An Electronic Alert for HIV Screening in the Emergency Department Increases Screening but not the Diagnosis of HIV
23 September 2013
accepted: 29 January 2014
20 December 2017 (online)
Objective: Based on US. Centers for Disease Control and Prevention recommendations, New York State enacted legislation in 2010 requiring healthcare providers to offer non-targeted human immunodeficiency virus (HIV) testing to all patients aged 13–64. Three New York City adult emergency departments implemented an electronic alert that required clinicians to document whether an HIV test was offered before discharging a patient. The purpose of this study was to assess the impact of the electronic alert on HIV testing rates and diagnosis of HIV positive individuals.
Methods: During the pre-intervention period (2.5–4 months), an electronic “HIV Testing” order set was available for clinicians to order a test or document a reason for not offering the test (e.g., patient is not conscious). An electronic alert was then added to enforce completion of the order set, effectively preventing ED discharge until an HIV test was offered to the patient. We analyzed data from 79,786 visits, measuring HIV testing and detection rates during the pre-intervention period and during the six months following the implementation of the alert.
Results: The percentage of visits where an HIV test was performed increased from 5.4% in the pre-intervention period to 8.7% (p<0.001) after the electronic alert. After the implementation of the electronic alert, there was a 61% increase in HIV tests performed per visit. However, the percentage of patients testing positive per total patients-tested was slightly lower in the post-intervention group than the pre-intervention group (0.48% vs. 0.55%), but this was not significant. The number of patients-testing positive per total-patient visit was higher in the post-intervention group (0.04% vs. 0.03%).
Conclusions: An electronic alert which enforced non-targeted screening was effective at increasing HIV testing rates but did not significantly increase the detection of persons living with HIV. The impact of this electronic alert on healthcare costs and quality of care merits further examination.
Citation: Schnall R, Liu N, Sperling J, Green R, Clark S, Vawdrey D. An electronic alert for HIV screening in the emergency department increases screening but not the diagnosis of HIV. Appl Clin Inf 2014; 5: 299–312 http://dx.doi.org/10.4338/ACI-2013-09-RA-0075
- 1 CDC.. US HIV/AIDS Surveillance Report, 2007. Atlanta: Centers for Disease Control and Prevention,; 2009
- 2 Centers for Disease Control and Prevention (CDC).. HIV and AIDS in the United States 2011. Available from: http://www.cdc.gov/hiv/resources/factsheets/us.htm.
- 3 Schackman BR. et al. Cost-effectiveness implications of the timing of antiretroviral therapy in HIV-infected adults. Arch Intern Med. 2002; 162 (21) 2478-2486. doi: ioi10799 [pii]. PubMed PMID: 12437408.
- 4 Paltiel AD. et al. Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med 2005; 352 (06) 586-595. doi: 352/6/586 [pii] 10.1056/NEJMsa042088. PubMed PMID: 15703423.
- 5 The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States. 2010.
- 6 Branson BM. et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006; 55(RR-14): 1–17; quiz CE1–4. doi: rr5514a1 [pii]. PubMed PMID: 16988643.
- 7 New York State Department of Health.. Frequently Asked Questions regarding the HIV Testing Law Albany, NY2012. Available from: http://www.health.ny.gov/diseases/aids/testing/law/faqs.htm.
- 8 Bernstein SL, Haukoos JS. Public health, prevention, and emergency medicine: a critical juxtaposition. Acad Emerg Med 2008; 15 (02) 190-193. Epub 2008/02/16. doi: ACEM055 [pii]
- 10 1111/j.1553–2712.2008.00055.x. PubMed PMID: 18275450.
- 9 Rothman RE, Lyons MS, Haukoos JS. Uncovering HIV infection in the emergency department: a broader perspective. Acad Emerg Med 2007; 14 (07) 653-657. Epub 2007/06/01. doi: j.aem.2007.04.004 [pii] 10.1197/j.aem.2007.04.004. PubMed PMID: 17538079.
- 10 Hall HI. et al. Estimation of HIV incidence in the United States. JAMA 2008; 300 (05) 520-529. doi: 10.1001/jama.300.5.520. PubMed PMID: 18677024; PubMed Central PMCID: PMC2919237.
- 11 Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Annals of emergency medicine 2000; 35 (01) 63-68. PubMed PMID: 10613941.
- 12 Asplin BR. et al. A conceptual model of emergency department crowding. Annals of emergency medicine 2003; 42 (02) 173-180. Epub 2003/07/29. doi: 10.1067/mem.2003.302 S019606440300444X [pii]. PubMed PMID: 12883504.
- 13 Olshaker JS, Rathlev NK. Emergency Department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the Emergency Department. J Emerg Med 2006; 30 (03) 351-356. Epub 2006/05/09. doi: S0736–4679(05)00442–7 [pii] 10.1016/j.jemermed.2005.05.023. PubMed PMID: 16677993.
- 14 Moskop JC. et al. Emergency department crowding, part 1 - concept, causes, and moral consequences. Annals of emergency medicine 2009; 53 (05) 605-611. Epub 2008/11/26. doi: S0196–0644(08)01783–6 [pii] 10.1016/j.annemergmed.2008.09.019. PubMed PMID: 19027193.
- 15 Olshaker JS. Managing emergency department overcrowding. Emerg Med Clin North Am 2009; 27 (04) 593-603 viii. doi: S0733–8627(09)00071–6 [pii] 10.1016/j.emc.2009.07.004. PubMed PMID: 19932394.
- 16 Pines JM. et al. International perspectives on emergency department crowding. Acad Emerg Med 2011; 18 (12) 1358-1370. doi: 10.1111/j.1553–2712.2011.01235.x. PubMed PMID: 22168200.
- 17 Schnall R, Clark S, Olender S, Sperling JD. Providers’ Perceptions of the Factors Influencing the Implementation of the New York State Mandatory HIV Testing Law in Two Urban Academic Emergency Departments. Acad Emerg Med 2013; 20 (03) 279-286. doi: 10.1111/acem.12084. PubMed PMID: 23517260; PubMed Central PMCID: PMC3608143.
- 18 Office. USGA.. Hospital emergency departments crowded conditions vary among hospitals and communities, report to the ranking minority member, Committee on Finance, U. S. Senate.; 2003 2003.
- 19 Derlet R, Richards J, Kravitz R. Frequent overcrowding in U. S. emergency departments. Acad Emerg Med 2001; 8 (02) 151-155. PubMed PMID: 11157291.
- 20 Green LV, Soares J, Giglio JF, Green RA. Using queueing theory to increase the effectiveness of emergency department provider staffing. Acad Emerg Med 2006; 13 (01) 61-68. doi: j.aem.2005.07.034 [pii] 10.1197/j.aem.2005.07.034. PubMed PMID: 16365329.
- 21 Schedlbauer A. et al. What evidence supports the use of computerized alerts and prompts to improve clinicians’ prescribing behavior?. J Am Med Inform Assoc 2009; 16 (04) 531-538. doi: 10.1197/jamia. M2910.
- 22 Kurth AE, Severynen A, Spielberg F. Addressing Unmet Need for HIV Testing in Emergency Care Settings: A Role for Computer-Facilitated Rapid HIV Testing?. AIDS Educ Prev 2013; 25 (04) 287-301. doi: 10.1521/aeap.2013.25.4.287.
- 23 Wilbur L, Huffman G, Lofton S, Finnell JT. The use of a computer reminder system in an emergency department universal HIV screening program. Annals of emergency medicine 2011; 58 (01) S71-S3. e1.
- 24 New York City Department of Health and Mental Hygiene.. Reported HIV/AIDS Diagnoses and Deaths in 2011 2011. Available from: http://www.nyc.gov/html/doh/html/data/hivtables.shtml.
- 25 United Hospital Fund.. United Hospital Fund Zip Codes 2013. Available from: http://www.nyc.gov/html/ doh/html/data/hivtables.shtml.
- 26 New York State Department of Health.. New York State Hospital Profile 2012. Available from: http://hospitals.nyhealth.gov/index.php?PHPSESSID=ea42335cd805a2277728fc403e9a5a1f.
- 27 Singer RF. et al. The use of and satisfaction with the Emergency Severity Index. Journal of emergency nursing: JEN: official publication of the Emergency Department Nurses Association 2012; 38 (02) 120-126. doi: 10.1016/j.jen.2010.07.004. PubMed PMID: 22401616.
- 28 Hoover JB, Tao G, Heffelfinger JD. Monitoring HIV testing at visits to emergency departments in the United States: very-low rate of HIV testing. Journal of acquired immune deficiency syndromes 2013; 62 (01) 90-94. doi: 10.1097/QAI.0b013e3182742933. PubMed PMID: 23018376.
- 29 Avery A, Toro M, Einstadter D. Decreasing Missed Opportunities for HIV Testing in Primary Care through Enhanced Utilization of the Electronic Medical Record. J AIDS Clinic Res. 2012 ; S4(006). doi: 10.4172/2155–6113. S4-006.
- 30 Sanders GD. et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005; 352 (06) 570-585. doi: 352/6/570 [pii] 10.1056/NEJMsa042657. PubMed PMID: 15703422.
- 31 New York City Department of Health and Mental Hygiene.. Epiquery: NYC Interactive Health Data System 2012. Available from: http://nyc.gov/health/epiquery
- 32 The Kaiser Family Foundation.. Golbal data on HIV/AIDS, TB, Malaria & more 2010. Available from: http://www.globalhealthfacts.org/data/factsheet/factsheet.aspx?loc=221&ind=1,2,3,4,5,6,7,8,9,10,11.
- 33 Center for Disease Control.. Estimates of New HIV Infections in the United States, 2006–2009. Atlanta, GA: Center for Disease Control and Prevention,; 2011
- 34 Hospital-Based Emergency Care: At the Breaking Point: The National Academies Press; 2007.
- 35 Demarco RF. et al. Recommendations and reality: Perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions. Nurs Outlook 2012; 60 (02) 72-80. doi: S0029–6554(11)00215–6 [pii] 10.1016/j.outlook.2011.06.002. PubMed PMID: 21840554.
- 36 Rothman RE. Current Centers for Disease Control and Prevention guidelines for HIV counseling, testing, and referral: critical role of and a call to action for emergency physicians. Annals of emergency medicine 2004; 44 (01) 31-42. doi: 10.1016/S0196064404000678 S0196064404000678 [pii]. PubMed PMID: 15226706.