We frequently get asked to do a little bit more in the ED. Over the years, we have been asked to screen for lots of conditions that may be opportunistically screened for or which may be associated with the presenting condition. Alcohol consumption, for example, is related to many ED attendances, so it is reasonable to screen patients for hazardous and dependent drinking behaviours. So there are many conditions that we either actively or inadvertently screen for.
- alcohol consumption
- drug use
- blood pressure
- asymptomatic haematuria
- growth and development (paediatrics)
- weight/BMI
- HIV
- the list goes on…
Many of these are incidental in our assessment of patients and we may do little more than raise awareness with the patient (and in the UK, their general practitioner) but if you stop and think about it there are potentially great benefits to screening in the ED. While these questionnaires may feel arduous, it’s important that we remember that these are opportunities to improve public health and potentially reduce future healthcare encounters.
Our population is different from many other healthcare settings and I always like to remind colleagues about how diverse our population is, not just in terms of language and ethnicity, but in particular we have contact with one group of patients who hardly ever access routine healthcare at all. Young men. The ED population is the only one in my group of hospitals that has an excess of this group, so think about that next time you are asked about your equality and diversity strategy: diversity in the ED goes beyond the obvious 😉
So the ED has some population advantages for screening, and our patients are a captive audience for healthcare promotion. Sitting in the waiting room, waiting for triage and reviewing X-rays of the results of tests, they are bored and restless as anyone who has spent time in an ED as a patient knows only too well.
How could we use this opportunity for our advantage?
As EM physicians perhaps we shouldn’t, we are busy enough dealing with the patients who require our skills, but what about opening this opportunity up to those who are interested in screening our population. Why couldn’t/shouldn’t we have a screening service based in the ED in order that our patients may get targeted evidence based screening?
The reason I’m thinking about this today is this recent RCT in Annals of Emergency Medicine article on screening for STI’s in the ED. It’s also a great excuse to show this video again around Christmas as it appears that attendances to STI clinics may peak in January.
So, if that’s filled you with festive cheer, read the abstract and paper below. This rather took my fancy as it involves screening for STIs in the ED. I spend quite a lot of time with our local GU docs (long story) and we have had several conversations about this as for the reasons stated above, we see a lot of young sexually active patients, and with plenty of cheer on offer in the bars and clubs of Virchester this Christmas I’m fairly sure that the love will be shared over the next few weeks.
Abstract
OBJECTIVES: The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women.
METHODS: This was a randomized controlled trial. Research assistants (RAS) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAS randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman’s personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment.
RESULTS: A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (+4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women’s awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing.
CONCLUSIONS: The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group.
What type of study is this?
This is an RCT which is great as many studies looking at screening in the ED are observational or single cohort studies. The authors here have tested the hypothesis by randomising patients to brief intervention and investigation vs. the offer of investigation alone.
Who was studied?
The population chosen is women aged 18-35 years of age. That’s interesting as we are seeing a rise in STIs at all ages in the UK across all age bands, and in particular in men who have sex with men (1). Young women are an at risk group, but this study seems a bit limited. In Virchester, which has a large MSM catchment, this restriction presents difficulties with the generalisability of the findings. Similarly as this is only a 2-centre study we must be cautious about interpreting the findings for my and your population.
How many patients were studied
171 patients were studied, which is a fairly small population. A sample size calculation was performed based on a 20% increase in screening. The authors relate this to similar rates for HIV screening, but I still think that’s a rather ambitious difference in screening rates. Such a large difference means that you don’t need that many patients, but it does mean that you are committed to finding a big difference to gain statistical significance.
What was the intervention?
Potentially eligible patients were approached in the ED. Those who agreed to participate were randomised to either a brief intervention designed to encourage participation in testing. All patients completed a data collection process that included information on condom use, sexual history, substance use and attitudes to screening. Arguably that is an intervention in itself.
Those receiving the brief intervention met with the research team directly after baseline data collection.
Participants were then invited to take a chlamydia/gonorrhea test in the ED.
What are the main results?
The main outcome measure was the proportion of patients accepting screening. 48% in the intervention group accepted screening vs. 36% in the non-intervention group. That’s a 12% difference which is not statistically significant and does not reach the 20% in the sample size calculation but I cannot help thinking that they should have just studied more patients. A 12% difference (if true) is still quite high.
7% of asymptomatic patients were positive for chlamydia which is in keeping with other studies. No patients tested positive for gonorrhea.
Other issues
There are many, but I’ll pick a big one, and that’s the outcome was testing in the ED, not testing over time. It is entirely possible that patients may have sought further testing in another setting so it would have been great to see some later follow up with patients. In the UK this could have been with the GP, though I am unsure as to such arrangement in the US health system (maybe it does not happen).
So where does this leave us?
It’s difficult to take anything definitive away from this study. It’s too small, too parochial and too focused to allow any form of generalisability to my patients here in Virchester, but I suppose it does prove the concept that we could do STI screening in the ED. We sort of know that though, it’s been done for HIV before so no surprises. We should also take note that screening does not have to take place in a traditional health care setting. Workplace, education, pharmacy, out reach and drop in screening services may also offer opportunities to capture individuals at risk.
Maybe dogs could do it better?
So, until we have one of these dogs in the ED we don’t have a definitive answer, but please let this paper make you stop and think about whether those boring hours in the waiting room, with a captive audience, of patients who are not routinely seen in other settings might be better used.
References
- Sexually transmitted infections and chlamydia screening in England, 2013
- Urine based screening for asymptomatic/undiagnosed genital chlamydial infection in young people visiting the accident and emergency department is feasible, acceptable, and can be epidemiologically helpful T Aldeen1, A Haghdoost2, P Hay1 Sex Transm Infect 2003;79:229-233 doi:10.1136/sti.79.3.229
- What are seasonal and meteorological factors are associated with the number of attendees at a sexual health service? An observational study between 2002–2012. Sex Transm Infect 2014;90:635-640 doi:10.1136/sextrans-2013-051391
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