Partnering with hospital emergency departments

1. Partnering with hospital emergency departments Caroline Moseley, M.Ed. Mark Schulz, Ph.D. Manjunath Mahadevappa, MBBS, MPH

2. Objectives • Understand the vital role that HEDs play in syphilis elimination. • Develop a strategy for engaging HEDs in syphilis elimination. • Implement a plan for incorporating HEDs into strategic plans for eliminating syphilis.

3. What will we do today? • Learn about Guilford County’s project with emergency departments • Collaborations, history of the issue, status and results of current project • Work in groups to uncover our strengths and challenges • Develop action plans including a plan for accountability

4. Collaboration • University of North Carolina Greensboro, • Guilford County Department of Public Health, • Moses Cone Hospital & • High Point Community Hospital

5. University of North Carolina Greensboro • School of Health & Human Performance • Department of Public Health Education • MPH & BS • Epidemiologist & MPH student • Data entry • Data analysis • Literature review • Internal Review Board (IRB)

6. Data entry • Many hours • Graduate assistant time donated • Followed conventions established @ 1st hospital • C Moseley

7. Data analysis • SPSS • Easiest • Analysis questions discussed & developed early w/C. Moseley • One way frequencies • Cross tabulations & more complicated analyses • Opportunities for further analysis

8. Literature review • Focused on syphilis & emergency departments. • Syphilis & jails • Guidance from C. Moseley

9. Internal Review Board (IRB) • Necessary for publication • Informed Consent • HIPPA • Coordination w/hospitals • C. Moseley provided links to hospitals

10. Guilford County Department of Public Health • Had idea & initiated project • Collected data from 1st hospital • Connections to hospitals • Knew of STD reporting system • Funded MPH student for final semester

11. Hospitals • Key contacts • Made data easily available • Open to changing policy • Open to in-service training • Facilitated IRB approval

12. Why partner with emergency departments • Similar high risk populations • EDs are primary care centers • EDs have easy access to people at high risk for STDs • Screening programs are fairly easy to implement • Screening programs can be done for little money

13. Some background on Guilford County • North Central North Carolina • Population 388,062 (1998) • Two major cities, Greensboro and High Point • Consistently high rates of STDs, including HIV

14. Trends in early syphilis, 1991-2003

15. Early syphilis 2003 • Primary, secondary, and late latent syphilis is decreasing • The increase in syphilis between 2002 and 2003 is due to an increase in early latent cases

16. Some background on hospitals in Guilford County • Two non-profit hospital systems that include four hospitals, three of which have emergency departments • Two private hospitals • Many people receive care outside of the county, especially for HIV

17. Background on relationship with emergency departments • No previous direct collaborative relationship • Health director knew the ED heads through the medical societies • Health director had a personal connection with the head of Cone’s ED

18. Syphilis and emergency departments in Guilford County • In 1996, 14.7% of all P & S syphilis cases were being diagnosed in an emergency department • Reports from emergency departments have steadily declined • This may be changing because of our study

19. Syphilis and emergency departments in Guilford County • In the last quarter of 2003, 30% of all early syphilis cases were being diagnosed in an emergency department • Of all the cases reported by emergency departments, 67% of the cases were early latent

20. What was the process? • Health director made a phone call • Staff met with the medical director • Medical director agreed to have screening practices assessed • Staff obtained permission from medical records • Staff conducted a records review

21. Assessment methods • SPSS was used for data entry and analysis (2 separate databases) • 406 records were randomly selected and reviewed • 203 STD related (by ICD-9 Code) • 203 records pulled from the same time frame

22. Assessment methods: Demographic variables • Race • Gender • Age • Marital status • Zip code • Admission date

23. Assessment methods: Behavioral variables • Pregnancy status • Primary ICD-9 code • Presenting symptoms • RPR results (including titer) • Results of gonorrhea and chlamydia tests • Follow-up care for syphilis • Co-factors for syphilis (cocaine use, history of substance abuse) • Patient status

24. Assessment results • 94% of the general sample had ICD-9 codes that were not life threatening emergencies (one person in the STD sample) • The demographic characteristics of both samples are almost identical to those of people at risk for syphilis

25. Assessment results • Very few people in both samples received syphilis tests • 1% general got a test, 7% STD • Many more men than women in both samples were screened • 100% general were men, 14% STD

26. Assessment results • The majority who got screened in both samples were Black • 100% general were black, 79% STD • No pregnant women in either sample were screened • No one in either sample who was positive for cocaine received and RPR

27. Assessment results • Those who tested positive for gonorrhea/chlamydia in both samples were no more likely to receive and RPR than those who tested negative • Those in the STD sample had similar demographic and behavioral characteristics to those in the general sample but were no more likely to receive an RPR

28. Next steps • Cross-sectional study in the two major emergency departments to test a screening protocol

29. Screening protocol • Screen all pregnant women who don’t have prenatal care • Screen all people who get a gonorrhea and chlamydia test • Screen anyone who has a positive cocaine test or reports a history of drug use or prostitution • Treat all symptomatic patients

30. Study objectives • Evaluate effectiveness of screening for syphilis in high risk patients visiting the Emergency departments (EDs). • Compare demographics of high risk patients in ED with syphilis cases in Guilford County, North Carolina.

31. Study design • Cross-sectional study conducted over a period of six months in emergency departments of two big hospitals of Guilford County located in two different cities. • Over 2200 records of patients attending the EDs who are considered high risk for syphilis were reviewed.

32. Study designContinued

33. Methods • SPSS was used to enter data obtained from reviewing the records. • Over 1200 records were reviewed in High Point Regional. • Over 1000 records were reviewed in Moses Cone • Over 38 variables were used to record the data.

34. Demographic variables Race/Ethnicity Sex Age Zip code Street address Other important variables Shift Primary care provider Complaints Screening results of gonorrhea, chlamydia and syphilis. Drug screen result Social history Variables used

35. Race/Ethnicity

36. Sex

37. Comparison by age

38. Comparison by zip codes (Greensboro)

39. Comparison by zip codes (High Point)

40. Syphilis and other STDs

41. Patients with primary care physicians

42. Shifts seen in EDs

43. Cocaine positives among population screened at EDs

44. RPR positives among cocaine positives

45. Cocaine users among RPR positives

46. Lessons learned • Make screening decision an ED policy • Bundle STD tests • Write standing orders for labs to screen cocaine positives for syphilis • Collaboration works • University, county, EDs • Cocaine positives need to be screened

47. Things we will be doing in the future • Analyze cost effectiveness of screening high risk patients. • Implement a research protocol for screening cocaine positives. • Publish results