- Email: [email protected]
407: Implementation of Hemoglobin A1c Testing to Identify Undiagnosed and Uncontrolled Diabetes in the Emergency Department
Research Forum Abstracts considered children ages 0-18 as having been treated for acute asthma either if, by protocol, they were treated with nebulized ipratropium bromide, which was available from the ED automated medication management system during the entire study period, or if they were treated with nebulized levalbuterol. Analysis: Levalbuterol use in children treated for acute asthma was compared before and after its addition to the ED automated medication management system. Data were analyzed with the Fisher’s exact test. Results: In the year prior to the addition of levalbuterol in the ED automated medication management system, 1019 children were treated for acute asthma; 6 of them received nebulized levalbuterol. In the year following the addition of levalbuterol in the system, 956 children were treated for acute asthma; 7 of them received nebulized levalbuterol (p⫽0.78). Conclusion: Addition of levalbuterol to a pediatric ED’s automated medication management system did not increase its use in treating acute asthma in children. Although emergency physicians consider drug availability when making prescribing decisions, this readier availability alone is not sufficient to increase a drug’s use.
407
Implementation of Hemoglobin A1c Testing to Identify Undiagnosed and Uncontrolled Diabetes in the Emergency Department
Ginde AA, Delaney KE, Camargo Jr. CA/Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: One-third of the more than 19 million Americans with type 2 diabetes remain undiagnosed and many patients with known diabetes are uncontrolled. Opportunistic screening in the emergency department (ED) using hemoglobin A1c (HbA1c) may improve diagnosis and provide valuable clinical data in a high-risk patient population. We sought to evaluate the role and efficacy of point-of-care (POC) HbA1c in screening ED patients for undiagnosed and uncontrolled diabetes. Methods: Prospective, cross-sectional, pilot study at Massachusetts General Hospital. We approached consecutive adult ED patients on two designated 24-hour data collection days in April 2007 for enrollment, and stratified patients by prior diagnosis of diabetes. We interviewed participants for demographics and diabetes risk factors and measured POC HbA1c using A1CNow⫹® (Metrika; Sunnyvale, CA) and capillary blood glucose. Additionally, for participants who had venous blood samples sent from the ED, we measured HbA1c in our diabetes laboratory for correlation with POC testing. We referred non-diabetic participants with abnormal HbA1c (defined as ⱖ 6.1%) for outpatient oral glucose tolerance testing. Results: We enrolled 75 patients during the pilot phase of this protocol. The participants were median age 40 (IQR 30-50); 39 (52%) were female, 55 (73%) were white, 20 (25%) had Medicaid or no insurance, and 10 (13%) did not have a PCP. 67 (89%) of subjects were not known to have diabetes, while 8 (11%) of participants had known diabetes. The median body mass index was 25 (IQR 24-29) kg/m2 and 30 (IQR 27-39) kg/m2, respectively. Participants without known diabetes had mean HbA1c 5.9% (95%CI 5.7-6.2) and mean glucose 105 mg/dl (95%CI 95-114). Those with known diabetes had mean HbA1c 8.5% (95%CI 6.5-10.5) and mean glucose 170 mg/dl (95%CI 96-244). Of the 67 participants without known diabetes, 14 (21%, 95%CI 12-33%) had abnormal HbA1c. We obtained laboratory HbA1c for 36 participants, which highly correlated with POC HbA1c in the ED (slope⫽1.2, r⫽0.97). Participant follow-up for diagnostic oral glucose tolerance testing is underway. Conclusion: Implementation of POC HbA1c testing in the ED is feasible and accurate, and identifies one-fifth of patients as high risk for undiagnosed diabetes. HbA1c, unlike glucose, offers the advantage of being unaffected by fasting status and stress response, and may be a useful tool in opportunistic diabetes screening in the ED. Moreover, patients with diabetes, especially if uncontrolled, have higher rates of morbidity for many common ED presentations. Identification of undiagnosed and uncontrolled diabetes may have implications for the ED diagnostic and treatment plan (e.g., chest pain or infection), in addition to the long-term benefit of early diabetes diagnosis and counseling/referral for improved diabetes care.
S128 Annals of Emergency Medicine
408
Who Has Not Been Tested for HIV? HIV Testing History Varies by Patient Demography
Merchant RC, Catanzaro BM, Mayer KH, Seage III GR, Clark MA, DeGruttola VG, Becker BM/Brown Medical School, Providence, RI; Brown University Program in Public Health, Providence, RI; Harvard School of Public Health, Boston, MA
Study Objectives: The Centers for Disease Control and Prevention recently advocated for expanded HIV screening in emergency departments (EDs). Part of the challenge in implementing HIV screening is determining which patients need to be tested. Our objectives were to determine how many and which patients in the ED have never been tested for HIV and ascertain their reasons for having been or never having been tested for HIV. Methods: This study was conducted on a random sample of dates each month and on randomly selected day, evening, and night shifts from July 2005-July 2006 at a northeastern US ED. During each shift, we obtained a random sample of 18-55year-old English-speaking patients being treated for sub-critical injury or illness and interviewed them in-person on their history of HIV testing. HIV-infected patients were excluded. Summary statistics were calculated for patient demographics, history of prior HIV testing, reasons for the last HIV test, and reasons for never having been tested for HIV. Logistic regression models were created to generate odds ratios (ORs) with 95% confidence intervals and predicted probabilities to compare patients by their history of being tested for HIV, according to their demographic characteristics. Results: Of 2,107 HIV-negative patients surveyed, the median age was 32 years; 54% were male, 71% were white, and 45% were single/never married; 57% had twelve or fewer years of formal education; 49% had private healthcare insurance; and 45% had never been tested for HIV. Of those previously tested for HIV, 43% had been tested within the previous year. In terms of the main reason for their last HIV test, 26% said that they “just wanted to know,” 22% stated that testing was part of a medical examination, and 15% were tested because of a possible exposure to HIV. Of those who had never been tested for HIV, 55% believed that they were not at risk for HIV and 29% had not considered getting tested. In multivariable logistic regression analyses, patients who were male (OR 1.32 [1.37-2.73]), white (OR 1.93 [1.73-2.37]), married (OR 1.53 [1.122.08]), and who had private healthcare insurance (OR 2.10 [1.69-2.61]) had a greater odds of never having been tested for HIV. There was a U-shaped relationship between age and history of being tested for HIV; younger and older patients were less likely to have been tested. The predicted probabilities of prior HIV testing were lowest across all ages for white males and highest for non-white females. History of HIV testing and years of formal education were not related. Conclusion: Over half of the ED patients surveyed had never been tested for HIV. Many did not perceive themselves to be at risk of an infection. Younger and older patients, males, whites, married people and those with private health care insurance comprised demographic groups less likely to have ever been tested for HIV. These results show that certain ED patients are being missed though HIV testing programs in other settings. These patients could potentially be reached through universal HIV screening in EDs.
409
Intimate Partner Violence and Out-of-Hospital Intervention: A Public Health and Emergency Medical System Alliance
Eliseo LJ, White D, Brinsfield K/Boston University Medical Center, Boston, MA; Boston EMS, Boston, MA
Study Objectives: Intimate partner violence (IPV) is a serious public health problem. We saw the need for heightened recognition and intervention of IPV by out-of-hospital personnel. Previous studies demonstrated the potential benefits of such a program, particularly for those victims who refuse to be transported to a hospital. Our program combined the efforts of Boston Emergency Medical Services (EMS), emergency physicians, advocates, IPV agencies and resources. Methods: Boston EMS implemented the Community Outreach Program (BECOP), a public health referral program to improve services for victims of IPV. BECOP provided EMS personnel 5 venues to identify IPV victims. EMS staff received 6 hrs of training encompassing risk assessment, intervention, and referral. The program partnered with existing providers offering a out-of-hospital approach to victims of IPV initiated by the 911 call and on scene services with follow-up by trained EMS providers. EMS providers also staffed a Community Service Unit (CSU). The CSU included 6 female EMS staff trained in providing advocacy and referrals. CSU advocates received 40 hrs of training in crisis intervention, safety planning, threat assessment, and caring for children witnesses to violence. The CSU responded 7 PM - 3 AM, 5 days/week offering referrals and providing transport to a
Volume , . : September
407
Implementation of Hemoglobin A1c Testing to Identify Undiagnosed and Uncontrolled Diabetes in the Emergency Department
Ginde AA, Delaney KE, Camargo Jr. CA/Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: One-third of the more than 19 million Americans with type 2 diabetes remain undiagnosed and many patients with known diabetes are uncontrolled. Opportunistic screening in the emergency department (ED) using hemoglobin A1c (HbA1c) may improve diagnosis and provide valuable clinical data in a high-risk patient population. We sought to evaluate the role and efficacy of point-of-care (POC) HbA1c in screening ED patients for undiagnosed and uncontrolled diabetes. Methods: Prospective, cross-sectional, pilot study at Massachusetts General Hospital. We approached consecutive adult ED patients on two designated 24-hour data collection days in April 2007 for enrollment, and stratified patients by prior diagnosis of diabetes. We interviewed participants for demographics and diabetes risk factors and measured POC HbA1c using A1CNow⫹® (Metrika; Sunnyvale, CA) and capillary blood glucose. Additionally, for participants who had venous blood samples sent from the ED, we measured HbA1c in our diabetes laboratory for correlation with POC testing. We referred non-diabetic participants with abnormal HbA1c (defined as ⱖ 6.1%) for outpatient oral glucose tolerance testing. Results: We enrolled 75 patients during the pilot phase of this protocol. The participants were median age 40 (IQR 30-50); 39 (52%) were female, 55 (73%) were white, 20 (25%) had Medicaid or no insurance, and 10 (13%) did not have a PCP. 67 (89%) of subjects were not known to have diabetes, while 8 (11%) of participants had known diabetes. The median body mass index was 25 (IQR 24-29) kg/m2 and 30 (IQR 27-39) kg/m2, respectively. Participants without known diabetes had mean HbA1c 5.9% (95%CI 5.7-6.2) and mean glucose 105 mg/dl (95%CI 95-114). Those with known diabetes had mean HbA1c 8.5% (95%CI 6.5-10.5) and mean glucose 170 mg/dl (95%CI 96-244). Of the 67 participants without known diabetes, 14 (21%, 95%CI 12-33%) had abnormal HbA1c. We obtained laboratory HbA1c for 36 participants, which highly correlated with POC HbA1c in the ED (slope⫽1.2, r⫽0.97). Participant follow-up for diagnostic oral glucose tolerance testing is underway. Conclusion: Implementation of POC HbA1c testing in the ED is feasible and accurate, and identifies one-fifth of patients as high risk for undiagnosed diabetes. HbA1c, unlike glucose, offers the advantage of being unaffected by fasting status and stress response, and may be a useful tool in opportunistic diabetes screening in the ED. Moreover, patients with diabetes, especially if uncontrolled, have higher rates of morbidity for many common ED presentations. Identification of undiagnosed and uncontrolled diabetes may have implications for the ED diagnostic and treatment plan (e.g., chest pain or infection), in addition to the long-term benefit of early diabetes diagnosis and counseling/referral for improved diabetes care.
S128 Annals of Emergency Medicine
408
Who Has Not Been Tested for HIV? HIV Testing History Varies by Patient Demography
Merchant RC, Catanzaro BM, Mayer KH, Seage III GR, Clark MA, DeGruttola VG, Becker BM/Brown Medical School, Providence, RI; Brown University Program in Public Health, Providence, RI; Harvard School of Public Health, Boston, MA
Study Objectives: The Centers for Disease Control and Prevention recently advocated for expanded HIV screening in emergency departments (EDs). Part of the challenge in implementing HIV screening is determining which patients need to be tested. Our objectives were to determine how many and which patients in the ED have never been tested for HIV and ascertain their reasons for having been or never having been tested for HIV. Methods: This study was conducted on a random sample of dates each month and on randomly selected day, evening, and night shifts from July 2005-July 2006 at a northeastern US ED. During each shift, we obtained a random sample of 18-55year-old English-speaking patients being treated for sub-critical injury or illness and interviewed them in-person on their history of HIV testing. HIV-infected patients were excluded. Summary statistics were calculated for patient demographics, history of prior HIV testing, reasons for the last HIV test, and reasons for never having been tested for HIV. Logistic regression models were created to generate odds ratios (ORs) with 95% confidence intervals and predicted probabilities to compare patients by their history of being tested for HIV, according to their demographic characteristics. Results: Of 2,107 HIV-negative patients surveyed, the median age was 32 years; 54% were male, 71% were white, and 45% were single/never married; 57% had twelve or fewer years of formal education; 49% had private healthcare insurance; and 45% had never been tested for HIV. Of those previously tested for HIV, 43% had been tested within the previous year. In terms of the main reason for their last HIV test, 26% said that they “just wanted to know,” 22% stated that testing was part of a medical examination, and 15% were tested because of a possible exposure to HIV. Of those who had never been tested for HIV, 55% believed that they were not at risk for HIV and 29% had not considered getting tested. In multivariable logistic regression analyses, patients who were male (OR 1.32 [1.37-2.73]), white (OR 1.93 [1.73-2.37]), married (OR 1.53 [1.122.08]), and who had private healthcare insurance (OR 2.10 [1.69-2.61]) had a greater odds of never having been tested for HIV. There was a U-shaped relationship between age and history of being tested for HIV; younger and older patients were less likely to have been tested. The predicted probabilities of prior HIV testing were lowest across all ages for white males and highest for non-white females. History of HIV testing and years of formal education were not related. Conclusion: Over half of the ED patients surveyed had never been tested for HIV. Many did not perceive themselves to be at risk of an infection. Younger and older patients, males, whites, married people and those with private health care insurance comprised demographic groups less likely to have ever been tested for HIV. These results show that certain ED patients are being missed though HIV testing programs in other settings. These patients could potentially be reached through universal HIV screening in EDs.
409
Intimate Partner Violence and Out-of-Hospital Intervention: A Public Health and Emergency Medical System Alliance
Eliseo LJ, White D, Brinsfield K/Boston University Medical Center, Boston, MA; Boston EMS, Boston, MA
Study Objectives: Intimate partner violence (IPV) is a serious public health problem. We saw the need for heightened recognition and intervention of IPV by out-of-hospital personnel. Previous studies demonstrated the potential benefits of such a program, particularly for those victims who refuse to be transported to a hospital. Our program combined the efforts of Boston Emergency Medical Services (EMS), emergency physicians, advocates, IPV agencies and resources. Methods: Boston EMS implemented the Community Outreach Program (BECOP), a public health referral program to improve services for victims of IPV. BECOP provided EMS personnel 5 venues to identify IPV victims. EMS staff received 6 hrs of training encompassing risk assessment, intervention, and referral. The program partnered with existing providers offering a out-of-hospital approach to victims of IPV initiated by the 911 call and on scene services with follow-up by trained EMS providers. EMS providers also staffed a Community Service Unit (CSU). The CSU included 6 female EMS staff trained in providing advocacy and referrals. CSU advocates received 40 hrs of training in crisis intervention, safety planning, threat assessment, and caring for children witnesses to violence. The CSU responded 7 PM - 3 AM, 5 days/week offering referrals and providing transport to a
Volume , . : September