1. PEPSE* PRESCRIPTION IN THE EMERGENCY DEPARTMENT
Dr Stephen Megarity
Specialty Doctor
Genitourinary Medicine RVH
*Post exposure prophylaxis following sexual exposure

2. Aims of Project
Analyse numbers and demographics of ED PEPSE prescription
Assess adherence to BASHH guidelines
Identify and implement improvement strategies for PEPSE prescription in ED/Follow up of patients

3. Methods Retrospective case note review
PEPSE prescription from 1 April March 2016 in the Emergency Department - Royal Victoria Hospital, Belfast
Use of Pharmacy records – PEP pack reorder forms
ED Symphony System – Search criteria:
“PEP, post-exposure prophylaxis, HIV prophylaxis, HIV, sexual assault, unprotected sex”

4. Data Collection
37 patient episodes identified in period between 1 April 2015 – 31 March 2016
PEP for other indications excluded – PEPSE only
Case note review
Identified 37 patient episodes using defined search criteria. May be an slight underestimation but should have collected the majority of prescriptions. Important to note that PEP for some indications was excluded – sexual assualt/occupational

5. Demographic information collected
Age
Postcode
Time/Date of attendance
Grade of Doctor
Indication/Risk group
HIV status of partner
Sexually transmitted infections diagnosed
While analysing data I thought it would be useful to identify the demographics of patients attending for PEPSE

6. Audible outcomes As per BASHH 2015 guidelines –
Proportion of PEPSE patients having a baseline HIV test: aim 100% within 72 hours of presenting for PEPSE
Proportion of PEPSE prescriptions that fit within recommended indications: aim 90%
Proportion of PEPSE prescriptions administered within 24 hours of risk exposure: aim 90%
Proportion of individuals completing 4-week course of PEPSE: aim 75%
Proportion of individuals seeking PEPSE undergoing testing for STIs: aim 90%
Proportion of individuals completing 8-12 week post-exposure HIV antibody/antigen test: aim 75%.

7. Patient demographics

8. Patient demographics 37 patients Mean age of 28.2 years (range 18-51)
Male – 36 Patients (97%)
Female – 1 Patient
84% of patients MSM

9. Address 2 patients - England
Majority of patients from Greater Belfast area. 2 patients from England who were visiting.
2 patients - England

10. Day of Attendance
With GU services closed Saturday and Sunday, the spike in attendance at the weekend is not unexpected. The increased attendance on Monday is in keeping with what we see in GUM.

11. Time of Attendance
Again, a spike of patient episodes towards late afternoon/evening when GU services more difficult to assess. This is of course when ED starts to get busy with GP referrals/unwell patients backing up. The awareness and training of ED staff is therefore important to allow them to easily and accurately assess patients for PEP. This will allow a more efficient for PEP seeking patients as well as allowing the ED staff to attend to unwell patients also using their department.

13. 0RAL/PROTECTED VAGINAL
Indication
DOCUMENTED TYPE OF SEX
NUMBER
RECEPTIVE 14
ANAL 10
INSERTIVE 4
VAGINAL
ORAL 1
ORAL/PROTECTED ANAL
0RAL/PROTECTED VAGINAL
UNABLE TO RECALL
OTHER
28/37 for ‘anal sex’
Other – laceration to toe in Sauna

14. 1 msm
2 csw
3 hiv contact
4 endemic country

15. 12/37 claim an HIV positive contact

16. I thought this information would be useful to see what level of experience the ED doctor would have. Unfortunately most staff did not document their grade. Of those that did – majority were non consultant grade and quite junior staff. The majority of doctors there are f2 doctors - this is their 2nd year post graduate and likely first experience of PEP/ED.

17. Auditable Outcomes

18. HIV Test ? % Proportion of PEPSE patients having a baseline HIV test:
-aim 100% within 72 hours of presenting for PEPSE
HIV Test ? %
YES*
81% (n=30) NO
19% (n=7)
*3 Patients no baseline HIV test in ED but attended GUM within 72hours

19. Proportion of PEPSE prescriptions that fit within recommended indications:
-aim 90%
As Per Guidelines %
YES
84% (n=31) NO
16% (n=6)

20. Proportion of PEPSE prescriptions administered within 24 hours of risk exposure:
-aim 90%

21. Proportion of individuals completing 4-week course of PEPSE:
-aim 75%
Complete 4 weeks? %
YES
59% (n=20)
DNA
41% (n=14)
EXCLUDED* 3
* 2 Outside NI/ 1 stopped in GUM

22. Proportion of individuals seeking PEPSE undergoing testing for STIs:
-aim 90%
Attend GUM %
YES*
63% (n=22) NO
37% (n=13)
OUTSIDE NI 2
*GUM attendance only - Some patients may have sought STI testing in Primary Care

23. Proportion of individuals seeking PEPSE undergoing testing for STIs:
-aim 90%
Attend GUM %
YES*
63% (n=22) NO
37% (n=13)
OUTSIDE NI 2
*GUM attendance only - Some patients may have sought STI testing in Primary Care

24. Proportion of individuals seeking PEPSE undergoing testing for STIs:
-aim 90%
Attend GUM
YES* NO
OUTSIDE NI
STI?
YES**
9% (n=2) NO
91% (n=20)
**2 cases - GC
*GUM attendance only - Some patients may have sought STI testing in Primary Care

25. Lost to Follow up
This was interesting as I expected all those not attending for follow up would be from locations outside of Belfast.

26. Proportion of individuals completing 8-12 week post-exposure HIV antibody/antigen test:
-aim 75%.
Window HIV %
YES
51% (n=18) NO
9% (n=3)
DNA
40% (n=14)
OUTSIDE NI 2

27. Areas For Improvement Baseline HIV testing
PEPSE prescription meeting BHIVA indications
Completing 4 week course
STI testing
Window HIV/BBV tests

28. Areas For Improvement Baseline HIV testing
PEPSE prescription meeting BHIVA indications
Completing 4 week course
STI testing
Window HIV/BBV tests

29. Areas For Improvement Baseline HIV testing
PEPSE prescription meeting BHIVA indications
Action
ED Teaching sessions
Introduction of PEP assessment proforma

30. Areas For Improvement Baseline HIV testing
PEPSE prescription meeting BHIVA indications
Completing 4 week course
STI testing
Window HIV/BBV tests

31. Areas For Improvement Baseline HIV testing
PEPSE prescription meeting BHIVA indications
Completing 4 week course
STI testing
Window HIV/BBV tests
Action
GUM follow up

32. Implementation (a) Action ED Teaching sessions
Introduction of PEP assessment proforma
ED Teaching sessions – 1st session provided October 2016
ED PEPSE proforma development – near completion
In order to address these issues I have offered ED teaching sessions to target junior and middle grade staff. These will be most beneficial at staff changeover times. First session was delivered in October of this year. I am working with ED to finalise a PEPSE assessment proforma

33. This is a draft copy of the proforma
This is a draft copy of the proforma. Main benefits are questions to prompt for info needed for accurate risk assessment. The checklist prior to dispensing PEP reminds the doctor of the baseline HIV testing/bloods and to prompt discussion about follow up

34. Implementation (b) Action GUM follow up
Introduction of referral system – e-referral with consent of patient
Contacted within 72 hours for follow up to be arranged by Triage Nurse
6 month Pilot Scheme
Improving attendance at GUM clinic following PEPSE presciption is important to allow STI testing/vaccine administration/education/full risk assessments. This group of patients, particularly those who frequency acquire PEP are patients we need to be seeing in GUM. To address the low GU attendance rates one of the ED consultants and myself worked together to decide what system would work best to improve follow up. referral systems seem to work well in ED with other specialties so we went down this line. An account specifically for PEPSE follow up has been created and a system for offering patients appointment put in place in GUM month pilot in first instance

35. Future Plans Continue and expand education programme with ED
Implement ED PEP assessment proforma
Audit in 2017 to assess pilot referral system
Education of ED staff is an area that needs more attentions and I will continue to provide teaching for ED staff. Hopefully adherence to guidelines and baseline testing will be further improved with the proforma. PEPSE prescription will be audited in the new year to see if this quality improvement strategies have made a difference.

36. Acknowledgements
BHSCT Pharmacy Department
RVH Emergency Department