Public Health Initiative Seeks to Provide Lifesaving Screenings to E.D. Patients

Posted on Mon, Jan 30, 2017
Public Health Initiative Seeks to Provide Lifesaving Screenings to E.D. Patients

The emergency department (E.D.) is rarely the proper venue for screening and counseling patients about chronic illnesses. Our focus in the E.D. is usually to treat acute illness or injury quickly and efficiently, not screen for chronic diseases like Hepatitis B. However, last spring, the emergency department (E.D.) team at New York-Presbyterian/Queens in Queens, N.Y., launched a one-of-a-kind public health initiative.
The “Viral Triple Initiative” seeks to reduce Hepatitis B (HBV), Hepatitis C (HCV) and HIV/AIDS-related morbidity and mortality by dramatically increasing routine testing of the medical center’s patient population. Through screenings conducted in the E.D. and Ambulatory Care Center, the groundbreaking program links infected patients to care, either under hospital specialists or patients’ primary physicians.
We recently spoke with Jonathan Siegal, M.D., vice chair of the Department of Emergency Medicine at New York-Presbyterian/Queens, to learn more about the initiative.
What are the demographics at NewYork-Presbyterian/Queens (NYPQ)?
NYPQ is a 535-bed acute care hospital in the NewYork-Presbyterian Healthcare System, which is now one of the largest healthcare systems in the country. In 2015, we admitted more than 32,000 patients, saw more than 162,000 outpatient visits, and treated 124,000 people through the E.D. Our patients speak a variety of languages: English (61.5 percent), Spanish (18.3 percent), Chinese (10.3 percent) and Korean (3.9 percent) among others. We are an American College of Surgeons-designated Level 1 Trauma Center and treat more than 1,000 adult and pediatric trauma cases each year.
What spurred the development of this initiative?
NYPQ has witnessed unusually high rates of Hepatitis C (HCV) among the growing population of first-generation Asian immigrants, and there is also an increase is overall rate of Asians with Hepatitis B (HBV), HBV with an infection rate that is 35 times higher than is found in the general U.S. population. A pharmaceutical company that created a drug to treat Hepatitis C wanted more research about the prevalence of the disease. The company offered a grant to fund Hepatitis screenings to hospitals in exchange for the screening data. Ari Bunim, MD (NYPQ Liver Center) and Ming-der Chang, PhD (NYPQ Community Health) applied for the year-long grant, which we received in May 2016.
Why is there a high incidence of Hepatitis B and Hepatitis C among first-generation Asian immigrants?
I don’t want to generalize, but we suspect that it has to do with lack of screening blood for blood transfusions in certain parts of Asia. Also, I don’t believe that the Hepatitis B vaccine has been readily available in certain parts of Asia.
How were patients screened before the initiative?
New York state law requires us to offer HIV Testing to all patients 13 to 64 years old, so we’ve offered that for several years. Prior to the grant, we only offered Hepatitis B & C screenings to symptomatic patients. Now, screenings for all three – HIV, Hepatitis B and Hepatitis C – are offered to walk-in ED patients aged 22 and older. We are the first ED in the country that I am aware of that is offering this.
How was staff educated and trained for this initiative? How are patients informed about the service?
Screenings are solely offered and conducted by the 24 advanced practice providers who staff the medical screening portion of our ED. These providers were trained through the NewYork-Presbyterian health system.
To educate patients about the screening process, we’ve developed a script in five languages. We also provide patients with fact sheets developed by the CDC on all three viruses. The fact sheets include information on symptoms, transmission, treatment and prevention.
How are patients notified of their results?
It takes a few days for results to come back. Patients can call in to receive their results, if they just want to know either way. Patients with a positive result will be called by a patient navigator, a position funded by the grant. The navigator will walk them through what a positive result means and connect them with treatment options, further counseling and coordinate care for follow up.
In the first six months of the initiative, the program had a 30-percent consent rate. Is this what you expected?
That’s what we expected, but we’re striving for a 40 percent rate of consent. It’s a free test, and there’s a new curative treatment for Hepatitis C now. We’re working on educating patients about available treatments. We’re hoping to screen more than 10,000 patients in the first year.
And, positive screening rates are low. Is this what you expected?
We weren’t sure what to expect, but it’s good news. We expected a significant percent of positive Hepatitis B cases, particularly for patients from endemic countries. 1.5 percent positive may seem small, but it’s significant. It’s the most interesting data point that we’ve found.
Hepatitis C isn’t as common as we originally thought, but we are seeing a rise in incidence among Baby Boomers, who may have tried IV drugs years ago or may have received contaminated blood via transfusion before screening protocols were in place.
What are the challenges with launching an initiative like this?
There are a few, including interdepartmental coordination, leadership support, EMR modification, integration into workflow, resources and patient volume. Some of these issues aren’t controlled solely by the ED, but one thing that we can improve is integration into our workflow. Public health outreach is not the primary function of the Emergency Department, so this takes time, resources, education and process improvement to weave it into the workflow. We’ve added the screening question into the medical screening exam (MSE), so it’s just another question among the traditional information that we collect. The quicker that this becomes second nature, the quicker the patient visit. Luckily, adding the VTI screening has not adversely affected length of visit.

Dr. Jonathan Siegal
Jonathan Siegal, M.D., is vice chair of the Department of Emergency Medicine at New York-Presbyterian/Queens.

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