex, arrival time and clinical diagnosis were evaluated. the entities were separated into cases of pharingolaryngoesthomatology, otology, rhinology, and head and neck surgery. these were evaluated according to the urgency level, the required care, and the arrival time. results: 26,584 data records were selected, of which 2,001 were excluded. the group comprised 54. 48% women, and 45. 51% men. otological complaints (62. 27%) prevailed. 61. 26% of cases were considered emergencies. only 9. 7% of those required medium or high complex resources for resolution. conclusions: the study showed that 61. 26% of the otorhinolaryngological cases are emergencies, and only 9. 7% required medium or high complexity resources
Characteristics of patients presenting to the vascular emergency department of a tertiary care hospital: a 2-year study
Ioannis Kotsikoris, Theofanis T Papas, Nikolaos Papanas, Dimitrios Maras, Paraskevi Tsiantula, Polyvios Pavlidis, Maria Andrikopoulou, Stamatia Kotsiou, Efstratios Maltezos, Nikolaos Bessias
BMC Research Notes , 2011, DOI: 10.1186/1756-0500-4-481
Abstract: Overall, 2452 (49.4%) out of 4961 patients suffered from pathologies that should have been treated in primary health care. Only 2509 (50.6%) needed vascular surgical intervention.The emergency department of vascular surgery in a Greek tertiary care hospital has to treat a remarkably high percentage of patients suitable for the primary health care level. These results suggest that an improvement in the structure of health care is needed in Greece.The emergency department of vascular surgery in a tertiary care hospital is a pivotal constituent of the Greek health care system [1,2]. It is designed for the treatment of patients with various vascular pathologies, such as vascular trauma, ruptured aortic aneurysm or acute arterial occlusion, that prompt urgent hospital admission and vascular surgery. At the same time, it is frequented by patients suffering from chronic vascular diseases that could be treated at the primary health care level or in the outpatient vascular clinics [1-3]. Such conditions include, for instance, chronic intermittent claudication, varicose veins, lymphoedema, or lower extremity infections. The aim of this study was to examine the epidemiological characteristics of patients presenting to the vascular emergency department of a Greek tertiary care hospital during a 2-year period.We studied the epidemiological characteristics of all patients presenting to the vascular emergency department of Red Cross Hospital, Athens, Greece between 1st January 2009 and 31st December 2010. Patient records were studied retrospectively. Information retrieved included permanent address, presenting symptom, mode of attendance (private vehicle, ambulance, physician referral, referral from other hospitals of Athens or the rest of the country), underlying disease and treatment. In total, 4961 patients (3780 men, 1181 women, mean age 63 years) presented to the vascular emergency department for diagnosis and treatment. Of these, 4018 (81%) were residents of Athens and 943 (
Spectrum of emergency department presentation in patients of acute intermittent porphyria: Experience from a North Indian tertiary care center  [cached]
Kumar Susheel,Sharma Navneet,Modi Manish,Sharma Aman
Neurology India , 2010,
Abstract: Of the porphyrias, acute intermittent porphyria (AIP) is the most frequently encountered porphyria. The clinical characterestics of thirteen patients of AIP who presented to the Emergency Department were analyzed. The most common precipitating factor was drugs. Eleven patients presented with pain abdomen. Neurological manifestations included: Seizures in six and motor weakness in six. Of the four patients with hyponatremia, three had associated neuropathy and the fourth patient demonstrated a severe course marked by pontine-extrapontine myelinolysis and profound adrenergic activity. In conclusion, even though AIP is less frequently reported from India the emergency physicians should be vigilant to exclude the diagnostic possibility of AIP in a patient with an appropriate clinical setting.
Utilizing video on myocardial infarction as a health educational intervention in patient waiting areas of the developing world: A study at the emergency department of a major tertiary care hospital in India
Naveen Dhawan, Omar Saeed, Vineet Gupta, Rishi Desai, Melvin Ku, Sanjeev Bhoi, Sanjay Verma
International Archives of Medicine , 2008, DOI: 10.1186/1755-7682-1-14
Abstract: An educational video on signs, symptoms, and risk factors of myocardial infarction (MI) was played in an Emergency Department (ED) patient waiting area of an urban tertiary care hospital in India. Participants (n = 217) were randomly assigned to two groups: an intervention group that viewed the MI video (n = 111) and a control group that did not view the video (n = 106). Each group took a standard survey of thirty-seven questions to assess baseline knowledge pertaining to MI (pretest). The intervention group then viewed the video and the initial survey was re-administered to each group (posttest).At baseline (pretest) there was no statistically significant difference between the intervention and control group in the mean number of correct (18.1 vs. 19.0, p = 0.19), incorrect (9.4 vs. 8.6, p = 0.27) and unsure (9.6 vs. 9.3, p = 0.78) responses per participant. After viewing the video on MI, the intervention group had a statistically significant improvement in the mean number of correct responses (27.0 vs. 20.0, p < 0.001), and a significant decline in the mean number of unsure responses (1.8 vs. 9.4, p < 0.001) compared to the posttest responses of the control group. There was no significant change in the number of incorrect responses on the posttest between the intervention and control groups, (8.3 vs. 7.7, p = 0.35), respectively.A health educational video can serve as an effective tool for increasing patients' short-term knowledge and awareness of health conditions in a hospital waiting area of a developing country.Health educational videos serve as a public health low cost intervention that demonstrates clear short term benefits. Health care workers in developing countries can help educate individuals presenting to hospitals by displaying these videos in hospital waiting areas.As a developing country, India has witnessed unprecedented socioeconomic growth in the past few decades. However, the Indian healthcare system has struggled to keep up with the increasing d
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