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 and 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)
- 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, review of X-rays of the results of tests, they are bored and restless as anyone who has spent time in an ED as a patients 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 (Ed – why’s that then?).
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.
What type of study is this?
Well, the clue is in the title. 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.
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.
2. 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
3.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