1. Rapid Testing in Emergency Departments: New Jersey Sindy M. Paul, MD, MPH, FACPM November 8, 2007

2. Why is it Important to do Rapid Testing in ED’s? For many, only access to health care system CDC recommendations integrate into care Patients often won’t return for results of conventional tests Negatives receive final results before leave ED & if appropriate prevention referral Reactives confirmatory test & referral for final results (usually HIV or ID clinic)

3. Why is it Important to do Rapid Testing in ED’s? Test results may help in diagnosis and management in ED –Particularly helpful for patients with pneumonia ( a frequent reason to come to EDs)

4. ED Seroprevalence Data: Urban Teaching Hospital Anonymous, unlinked survey 10/7/02 – 12/31/02 Persons > 18 years of age 332/3,193 (10.4%) positive 11.0% males and 9.6% females positive 198/332 (60%) knew they were positive 66% females, 55% males knew they were +

5. HIV Seroprevalence by Age and Gender

6. HIV Seroprevalence by Race/Ethnicity and Gender

7. Comparison of Knowledge of HIV Status by Gender MenWomen Undiagnosed HIV Diagnosed HIV Antiretroviral use indicated Diagnosed HIV No antiretroviral use indicated

8. Rapid Testing in New Jersey EDs Major statewide initiative Goal: expand access to HIV counseling and testing for high risk persons CDC and state funding –RFP included EDs Media campaign State lab regulations requiring a license and a lab director

9. New Jersey Models Funded by NJDHSS –Counselors –Supplies –Test and control kits ED = counseling and testing site ED = satellite of another counseling and testing site Hospital or NJDHSS lab director

10. Cost Comparison with Non- Rapid Testing Counselors same just reassigned to ED Rapid test kits less expensive than Orasure because Orasure bundled with warehousing and testing fees from NJDHSS lab Volume price negotiated with company No cost test kits from CDC very helpful!! New expense = lab director

11. What to do with Cost Savings and Additional State Funds? Rapid testing interested all stakeholders resulting in state funding Cost savings from lab expenses & state funding  media campaign & expansion –22 Emergency Departments

12. Caveats to Working with EDs All EDs are different All hospitals are different The approach to each hospital/ED is different The key players are different Not all ED directors recognize risk of HIV in their catchment area

13. What is an ED? The definition varies –not necessarily the 4 walls of the ED Sexual assault area – frequently a separate room not within the 4 walls of the ED Adjacent areas i.e. OB “ED” Hospital floors if admitted when rapid testing not available in ED

14. Key Players CTS Coordinator ID or HIV clinic physician ED director Hospital lab director Hospital administrator NJDHSS staff

15. Identify a Champion within the Hospital and/or ED “Right” person varies from hospital to hospital CEO ID physician CTS coordinator University President’s Assistant ED physician

16. Helpful Information Data on rapid testing in EDs –In your area & other areas –Publications on ED RT in NJ Information on which EDs are doing rapid testing with contact information The other hospital in town is doing rapid testing in the ED …. 9/06 CDC Recommendations

17. Provide Technical Assistance: Make it as Easy as Possible Initial discussions Meeting at hospital with key players Tour of “ED” Demonstration of rapid testing Who can help –Statewide lab director (licensing, QA, supplies, template forms) –NJDHSS staff

18. Training Counseling – No Cost –NJDHSS, ½ Day, –On request with variable location (could be done at ED) Testing – No Cost –Lecture and hands on –QA, form completion competency testing –1 Day in central NJ –Provided by NJDHSS/RWJ or Hosp. Lab Director

19. Patient Flow Information in waiting area Flow varies based on established patient flow in the ED Intake staff, then triage nurse, then ED staff Just ED staff Space for CTS staff –Mobile (cart with supplies)

20. What if the ED is Undergoing Construction? Not an infrequent occurrence Be flexible – this is temporary Several models –CTS staff in ED escort patient to another area for counseling and testing –CTS staff paged to ED when a patient agrees to have counseling and testing –Less space, but able to remain in ED

21. New Issue: Hospital Closures The hospital with ED RT may be closing –Impacts resource allocation & access Surrounding hospital(s) may be closing –Increased number ED patients at existing RT EDs –Change in patient flow at ED with RT –? Need to modify funding for ED with RT due to increased patient volume

22. What if a Patient Has a Reactive (Preliminary Positive) Test? Same post test counseling as for any reactive rapid test Refer patient to ID or HIV clinic for confirmatory results and counseling If confirmed positive patient has immediate appointment to start RX at clinic If discordant follow discordant protocol and refer to clinic

23. Improvement in Quality of Care: Case Scenarios Case # 1: Pneumocystis Pneumonia –Rapid testing in ED = reactive –Decision which service for admission –Decision on treatment Case # 2 Toxoplasmosis –No rapid testing in ED –Large workup including CJD (mad cow) –When non-rapid HIV test done after admit = +

24. Rapid Testing in New Jersey EDs: First ED started rapid testing 3/1/04 22 EDs 12 counties Selection based on prevalence Phased in over time Time frame to start-up variable –Satellite vs new site

25. Essex Sussex Burlington Atlantic Cumberland Salem Gloucester Camden Cape May Somerset Morris Bergen Passaic Warren Middlesex Hunterdon Union Hudson Monmouth Mercer Ocean ED Rapid Testing Sites September 1, 2007 Shaded: rapid testing available

26. New Jersey ED Rapid Testing Data through October 5, 2007 17,506 tested 17,292 (98.78%) received results 17,069 (97.50%) negative 421 (2.40%) positive 314 (74.58%) new positive 244/314 (77.71%) new +’s got confirmed results 16 (0.09%) discordant Non ED statewide RT prevalence 1.7%

27. New Jersey ED Rapid Testing Data through October 5, 2007 TestedPositive Male8,761 (50%) 248 (2.83%) Female 8,727 (50%) 173 (1.98%) Black 8,882 (51%) 329 (3.70%) Hispanic 4,301 (25%) 63 (1.46%) White 3,679 (21%) 23 (0.63%)

28. New Jersey ED Rapid Testing Data through October 5, 2007 Age (Years)TestedPositive 13-19 1,637 (9.35%) 5 (0.31%) 20-29 6,481(37.02%) 59 (0.91%) 30-39 4,122 (23.55%) 132 (3.20%) 40-49 3,407 (19.46%) 153 (4.49%) > 50 1,844 (10.53%) 72 (3.90%)

29. Lessons Learned for Rapid HIV Testing in New Jersey EDs Rapid testing can be done in EDs! Higher prevalence than other sites Hard to reach at-risk persons not previously diagnosed Win-win for hospitals and public health One step to integrating HIV testing into patient care