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

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

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

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

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

Data entry Many hours Many hours Graduate assistant time donated Graduate assistant time donated Followed conventions 1 st hospital Followed conventions 1 st hospital C Moseley C Moseley

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

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

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

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

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

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

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

Trends in early syphilis,

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

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

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

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

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 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 Of all the cases reported by emergency departments, 67% of the cases were early latent

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

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

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

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

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

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

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

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 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 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

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

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

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

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.

Study design Continued

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

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

Race/Ethnicity

Sex

Comparison by age

Comparison by zip codes (Greensboro)

Comparison by zip codes (High Point)

Syphilis and other STDs

Patients with primary care physicians

Shifts seen in EDs

Cocaine positives among population screened at EDs

RPR positives among cocaine positives

Cocaine users among RPR positives

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

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