Partnering with hospital emergency departments

Partnering with Partnering with hospital emergency hospital emergency

departmentsdepartmentsCaroline Moseley, M.Ed.Caroline Moseley, M.Ed.

Mark Schulz, Ph.D.Mark Schulz, Ph.D.Manjunath Mahadevappa, MBBS, Manjunath Mahadevappa, MBBS,

MPHMPH

ObjectivesObjectives

Understand the vital role that HEDs Understand the vital role that HEDs play in syphilis elimination.play in syphilis elimination.

Develop a strategy for engaging Develop a strategy for engaging HEDs in syphilis elimination.HEDs in syphilis elimination.

Implement a plan for incorporating Implement a plan for incorporating HEDs into strategic plans for HEDs into strategic plans for eliminating syphilis.eliminating syphilis.

What will we do today?What will we do today?

Learn about Guilford County’s project Learn about Guilford County’s project with emergency departmentswith emergency departments Collaborations, history of the issue, status Collaborations, history of the issue, status

and results of current projectand results of current project Work in groups to uncover our Work in groups to uncover our

strengths and challengesstrengths and challenges Develop action plans including a plan Develop action plans including a plan

for accountabilityfor accountability

CollaborationCollaboration 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 HospitalHigh Point Community Hospital

University of North University of North Carolina GreensboroCarolina Greensboro

School of Health & Human PerformanceSchool of Health & Human Performance Department of Public Health EducationDepartment of Public Health Education

MPH & BSMPH & BS

Epidemiologist & MPH studentEpidemiologist & MPH student Data entryData entry Data analysisData analysis Literature reviewLiterature review Internal Review Board (IRB)Internal Review Board (IRB)

Data entryData entry

Many hoursMany hours Graduate assistant time donatedGraduate assistant time donated Followed conventions established Followed conventions established

@ 1@ 1stst hospital hospital C MoseleyC Moseley

Data analysisData analysis

SPSSSPSS EasiestEasiest

Analysis questions discussed & developed Analysis questions discussed & developed early w/C. Moseleyearly w/C. Moseley

One way frequenciesOne way frequencies Cross tabulations & more complicated Cross tabulations & more complicated

analysesanalyses Opportunities for further analysisOpportunities for further analysis

Literature reviewLiterature review

Focused on syphilis & emergency Focused on syphilis & emergency departments.departments. Syphilis & jailsSyphilis & jails Guidance from C. MoseleyGuidance from C. Moseley

Internal Review Board Internal Review Board (IRB)(IRB)

Necessary for publicationNecessary for publication

Informed ConsentInformed Consent

HIPPAHIPPA

Coordination w/hospitalsCoordination w/hospitals C. Moseley provided links to hospitalsC. Moseley provided links to hospitals

Guilford County Department Guilford County Department of Public Healthof Public Health

Had idea & initiated projectHad idea & initiated project Collected data from 1Collected data from 1stst hospital hospital Connections to hospitalsConnections to hospitals Knew of STD reporting systemKnew of STD reporting system Funded MPH student for final semesterFunded MPH student for final semester

HospitalsHospitals

Key contactsKey contacts Made data easily availableMade data easily available Open to changing policyOpen to changing policy Open to in-service trainingOpen to in-service training Facilitated IRB approval Facilitated IRB approval

Why partner with emergency Why partner with emergency departmentsdepartments

Similar high risk populationsSimilar high risk populations EDs are primary care centersEDs are primary care centers EDs have easy access to people at high EDs have easy access to people at high

risk for STDs risk for STDs Screening programs are fairly easy to Screening programs are fairly easy to

implementimplement Screening programs can be done for little Screening programs can be done for little

moneymoney

Some background on Some background on Guilford CountyGuilford County

North Central North CarolinaNorth Central North Carolina Population 388,062 (1998)Population 388,062 (1998) Two major cities, Greensboro and High Two major cities, Greensboro and High

PointPoint Consistently high rates of STDs, Consistently high rates of STDs,

including HIVincluding HIV

Trends in early syphilis, 1991-Trends in early syphilis, 1991-20032003

0

10

20

30

40

50

60

70

Guilford CountyNorth Carolina

Early syphilis 2003Early syphilis 2003

Primary, secondary, and late latent Primary, secondary, and late latent syphilis is decreasingsyphilis is decreasing

The increase in syphilis between 2002 The increase in syphilis between 2002 and 2003 is due to an increase in early and 2003 is due to an increase in early latent caseslatent cases

Some background on Some background on hospitals in Guilford Countyhospitals in Guilford County

Two non-profit hospital systems that Two non-profit hospital systems that include four hospitals, three of which include four hospitals, three of which have emergency departmentshave emergency departments

Two private hospitalsTwo private hospitals Many people receive care outside of Many people receive care outside of

the county, especially for HIVthe county, especially for HIV

Background on relationship with Background on relationship with emergency departmentsemergency departments

No previous direct collaborative No previous direct collaborative relationshiprelationship

Health director knew the ED heads Health director knew the ED heads through the medical societiesthrough the medical societies

Health director had a personal Health director had a personal connection with the head of Cone’s EDconnection with the head of Cone’s ED

Syphilis and emergency Syphilis and emergency departments in Guilford departments in Guilford

CountyCounty In 1996, 14.7% of all P & S syphilis In 1996, 14.7% of all P & S syphilis

cases were being diagnosed in an cases were being diagnosed in an emergency departmentemergency department

Reports from emergency departments Reports from emergency departments have steadily declinedhave steadily declined

This may be changing because of our This may be changing because of our studystudy

Syphilis and emergency Syphilis and emergency departments in Guilford departments in Guilford

CountyCounty In the last quarter of 2003, 30% of all In the last quarter of 2003, 30% of all

early syphilis cases were being early syphilis cases were being diagnosed in an emergency diagnosed in an emergency departmentdepartment

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

What was the process?What was the process?

Health director made a phone callHealth director made a phone call Staff met with the medical directorStaff met with the medical director Medical director agreed to have Medical director agreed to have

screening practices assessedscreening practices assessed Staff obtained permission from medical Staff obtained permission from medical

recordsrecords Staff conducted a records reviewStaff conducted a records review

Assessment methodsAssessment methods

SPSS was used for data entry and SPSS was used for data entry and analysis (2 separate databases)analysis (2 separate databases)

406 records were randomly selected 406 records were randomly selected and reviewedand reviewed 203 STD related (by ICD-9 Code)203 STD related (by ICD-9 Code) 203 records pulled from the same time 203 records pulled from the same time

frameframe

Assessment methods: Assessment methods: Demographic variablesDemographic variables

RaceRace GenderGender AgeAge Marital statusMarital status Zip codeZip code Admission dateAdmission date

Assessment methods: Assessment methods: Behavioral variablesBehavioral variables

Pregnancy statusPregnancy status Primary ICD-9 codePrimary ICD-9 code Presenting symptomsPresenting symptoms RPR results (including titer)RPR results (including titer) Results of gonorrhea and chlamydia testsResults of gonorrhea and chlamydia tests Follow-up care for syphilisFollow-up care for syphilis Co-factors for syphilis (cocaine use, history of Co-factors for syphilis (cocaine use, history of

substance abuse)substance abuse) Patient statusPatient status

Assessment resultsAssessment results

94% of the general sample had ICD-9 94% of the general sample had ICD-9 codes that were not life threatening codes that were not life threatening emergencies (one person in the STD emergencies (one person in the STD sample)sample)

The demographic characteristics of The demographic characteristics of both samples are almost identical to both samples are almost identical to those of people at risk for syphilisthose of people at risk for syphilis


Very few people in both samples Very few people in both samples received syphilis tests received syphilis tests 1% general got a test, 7% STD1% general got a test, 7% STD

Many more men than women in both Many more men than women in both samples were screened samples were screened 100% general were men, 14% STD100% general were men, 14% STD


The majority who got screened in both The majority who got screened in both samples were Black samples were Black 100% general were black, 79% STD100% general were black, 79% STD

No pregnant women in either sample No pregnant women in either sample were screenedwere screened

No one in either sample who was No one in either sample who was positive for cocaine received and RPRpositive for cocaine received and RPR


Those who tested positive for Those who tested positive for gonorrhea/chlamydia in both samples were gonorrhea/chlamydia in both samples were no more likely to receive and RPR than no more likely to receive and RPR than those who tested negativethose who tested negative

Those in the STD sample had similar Those in the STD sample had similar demographic and behavioral characteristics demographic and behavioral characteristics to those in the general sample but were no to those in the general sample but were no more likely to receive an RPRmore likely to receive an RPR

Next stepsNext steps

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

Screening protocolScreening protocol

Screen all pregnant women who don’t Screen all pregnant women who don’t have prenatal carehave prenatal care

Screen all people who get a gonorrhea Screen all people who get a gonorrhea and chlamydia testand chlamydia test

Screen anyone who has a positive cocaine Screen anyone who has a positive cocaine test or reports a history of drug use or test or reports a history of drug use or prostitutionprostitution

Treat all symptomatic patientsTreat all symptomatic patients

Study objectivesStudy objectives

Evaluate effectiveness of screening Evaluate effectiveness of screening for syphilis in high risk patients for syphilis in high risk patients visiting the Emergency departments visiting the Emergency departments (EDs).(EDs).

Compare demographics of high risk Compare demographics of high risk patients in ED with syphilis cases in patients in ED with syphilis cases in Guilford County, North Carolina. Guilford County, North Carolina.

Study designStudy design Cross-sectional study conducted over a Cross-sectional study conducted over a

period of six months in emergency period of six months in emergency departments of two big hospitals of departments of two big hospitals of Guilford County located in two different Guilford County located in two different cities. cities.

Over 2200 records of patients attending Over 2200 records of patients attending the EDs who are considered high risk for the EDs who are considered high risk for syphilis were reviewed.syphilis were reviewed.

Study designStudy design

ContinuedContinued High-Point Regional Hospital located in High-Point Meetings between ED staff and Public Health Department. Study Period April 2002 Sep 2002 Moses-Cone Hospital located in Greensboro Meetings between ED staff and Public Health Department Study Period Nov 2002 May2003

MethodsMethods

SPSS was used to enter data obtained from SPSS was used to enter data obtained from reviewing the records.reviewing the records.

Over 1200 records were reviewed in High Over 1200 records were reviewed in High Point Regional.Point Regional.

Over 1000 records were reviewed in Moses Over 1000 records were reviewed in Moses Cone Cone

Over 38 variables were used to record the Over 38 variables were used to record the data.data.

Variables usedVariables used

Demographic Demographic variablesvariables

Race/EthnicityRace/Ethnicity SexSex AgeAge Zip codeZip code Street addressStreet address

Other important Other important variablesvariables

ShiftShift Primary care providerPrimary care provider ComplaintsComplaints Screening results of Screening results of

gonorrhea, chlamydia gonorrhea, chlamydia and syphilis.and syphilis.

Drug screen resultDrug screen result Social history Social history

Race/EthnicityRace/Ethnicity

Race / Ethnicity

Guilford County 2002-03

cases (n=143)

%

RPR+ves @ EDs

Population screened at EDs

Moses Cone

(n=15) %

High Point Regional (n=19)

%

Moses Cone

(n=1036) %


% White, Not Hispanic

11.2 0.0 26.3 30.7 45.0

Black, Not Hispanic

88.1 93.3 68.4 61.5 48.1

Other Race 0.7 6.7 5.3 6.8 6.9

SexSex

Sex

Guilford

County 2002-03 cases (n=143)

%

RPR+ @ EDs


Moses Cone

(n=15) %


%

Moses Cone (n=1053)

%


% Male 53.1 33.3 26.3 29.9 25.2

Female 47.9 66.7 73.7 70.1 74.8

Comparison by ageComparison by age

Age (at first

report)

Guilford County 2002-

03 cases

RPR+ @ EDs Population screened at EDs

Moses Cone

(n=15) %


Moses Cone (n=1048)

%


% 13-19 yrs 7.0 0.0 10.5 14.8 17.0

20-29 yrs 27.2 6.7 21.1 38.3 42.9

30-39 yrs 25.2 40.0 42.1 23.0 24.3

40-49 yrs 34.3 53.3 15.8 16.9 10.4

50+ yrs 6.3 0.0 10.5 7.0 5.4

Comparison by zip codes Comparison by zip codes (Greensboro)(Greensboro)

Zip Codes Guilford County 2002-2003 cases

(n=143) %

RPR + @ Moses Cone

(n=15) %

Population screened @ Moses Cone ED (n=1046)

% 27401 10.5 40 13.3

27403 1.4 0.0 3.0

27405 14.7 20.0 23.7

27406 18.9 26.7 20.5

27407 2.0 6.6 6.9

27360 0.0 0.0 0.0

27249 0.0 6.7 0.6

Other Zip Codes 23.8 0.0 17.5

Out of County Not applicable 0.0 14.5

Comparison by zip codes (High Comparison by zip codes (High Point)Point)

Zip Codes Guilford County 2002-

03 cases %

RPR+ @ High Point Regional

(n=19) %

Population screened @ High Point

Regional (n=1212) %

27260 21.7 31.6 41.3

27261 0.0 10.5 1.2

27262 3.5 26.3 14.7

27263 0.7 0.0 6.3

27265 2.8 21.1 8.7

27360 0.0 0.0 3.5

Other Zip Codes

23.8 0.0 15.2

Out of County

Not applicable 10.5 9.0

Syphilis and other STDsSyphilis and other STDs


RPR test (Screening test for Syphilis)

Screening test for Gonorrhea Screening test for Chlamydia

Screening test results

Moses Cone (n=1050)


Moses Cone (n=1048)


Moses Cone (n=1049)


Positive 15 19 40 49 58 75

Rates/1000/Yr 77.3 45.8 120.3 118.8 173.9 184.5

Test not done 662 373 383 378 382 390

Patients with primary care Patients with primary care physiciansphysicians

Primary Care

Physician

RPR+ves @ EDs Population screened at EDs

Moses Cone (n=15)

%


%

Moses Cone (n=1004)

%


% Yes 42.1 73.3 37.5 46.1

No 57.9 26.7 62.5 53.9

Shifts seen in EDsShifts seen in EDs

Shifts seen in EDs


Moses Cone (n=1043)

%


% 7am-3pm 39.7 38.0 3pm-11pm 38.9 43.6 11pm-7am 20.9 18.2

Cocaine positives among Cocaine positives among population screened at EDs population screened at EDs

Drug Screening Population screened at EDs Moses

Cone (n=1053)

%


% Cocaine Positive 26.3 13.5

Positive for other drugs 0.6 12.3 Test Negative 0.9 0.9 Test not done 72.2 73.3

RPR positives among cocaine RPR positives among cocaine positivespositives

Cocaine positives among population screened at EDs

Moses Cone (n=276)


RPR results

Cases % Cases % Positive 3 1.1 2 1.2

Negative 12 4.3 58 36.0

Test not done 261 94.6 101 62.8

Moses Cone - RPR positives among cocaine positives that underwent RPR test 20% High Point Regional - RPR positives among cocaine positives that underwent RPR test 3.3%

Cocaine users among RPR Cocaine users among RPR positivespositives

RPR+ @ EDs Moses Cone

(n=14)


Drug Test Cases % Cases %

+ for Cocaine 3 21.4 2 10.5

+ for other drugs 0 0.0 1 5.3

Test not done 11 78.6 16 84.2

Lessons learnedLessons learned Make screening decision an ED policyMake screening decision an ED policy

Bundle STD testsBundle STD tests Write standing orders for labs to screen Write standing orders for labs to screen

cocaine positives for syphiliscocaine positives for syphilis Collaboration worksCollaboration works

University, county, EDsUniversity, county, EDs Cocaine positives need to be screenedCocaine positives need to be screened

Things we will be doing Things we will be doing in the futurein the future

Analyze cost effectiveness of Analyze cost effectiveness of screening high risk patients.screening high risk patients.

Implement a research protocol for Implement a research protocol for screening cocaine positives.screening cocaine positives.

Publish results Publish results

Partnering with hospital emergency departments

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