01 December 2008

Should ERs screen for HIV?

This blogger at the Utne Reader implies so.

Great. That's all we need. We're already screening for Domestic Violence, Depression, Fall risk, various and sundry immunizations, alcohol abuse and Jeebus-knows-what-else. Why not add one more critical social issue to the laundry list? The ER can be the one-stop shop for all epidemiologic screening! We'll do your cholesterol, your PSAs, your PAP smears, and colonoscopies on Tuesdays!

Don't come in for anything frivolous, though, like chest pain or a motor vehicle accident, because the primary and secondary surveys will have to wait until the triage nurse asks you if you have "ever felt unsafe or threatened in any of your personal relationships." Seriously, they have to ask everybody these questions. I always feel bad listening to the nurses as they have to go through the litany of screening questions which are completely unrelated to the serious issue which brought the patient to the ER.

So why not add HIV to the list?

The biggest reason, IMHO, is that it's not germane to our practice, and not relevant to the patient's presenting complaint (in 99% of cases). Furthermore, it would bog us down and worsen the delays in the waiting rooms as we complete the screenings. If a patient comes in for an ankle sprain or some such, they need to get blood drawn for an HIV test? That's gonna take 10-30 extra minutes (depending on phlebotomy's availability), not counting the detailed consents which most institutions perform before HIV testing. Then what's the turnaround time for the test to run? 30-60 minutes at best, I suspect (factoring in the sample transport time and lab processing time). This would be a minimal issue for patients with six-hour abdominal pain work-ups, but the large number of patients with simple or quick complaints would be slowed down. And the docs, already overburdened with a thousand other tasks and interruptions, would have the responsibility to counsel each and every patient on the meaning of their test (negative or positive), and that counseling is sure to provoke a conversation that eats into the time I have available for the rest of my patients.

This is not even considering the liability. If a test is misreported by the lab, or simply missed by the physician, or if the patient leaves prior to the result being communicated to them, this creates a terrible burden on the providers. And if a test is positive, and the patient does not get adequate counseling or follow-up, whose responsibility is that?

No, routine HIV screening should not be performed in the ER. It's not our job, we're too busy, and we don't want the extra liability. And I kinda wish that society and the government would stop pretending that the ER is the only (and universal) point of contact that Americans have with the health care system.

17 comments:

And so it goes said...

100% agree
only trained staff called "HIV counselors" can discuss testing with patients, and at most hospitals, like mine, there are not that many, so it is a major hassle to find someone who can come up and do the counseling before testing.
and if it comes back + what then? Aids is expensive, HIV is expensive, a lot of ER visitors are uninsured, underinsured, what have you, it just opens up a lot of liability and pointless drama

7 years said...

you are right on on this issue
7

Nurse K said...

My new favorite screening question is "have you had unplanned weight loss of greater than 10 pounds in the last 3 months?" Also, "do you have any learning disabilities?" I love asking VIPs that one.

People that come in specifically asking for an HIV test get referred to the Dept of Health or their PCP.

ERRN4U said...

"People that come in specifically asking for an HIV test get referred to the Dept of Health or their PCP."

As it should be!

Sallie

Gingerale said...

I think there would be some people who don't become patients, because they refuse to go to the ER, because they don't want an HIV test.

Graham said...

We have all patients asked at triage if they want a free HIV test. A small number say yes. This then flags the patients for the HIV counselor for the hospital, who's around M-F 10-6, who talks with the patient, gets the simple, one page consent form signed, and then either takes a buccal swab or a finger stick, and comes back in 15 minutes with the results.

If the counselor is not there and the patient wants the test, we explain it's a blood draw and will take an hour for the rapid test to be run up in the lab. I usually estimate how long I think the patient will be in the ED, and if it's at least an hour, they usually agree. If the results are negative, we tell them. If they're positive, there are pre-made packets we give to the patients.

Yes, the HIV counselor is certainly a resource, but he/she staffs HIV counseling for the entire hospital, so the cost is spread amongst all the departments (and I think is actually probably paid for through a grant).

1/3 of HIV positive people in the US don't know they're positive. And for most of the chief complaints you see in the ED, I bet knowing the patient has HIV would likely change your workup/management.

Rogue Medic said...

Here is the post I wrote a different proposed changes in the duties of triage nurses. This one is a Screening and Brief Intervention for alcohol use.
Drinking Problem? Try SBI.

MBPharmD said...

Good timing. We're finally getting out HIV testing rolled out in Labor & Delivery here. An interesting tidbit:

Most hospitals use the HIV Quick test for screening. It has a 1hr turn-around time, can be run by a single lab tech and doesn't have to be batched (all untrue with the ELISA test). The problem is that there's a 0.4% false positive rate. Multiply that by your number of ED visits/yr and you're looking at 160 false positives if you have 40,000 tests/yr. Yeah, sure, the confirmatory western blot will be negative - in 7 days. Meanwhile you've just changed their lives by telling them they "might" or "could" be HIV+. No thanks. This is going to be messy for us, with our pregnant patients, "oh by the way you might have HIV, what's your baby's name going to be?"

GuinnessPint said...

I have struggled with this concept ever since the CDC came out with recommendations that HIV testing be incorporated in all acute-care settings. I share those concerns mentioned regarding access to counseling and delays in testing results.

I also wonder if I would ever be able to properly consent a patient for HIV testing. Current CDC recommendations are for opt-out consenting (you get tested unless you specifically decline) and incorporation of the consent "into the general consent for medical care; separate written consent is not recommended."

[ Especially regarding the ED, are there any other lab/micro tests that a physician choses to perform that require specific consent? In my limited knowledge, most are covered under general consent for care. ]

HIV obviously has a pretty significant impact after a pt is discharge from the ED. For one, will a pt ever be able to get insurance again after a positive HIV? How can I consent a patient for a potentially life-altering lab test if they came in with a broken finger? (At least if I find out they're smoking, I can offer cessation assistance!)

marcia said...

MBPharmD said: This is going to be messy for us, with our pregnant patients, "oh by the way you might have HIV, what's your baby's name going to be?"

Yes, but isn't it particularly important to determine whether a pregnant woman is HIV+, because there are ways to reduce the incidence of transmission to the baby if this is known beforehand?

MBPharmD said...

@ Marcia:

Absolutely. But if we test all 9k of our deliveries, how many unknown HIV patients will we find? Not a lot in this area, in fact, based on the statistics we have we are expecting 1 genuine case plus 20-40 false positives/yr. A NNT of 20 ain't so bad, except for the psychological damage inflicted.

scalpel said...

"Should ERs screen for HIV?"

Of course not. That would be ridiculous.

"OMG, you have an emergent case of HIV! We'd better refer you to the ID specialist STAT!"

litbrit said...

I totally agree, too.

And I concur that asking emergency room personnel and doctors to also take care of things that should be the responsibilities of primary care doctors and healthcare providers is an unfortunate side effect, if you will, of having so many people forced to use the ER because they can't afford primary care and well care, so they go where they know they cannot, by law, be turned away.

The irony that so many anti-healthcare-reform/anti-single-payer people are missing is that the cost for "indigent care" (as it's called in FL) by the ER can't, of course, be absorbed by hospitals, so it's passed on to paying patients via expensive charges to their insurance companies, which is in turn passed on to them via ever-increasing premiums. It's socialized medicine, alright: the very priciest, utterly ill-regulated, and least cost-effective socialized medicine in the world. Yay us!

litbrit said...

(I meant that I agree with you, Dr. SF, that HIV testing falls under the purview of primary care. Also, with regard to how one would manage a patient if one suddenly found out he was HIV+, don't all hospital personnel wear protective clothing--i.e. latex gloves, eyewear, etc.--and use biohazard containers for used syringes anyway? In other words, they wisely assume there's always a chance of being infected by something, and protect themselves and their patients accordingly?)

gingerale said...

SF, the following link may seem unrelated to your post. But I had to pick some post of yours in order to share the link. The conceptual connection is "decisions made way way up the line from us with ramifications over which we have little or no control."

The link:
http://www.theinsomniablog.com/the_insomnia_blog/2008/12/has-your-doctor-had-a-nap.html

How you-all do it I do not know.

shadowfax said...

Gingerale -- thanks. You can always email me at the address on the front page.

Cheers,

SF

Online Pharmacies said...

ER - Emergency Response??? The keyword here is "emergency". The doctors should not check fully a patient's health, they must remove ailments that their patients have at the moment.