Article

Electronic health record triggered hepatitis C screening in the ED

1968 Correspondence / American Journal of Emergency Medicine 37 (2019) 1963-1988

Table 1

Ego surfing (the term denoting searching for oneself on a search engine) results over the years.

Year

Position

Search engine results

1998

2003

Medical student

Resident

My name was referenced two times:

  • speaker in a local conference
  • free message board listing a rug for sale that I no longer needed

One or two pages of references related to a book I had edited–mostly reviews and places where interested readers could potentially

2007

Junior attending

buy it

Two or three pages about research articles that I had authored, corroborating my academic endeavors as an assistant professor while

2018

Community physician

prior book references fell to the back of the search results

Over a dozen pages appeared. The first two pages were filled with personal information about me. Places that I had worked seemed to

predominate. But then I began seeing what I would later find out are citations from ”data aggregators” or ”data brokers.” Unknowingly, I clicked one search result and it immediately reported my full name, home address, relatives of mine and multiple previous addresses. After a few more search pages, I found properties I had owned, my cell phone number, date of birth and DEA number.

unscrupulous place and paying to delete information another shouldn’t have in the first place is extortion and criminal in my mind. All the worse if the data gathered were to be used to commit crimes against my family or me.

While I believe in transparency, I draw the line at my right for privacy and my personal safety. Thoughtful about my profession, I have always opted out of advertisements. I’m on the ”do not call list.” I haven’t joined social media. I believe that my right to privacy should take priority over anyone else’s desire to have my informa- tion. I am not interested in having my identity stolen again (at least twice that I know of), being stalked or even killed by a disgruntled patient whom I refuse to prescribe narcotics using good medical judgment [8].

Physicians are trained to always consider patient safety above all. We constantly act to protect patients’ personal information (HIPPA), safely do procedures, keep safe boundaries with patients and do no harm. Yet I am unaware of any federal laws that protect physicians in the same ways from these data brokers. As a private citizen, I believe that nobody should be subjected to this exposure of their personal lives unless they choose it. But this should be par- ticularly true of a physician who works with the public in a high profile, potentially dangerous work environment. When a data broker can eliminate the delineation between my work life and personal information, a safety alert must be called to provide us federal protections.

Kevin M. Takakuwa MD, MA

PO Box 27574, San Francisco, CA 94127, United States of America

E-mail address: [email protected]

16 February 2019

https://doi.org/10.1016/j.ajem.2019.03.043

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    Electronic health record triggered hepatitis C screening in the ED

    With an estimated prevalence of nearly 2.4 million in the Uni- ted States (US) and over 185 million worldwide, infection with hepatitis C virus (HCV) carries a significant burden on the health- care system [1,2]. In the US, upwards of 50% of affected patients are unaware of their diagnosis, putting them at an increased risk for progression to liver cirrhosis and subsequent organ failure [3]. With advancements in well-tolerated oral therapeutics, an increas- ing emphasis has been placed on early detection and routine screening practices. The Centers for Disease Control and Preven- tion (CDC) and the United States Preventive services Task Force (USPSTF) recommend a one-time ”birth cohort” screening for patients born between 1945 and 1965[4,5].

    The Emergency Department (ED) plays an important role in the surveillance and detection of HCV infection. Existing literature supports the notion that HCV infected individuals are more likely to utilize the ED for care more than any other healthcare venue with an estimated ED prevalence rate of 4% to 18% [6-8]. Given this, the ED serves as a front-line resource in the early detection of HCV virus, particularly in the medically underserved population. Utilization of the electronic health record to establish screening interventions has demonstrated effectiveness in cancer and viral screening in at risk patients in the ambulatory setting [9]. We conducted an IRB approved retrospective chart review to examine the utilization our EHR to initiate opt-out testing of eligi- ble patients for HCV screening in the ED. Descriptive statistics

    were used to analyze data.

    Our tertiary care hospital is located in an urban setting with an annual ED census of roughly 93,000 visits per year. A build was introduced into our EHR that prompted the triage nurse to ask eli- gible patients if he or she had ever been screened for HCV in the past. Patients were deemed eligible for inclusion based on the reg- istered date of birth in the EHR. Those born between January 1, 1945 and December 31, 1965 were included in the screening pro- cess. If the patient had not been previously screened, or was unsure, the EHR would prompt the nurse to place an order for a screening HCV antibody test. Positive antibody screening results would be automatically be forwarded to dedicated patient naviga- tors who would attempt to arrange for confirmatory RNA testing and outpatient follow up with the Hepatology clinic (Fig. 1). These linkages to care efforts were supported by grant funding unrelated to this study.

    During the six-month timeframe from June 1, 2018 to Decem- ber 31, 2018, a total of 3023 patients visited our ED and met the

    Correspondence / American Journal of Emergency Medicine 37 (2019) 1963-1988 1969

    Fig. 1. HCV Screening Algorithm.

    inclusion criteria. Of these, 1007 (33.3%) were subsequently screened for HCV through Antibody testing. Positive screens were identified in 112 (11.1%) of the cases.

    Of the 112 patients that were screened, 38 (33.9%) had a confir- matory RNA test performed. Patients either had the test performed as part of their inpatient workup or after being linked to care by a patient navigator. Of the 38 that had confirmatory testing, 28 (73.7%) had a positive confirmatory test, with 10 (26.3%) having a negative result. Of the confirmed positives, 14 were newly diag- nosed. The rest of the patients had been previously diagnosed, although some had been lost to follow up.

    Our results demonstrate the importance of screening for HCV from the ED. Newly diagnosed cases from the ED are now provided with an opportunity to obtain treatment and potentially halt pro- gression of disease. With appropriate oral antiviral medical ther- apy, curative rates for HCV approach 97% – 100% in as little as twelve weeks [10].

    linkage to care after positive screening poses a significant chal- lenge, particularly for medically underserved patients with limited resources. Fragmented healthcare systems as well as costly diag- nostics and therapeutics serve as significant barriers to healthcare access outside of the ED. Administrative efforts through the use of EHR-based screening protocols can augment detection rates and enhance surveillance efforts.

    The use of electronically driven best practice advisories and triggers from the ED can strengthen efforts towards improving public health. While linkage to care remains a significant hurdle to overcome, the ED serves as an important starting point in the curative journey. Future efforts should be aimed at improving access to outpatient care through a multidisciplinary approach. Additional research is needed to identify specific barriers to suc- cessful linkage of care in an effort to enhance the role of the ED in the healthcare system.

    Disclosures

    MU has no disclosures to report.

    GS – Gilead Sciences, research grant co-investigator.

    Gilead Sciences had no role in the execution of this study or Data interpretation.

    Presentations: Preliminary data accepted for presentation at Society for Academic Emergency Medicine (SAEM) Annual Meeting

    (May 2019), however the authors are unable to present due to scheduling conflicts.

    Acknowledgments

    The authors would like to acknowledge Dr. Shobha Swami- nathan, Associate Professor of Medicine at Rutgers New Jersey Medical School, for her work as principal investigator on grant pro- curement to aid in linkage of care efforts and laboratory testing.

    Michael Ullo MD *

    Gregory Sugalski MD

    Department of Emergency Medicine, Rutgers New Jersey Medical School,

    Newark, NJ, United States of America

    * Corresponding author at: Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, MSB E-609, United States of America.

    E-mail address: [email protected] (M. Ullo)

    20 March 2019

    https://doi.org/10.1016/j.ajem.2019.03.043

    References

    Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence. Hepatology 2013;57:1333-42.

  9. Anonymous hepatitis C questions and answers for health professionals | CDC, vol. 2019, 2019.
  10. Spradling PR, Rupp L, Moorman AC, Lu M, Teshale EH, Gordon SC, et al. Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence. Clin Infect Dis 2012;55:1047-55.
  11. Moyer VA. Screening for hepatitis C virus infection in adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2013;159:349-57.
  12. Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Teo C, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep 2012;61:1-32.
  13. Stepanova M et al. Insurance status and treatment candidacy of hepatitis C patients: analysis of population-based data from the United States – PubMed – NCBI, 2019.
  14. Brillman JC et al. prevalence and risk factors associated with hepatitis C in ED patients – PubMed – NCBI, 2019.

    1970 Correspondence / American Journal of Emergency Medicine 37 (2019) 1963-1988

    Kelen GD et al. Hepatitis B and hepatitis C in emergency department patients – PubMed – NCBI, 2019.

  15. Federman A. An electronic health record-based intervention to promote hepatitis C virus testing among adults born between 1945 and 1965: a cluster- randomized trial, 55, 2018. p. 1.
  16. Bragg DA, Crowl A, Manlove E. Hepatitis C. A New Era Prim Care 2017;44:631-42.

    ”Bandemia” without leukocytosis: A potential Emergency Department diagnostic pitfall

    Emergency physicians routinely employ leukocyte counts as a risk stratification tool in a variety of clinical presentations. While a leukocyte count within the normal reference range is widely acknowledged as unreliable, it is nonetheless commonly inter- preted as reassuring in a patient not otherwise suspected of har- boring severe and acute illness. However, recent data has drawn renewed attention to immature neutrophils (”bands”) as a reliable predictor of acuity, even in the presence of a normal leukocyte count.

    Peduzzi et al. reported no correlation between leukocyte counts and bacteremia in nearly 500 patients with sepsis in 1992 [1]. In 2012, Seigel et al. found that, among more than 300 patients with culture-confirmed bacteremia, 52% had normal leukocyte counts, and 17.4% had neither leukocytosis nor fever [2]. Several authors have previously reported a correlation between elevated immature Neutrophil counts (”bandemia”) and bacteremia, sepsis and death [2-4]. In a study of over 2000 admitted patients with normal leuko- cyte counts, Drees et al. found moderate to high band counts in 16% of cases, and reported a correlation between elevated bands and both bacteremia and death [4]. More recently, Shi et al. found steadily increasing risk for death with increasing bandemia, irre- spective of leukocyte count [5]. The authors further reported ban- demia with normal leukocyte count and normal heart rate in some patients requiring readmission following discharge from the ED (Table 1). Some authors have questioned the clinical utility of screening for elevated band counts [6-8]. Still, bandemia has remained a component of risk scoring tools for more than thirty years, and an association between bandemia and morbidity is evi- dent [9-11].

    Standard complete blood counts (CBC) provide automated,

    quantitative measurements of the number of leukocytes. When requested, a CBC with differential analysis will further provide an automated measurement of leukocyte morphologies (i.e. baso- phils, eosinophils, monocytes, neutrophils and lymphocytes), and will flag abnormal or immature morphologies (e.g. bands). Quanti- tative measurement of bands requires a manual differential per-

    Table 1

    Correlation between the total white blood cell count, ”bandemia”, fever, heart rate, and mortality.

    WBC Fever ”Bandemia” Heart rate Mortality

    4.1 k No 11 106-113 3.7%

    5.6 k No 13 102-126

    k No 17 66-95

    3.6 k Yes 18 101-108

    8.9 k Yes 18 63-99

    k No 29 58-67 3.9%

    4.0 k Yes 33 107-108 4.9%

    k No 33 95-102

    8.6 k No 41 136-137

    7.9 k No 45 98-126

    Ref: Shi E, Vilke GM, Coyne CJ, Oyama LC, Castillo EM. Clinical outcomes of ED patients with bandemia. Am J Emerg Med. 2015; 33 (7): 876-81.

    formed by a laboratory technician, and each hematology lab defines specified criteria to trigger performance of a manual differ- ential. Hospital-based labs commonly perform manual differen- tials when flagged cells are reported on automated counts, or when samples are submitted from specified departments (e.g. Emergency Departments). However, the process of identifying and quantifying ”bandemia” is time-consuming, and results may become available much later than initial CBC results. Further, clin- icians may be unaware of flagged results as manual differentials are queued and pending if no reporting system for flagged auto- mated results exists. Emergency physicians must recognize this complex and variable reporting process to avoid early discharge of otherwise well-appearing patients before determination of band counts.

    Emergency physicians face increasing external forces to improve both efficiency and accuracy while operating in an inher- ently high-stakes clinical setting. Throughput is a necessary surro- gate for quality, though health outcomes remain the primary operational driver. While emergency physicians may feel com- pelled to find reassurance in a normal leukocyte count, the balance of evidence strongly suggests a more prudent approach would be to wait for the bands.

    Conflict of interest

    The authors do NOT have a financial interest or relationship to dis-close regarding this research project.

    Financial support

    This is a non-funded study, with no compensation or honoraria for conducting the study.

    S. Davis MD

    R. Shesser MD, MPH

    K. Authelet BS

    A. Pourmand MD, MPH * Emergency Medicine Department, George Washington University School of Medicine and Health Sciences, Washington, DC, United States

    * Corresponding author at: Department of Emergency Medicine,

    George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037, United States. E-mail address: [email protected] (A. Pourmand)

    28 March 2019

    https://doi.org/10.1016/j.ajem.2019.03.050

    References

    Peduzzi P, Shatney C, Sheagren J, et al. Predictors of bacteremia and gram- negative bacteremia in patients with sepsis. Arch Intern Med 1992;152:529-35.

  17. Seigel TA, Cocchi MN, Salciccioli J, Shapiro NI, Howell M, Tang A, et al. Inadequacy of temperature and white blood cell count in predicting bacteremia in patients with suspected infection. J Emerg Med 2012;42 (3):254-9.
  18. Al-Gwaiz LA, Babay HH. The diagnostic value of absolute neutrophil count, band count and morphologic changes of neutrophils in predicting bacterial infections. Med Princ Pract 2007;16(5):344-7.
  19. Drees M, Kanapathippillai N, Zubrow MT. Bandemia with normal white blood cell counts associated with infection. Am J Med 2012;125(11):1124.e9-1124. e15.
  20. Shi E, Vilke GM, Coyne CJ, Oyama LC, Castillo EM. Clinical outcomes of ED patients with bandemia. Am J Emerg Med 2015;33(7):876-81.
  21. Ward MJ, Fertel BS, Bonomo JB, Smith CL, Hart KW, Lindsell CJ, et al. The degree of bandemia in septic ED patients does not predict inpatient mortality. Am J Emerg Med 2012;30(1):181-3.

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