Rapid Referral Research Articles

PB3 Head injury: a system of rapid referral

Objectives and BackgroundTo develop a streamlined referral pathway for isolated head injuries in Trauma Units. Severe head injury (ISS >15) is a major problem in the UK. For 2010, TARN...

Assisting the diagnosis of overt hypothyroidism with pattern recognition methods, making use of a set of routine tests, and their multiple correlation with total T4

In our previous papers we proposed a novel screening method that assists the diagnosis of patients with overt Graves’ hyperthyroidism by making use of routine test data and pattern recognition methods. This method can be applied by non-specialists during physical check-ups at low cost and is expected to lead to rapid referrals for examination and treatment by thyroid specialists, that is, to improve patients’ QOL. In this report, we investigate whether a similar screening method is also applicable for overt hypothyroidism. Fifty-six subjects with 12 routine test data with a known diagnosis (30 patients with overt hypothyroidism and 52 healthy female volunteers, and 26 patients with overt hypothyroidism and 48 healthy male volunteers) were used as training data. Then, test samples of patients who had also undergone the same routine tests at the Tohoku university hospital were screened by our method for overt hypothyroidism. The present examination of the screening method showed its high screening ability with the set of four parameters used (lactate dehydrogenase [LDH], total cholesterol [TC], red blood cell [RBC] and serum creatinine [S-Cr]). It was found that there was a strong multiple correlation between the set of routine test parameters and serum total thyroxine (TT4) in the patients with overt hypothyroidism, which supports the usefulness of our screening method.

P-573 - Analysis of diagnostic agreement among psychiatric assessment in emergency service and inpatient setting

Introduction Psychiatric emergencies are usually complex processes rather than discrete events, in which most clinicians have only two tools to deal with: hospital admission or crisis intervention in the emergency department followed by referral to low-intensity outpatient treatment. The triage model for psychiatric emergency services (PES), described by Gerson and Bassuk in the 80s, advocated “rapid evaluation, containment and referral (…), minimizing subtle diagnostic considerations. This model has been replaced by more comprehensive services, capable of providing comprehensive assessment and a broader range of services. This treatment model highlights the importance of establish a diagnosis, even if provisional, that allows a plan for immediate treatment. The literature suggests that reliable diagnostic assessments can be performed in emergency settings. Objectives To evaluate the validity of psychiatric diagnosis made in the PES of an university hospital. Method Retrospective study, in which data from all the patients admitted to Psychiatry Service of Coimbra University Hospitals between January and June of 2010, from the emergency department, were analyzed for socio-demographic and clinical characteristics, namely the diagnosis before psychiatric inpatient hospitalization (PES) and at discharge. Results From the 4.537 psychiatric episodes observed in the PES during this period, 8.1% where admitted to inpatient treatment. The most frequent diagnostics at admission were Major Depression (17.2%), Affective Disorder (17.1%) and Schizophrenia (13.1%). Conclusions Although the study is still running, preliminary results point to a good level of agreement between the diagnostics made in the PES and those established in the inpatient assessment.

A Rapid Two-Stage Screening Protocol for Palliative Care in the Emergency Department: A Quality Improvement Initiative

Background A rapid two-stage screening protocol was developed to improve referral for palliative care needs among frail elderly in the emergency department (ED). Measures A new triage tool was administered, with assessment tools for activities of daily living, performance, functional staging, symptom burden, and caregiver distress. Intervention Stage One identified elderly patients meeting criteria for life-limiting conditions. Stage Two referred patients with crescendo losses in activities of daily living, high symptom burden, and caregiver distress to palliative care or hospice. Outcomes Over eight months, 1587 patients were screened, representing 22% of ED visits made by patients older than 65 years during this time period. Of these, 140 met functional decline criteria, and 51 of these needed palliative care consultation. Five patients were referred to hospice, 20 received palliative care, and 26 received no further service. Conclusions/Lessons Learned The project shows unmet needs among elderly ED patients, and the feasibility of rapid screening and referral using a quality improvement approach. At its peak, the project accounted for half the referrals to the palliative care consultation service.

Stressing the need for rapid referral of complex open fractures to a specialist centre

Guidelines from the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons recommend the immediate referral of complex open fractures of the lower limb to a specialist centre for combined orthopaedic and plastic surgical management.1 However, Townley et al reported that across a large area of South-West England the mean delay in referral of open tibial fractures was 5.4 ±1.7 days.2

Using mobile clinics to deliver HIV testing and other basic health services in rural Malawi

The majority of Malawians are impoverished and primarily dependant on subsistence farming, with 85% of the population living in a rural area. The country is highly affected by HIV and under-resourced rural health centers struggle to meet the government's goal of expanding HIV testing, antiretroviral treatment, and other basic services. This report describes the work of two four-wheel drive mobile clinics launched in 2008 to fill an identified service gap in the remote areas of Mulanje District, Malawi. The program was developed by an international non-governmental organization, Global AIDS Interfaith Alliance (GAIA), and the Mulanje District Health Office, with funding from the Elizabeth Taylor HIV/AIDS Foundation. The clinics provide: (1) rapid HIV testing and treatment referral; (2) diagnosis and treatment of malaria; (3) sputum collection for TB screening; (4) diagnosis and treatment of sexually transmitted and opportunistic infections; and (5) pre-natal care. The clinic vehicles provide medical supplies and personnel (a clinical officer, nurse, and nurse aide) to set up clinics in community buildings such as churches or schools. In such a project,<strong> </strong>the implementation process and schedule can be affected by medication, supply chain and infrastructural issues, as well as governmental and non-governmental requirements. Timelines should be sufficiently flexible to accommodate unexpected delays. Once established, service scheduling should be flexible and responsive; for instance, malaria treatment rather than HIV testing was most urgently needed in the season when these services were launched. Assessing the impact of healthcare delivery in Malawi is challenging. Although mobile clinic and the government Health Management Information System (HMIS) data were matched, inconsistent variables and gaps in data made direct comparisons difficult. Data collection was compromised by the competing demand of high patient volume; however, rather than reducing the burden on existing health centers, the data suggest<strong> </strong>that the mobile clinics provided services for people who otherwise may not have attended a health center. The GAIA mobile clinics were integrated into a catchment area through a community participation model, allowing point-of-care primary health services to be provided to thousands of people in remote rural villagers. Strong relationships have been forged with local community leaders and with Malawi Ministry of Health officers as the foundation for long-term sustainable engagement and eventual integration of services into Health Ministry programs.

Time to Treatment for New Patients with Rheumatoid Arthritis in a Major Metropolitan City

To determine the proportion of patients with rheumatoid arthritis (RA) seen by rheumatologists and treated with disease-modifying antirheumatic drugs (DMARD) within 3 months of symptom onset, to determine where treatment delays occur, and to identify contributing factors. A retrospective cohort study in which adult patients with RA, diagnosed between January 1, 2003, and May 31, 2006, were recruited from rheumatologists' offices to participate in a telephone survey and chart review. The percentage treated with DMARD within 3 months of symptom onset was determined, along with median times for delay. Factors contributing to the delay were explored using multivariable logistic regression. Our study included 204 patients. Within 3 months of symptoms, 22.6% (95% CI 16.8%, 28.3%) received DMARD and within 6 months, 47.6% (95% CI 40.7%, 54.4%). The median time from symptom onset to DMARD was 6.4 months [interquartile range (IQR) 3.3, 12.0] with a median time from RA diagnosis by a rheumatologist to DMARD of 0.0 months (IQR 0.0, 1.0). Higher baseline swollen joint counts resulted in earlier treatment. Age, sex, education, comorbidity, rheumatologist practice type, and years since the physician's graduation did not affect time to treatment. Fewer than 25% of patients referred to rheumatologists were treated within 3 months of symptom onset. Identification of inflammatory arthritis and referral to rheumatologists are the key factors in timely care, because once patients are seen there is no delay to treatment. Future resources should be focused on development and evaluation of interventions to facilitate rapid triage, referral, and assessment by a rheumatologist.

Lessons learned during implementation of therapeutic hypothermia for neonatal hypoxic ischemic encephalopathy in a regional transport program in Ontario

Therapeutic hypothermia (TH) is the first intervention to consistently show improved neurological outcomes in neonates with hypoxic ischemic encephalopathy (HIE). Since the recent introduction of TH for HIE in many centres, reviews of practices during the implementation of TH in Canada have not been published. To determine if eligible neonates are being offered TH and to identify any barriers to the effective implementation of TH. A retrospective review of neonates referred to a regional tertiary centre at a gestational age of 35 weeks or more with HIE was conducted. Among 41 neonates referred, 29 (71%) were eligible for TH; among eligible patients, five were moribund and excluded, and TH was initiated in 16 (67%) of the remaining 24. Reasons for not cooling in eight eligible patients included a delay in referral (n=5, median age at referral was 14 h) and a failure to recognize the severity of HIE (n=3). Among cooled patients, median times were the following: 116 min for age at referral; 80 min for time from referral to transport team arrival; and 358 min for age at initiation of cooling. Seven (44%) patients had cooling initiated after 6 h of age. A significant proportion of eligible patients were not offered TH, and in many cooled patients, initiation of cooling was delayed beyond the recommended 6 h. For eligible patients to benefit from TH, it is imperative that all birthing centres be made aware that TH is now widely available as an important treatment option, but also that TH is a time-sensitive therapy requiring rapid identification and referral. In the region studied, for eligible patients, referring hospitals should initiate passive cooling before arrival of the transport team. Referring hospitals should be prepared to provide early, yet safe initiation of passive cooling by having the appropriate equipment, and having staff trained in the use and monitoring of rectal temperatures.

Assisting the diagnosis of Graves’ hyperthyroidism with pattern recognition methods and a set of three routine tests parameters, and their correlations with free T4 levels: Extension to male patients

In our previous paper, we proposed a novel screening method that aids the diagnosis of female patients with Graves’ hyperthyroidism via two types of neural networks and the use of routine test data. This method can be applied by non-specialists during physical checkups at a low cost and is expected to lead to rapid referrals for examination and treatment by thyroid specialists; i.e., to improve patients’ QOL. In this report, we investigate whether the screening method is also applicable to males since sex differences exist in routine test data. The values of 14 routine test parameters for 78 subjects with definite diagnoses (31 patients with Graves’ hyperthyroidism and 48 healthy volunteers) were adopted as training data, and 133 individuals who had also undergone the same routine tests at Tohoku University Hospital were screened for Graves’ hyperthyroidism using our method. The present examination of our screening method in males showed its high screening ability with the set of parameters used (low serum creatinine, elevated alkaline phosphatase, and low total cholesterol). It was also found that there is strong multiple correlation between a set of three parameters and serum free thyroxine (FT4) in male patients with Graves’ hyperthyroidism. A formula for FT4 consisting of three parameters was obtained, and this can be utilized in place of the true FT4 value. This result also supports the usefulness of our screening method.

Does the two-week rule pathway improve the diagnosis of soft tissue sarcoma? A retrospective review of referral patterns and outcomes over five years in a regional sarcoma centre

The NHS Cancer Plan was introduced in 2000 and included guidelines for the rapid assessment and referral of cases of suspected malignancy. We wished to assess the efficiency and appropriateness of patients referred under the Department of Health's general practitioner referral guidelines implemented for sarcomas in December 2000. A retrospective case-note review was performed of all patients referred to our regional soft tissue sarcoma unit between 1 January 2004 and 31 December 2008. Patients referred under the two-week guidelines and all patients referred routinely were analysed. The main outcome measures were the total number of patients referred on the basis of the two-week guidelines and the proportion they constitute of all referrals. The referring criteria were noted and compared to the observed criteria recorded. The final histological diagnosis of patients referred on the basis of the two-week guidelines are documented. A total of 2746 referrals for suspected sarcoma were made from January 2004 to December 2008. Of these, 154 referrals were made under the two-week rule of which 102 were referred purely on the clinical criteria for suspected soft tissue sarcoma. The remaining patients were referred after non-urgent special investigations indicated the possibility of sarcoma. Twelve patients referred under the two-week rule were proved to have sarcoma, nine after specific investigations including imaging or histological diagnosis. Of the 102 patients referred on clinical suspicion of a sarcoma, two patients had proven soft tissue sarcomas and one patient a cutaneous sarcoma. Between 2004 and 2008, the number of 2-week referrals rose 25-fold but accounted for an increase of less than 1% of the sarcomas treated in this unit. The numbers of all referrals for suspected sarcoma are increasing; however, the rate of increase of 2-week referrals is increasing faster than routine referrals and will exceed it in 2012 if current trends continue. There has not been a commensurate rise in the detection of sarcoma or, more specifically, diagnosis of the deep sarcomas associated with worse prognosis. Current clinical guidelines have essentially had no impact on the early diagnosis and treatment of soft tissue sarcoma, and may negatively impact on the treatment of patients with proven sarcoma by delaying treatment within a regional centre because of redirection of a large number of patients with benign abnormalities to such centres.

Portland Identification and Early Referral: A Community-Based System for Identifying and Treating Youths at High Risk of Psychosis

The Portland [Maine] Identification and Early Referral (PIER) program was established in 2000 as a prevention system for identifying and treating youths at high risk of an initial psychotic episode. During six years, 7,270 professionals from the educational, medical, and mental health sectors were provided information on prodromal symptoms and means for rapid referral of at-risk youths, which resulted in referral of 780 youths who met eligibility criteria. After screening, 37% of the community referrals were found to be at high risk of psychosis, and another 20% had untreated or early psychosis, yielding an efficiency ratio of 57%. Prodromal cases identified were 46% of the expected incidence of psychosis in the catchment area. Community educational presentations were significantly associated with referrals about six months later; half of referrals were from outside the mental health system. Community-based identification is an efficient public health strategy, offering the opportunity for preventive intervention.

Treatments for Age-related Macular Degeneration

Age-related macular degeneration (AMD) is the most common cause of irreversible visual loss in the developed world. There are two types of AMD: dry and wet. The exact cause of the disease is unknown, but is thought to result from interplay of genetic and environmental factors. Smoking, hypertension and low intake and/or low levels of serum antioxidants are known risk factors for both forms. As yet there are no treatments available for the dry form of AMD. Smoking cessation and healthy lifestyles are important in the prevention of progression of AMD. Progression of early stages of AMD to advanced forms is slowed by regular intake of ocular nutritional supplements as found in the Age-Related Eye Disease Study (AREDS) Study. Recently, there have been significant breakthroughs in the treatment of wet or neovascular AMD, including photodynamic therapy (PDT), intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs, including pegaptanib, ranibizumab and bevacizumab. Newer agents including aflibercept and anti-platelet-derived growth factor (anti-PDGF) compounds are under investigation. The current gold standard for treatment of wet AMD is intravitreal injections of ranibizumab. Combination therapy with PDT and anti-VEGF agents is useful especially in idiopathic polypoidal choroidopathy (IPCV) or when anti-VEGF monotherapy has failed. Rapid referral of patients with neovascular AMD is important as the visual outcome is dependent on the visual acuity at treatment. Diagnostic confirmation with retinal imaging, particularly fundus fluorescein angiography and optical coherent tomography, are required before treatment commencement. The new treatments for wet AMD are repetitive, and have significant service implications. These implications occur irrespective of which anti- VEGF agent is adopted. Visual rehabilitation is still important in the management of AMD.

Gaining time: early treatment of severe pediatric malaria in Tanzania

AbstractEarly effective treatment prevents death or disability from malaria. In malaria‐endemic rural areas, pediatric patients who cannot take drugs orally and require injectable treatment have to be transported to the nearest facility that can give injectable malaria drugs. If time to reach the hospital is long, pre‐referral treatment and effective referral can play a major positive role. We compare the clinical course of illness and time taken to reach hospital in patients from Study 13, a randomized controlled study of pre‐referral rectal artesunate in which rapid referral was emphasized, with a comparator group of pediatric patients admitted at the same hospital in Tanzania whose parents' actions prior to admission at the hospital reflected routine behavior. The key difference was that parents of sick children from the intervention study rapidly transferred their children to the hospital following the advice they were given. Time gained by the referral study was 48 h and this difference was reflected in less severe symptoms at admission. Efforts to improve referral advice in the community can be a powerful complement to other malaria case management strategies. Drug Dev Res 71: 92–98, 2010. © 2009 Wiley‐Liss, Inc.

Assisting the diagnosis of Graves’ hyperthyroidism with Bayesian-type and SOM-type neural networks by making use of a set of three routine tests and their correlation with free T4

In our previous paper, we proposed a novel screening method that assists the diagnosis of Graves’ hyperthyroidism via two types of neural networks by making use of routine test data. This method can be applied by non-specialists during physical check-ups at a low cost and is expected to lead to rapid referrals for examination and treatment by thyroid specialists, that is, to improve patients’ QOL. In this report, the amount of female sample data was increased and routine test data (14 parameters) from 120 subjects with a known diagnosis (35 patients with Graves’ hyperthyroidism and 85 healthy volunteers) were adopted as training data, before 171 individuals who had also undergone the same routine tests at the Tohoku University Hospital were screened by the network for Graves’ hyperthyroidism. The present re-examination of the screening method showed its high screening ability with the set of parameters used (low serum creatinine was added to the established measures of elevated alkaline phosphatase and low total cholesterol that appear in the Graves’ hyperthyroidism guidelines) and robustness due to the increase of the training sample data. It was also found that there is a strong correlation between the three parameters and serum free thyroxine (FT4) in Graves’ hyperthyroidism, which supports the usefulness of our screening method.

The leukemogenic activity of TaxHTLV-1 during human alphabeta T cell development

The regulatory Tax protein of HTLV-1 (Human T-cell Leukaemia Virus type 1) is critically involved in the initiation of ATL (adult T-cell leukaemia). Indeed, Tax provides infected T-cells with a growth advantage and with the potential to get transformed through the deregulation of cell-cycle progression and the acquisition of genetic alterations. Considering that leukemias are induced by disturbances in hematopoietic cells development, we hypothesize that the expression of Tax in human immature thymocytes is a prerequisite to the emergence of ATL cells. Studies of alph abeta T-cell development in the thymus have shown that beta-selection, an early important checkpoint, is regulated by transcription factors that are decisive in the control of cell proliferation, differentiation and survival. Interestingly, Tax is endowed with the ability to interfere with the activity of these transcription factors. We therefore propose that the HTLV-1 infection of these specific target thymocytes leads to a transcriptional deregulation of early alphabeta T cell development, thus inducing a pre-leukemogenic event that favours the subsequent proliferation of ATL cells.

Management of the Difficult and Failed Airway.

Management of the Difficult and Failed Airway. Edited by Orlando R. Hung, M.D., and Michael F. Murphy, M.D., F.R.C.P.C. New York, McGraw-Hill, 2008. Pages: 510. Price: $129.00.Few scenarios in the practice of medicine stoke the fires of immediate concern quite like encountering a difficult and failed airway. Unfortunately, adequate prediction of potentially challenging anatomy remains far from a perfect science despite having been the cornerstone of modern anesthetic practice for decades. The ever present possibility for disaster fuels continuing discourse not only throughout anesthesia but also across many other disciplines over methods and techniques with which to approach such problematic cases. The magnitude of this problem is reflected in the seemingly endless supply of novel and innovative airway devices and the sheer quantity of ongoing research ventures aimed at improved understanding of the complex interplay between anatomy, pharmacology, and airway manipulation. Indeed, the absolute increases in the volume of both our knowledge and technology are exceeded only by the rate at which they are escalating.Whether the discipline is anesthesiology, emergency medicine, intensive care, or first response, securing the difficult and challenging airway in virtually any situation is the focus of this extremely useful book. Edited by two of Canada’s well-regarded airway management experts, the text offers a number of additions to existing difficult airway manuals in both its content and its formulation of the difficult airway approach.Starting with a well-written and informative introduction to emergency airway algorithms and their similarities to and discrepancies from the American Society of Anesthesiologists Difficult Airway Algorithm, the book delves into a thoroughly informative discussion on how the editors’ Canadian twist on established practice results in improvements to airway management that can be applied to virtually any emergent situation. The text continues with a comprehensive background discussion of devices in and techniques for the difficult airway that serve as the basis of the aforementioned algorithmic progressions. These initial chapters build the foundation for the true value of this text.The book includes topics that vary from airway management in the intensive care unit setting to the management of a motorcyclist with a full face helmet. Each chapter tackles a new airway management dilemma with an informal question and discussion style that permits both straightforward reading and rapid browsing and referral. Through analysis of the pitfalls and caveats associated with unique situations encountered at every step in the process of securing the airway, the authors manage not only to elucidate the fundamental principles inherent to emergent airway control but also to foster an objective approach to the control of the airway in any potential scenario. Each chapter even concludes with a small set of self-evaluation questions that are certainly beneficial to readers, especially those still in training.It is difficult to edit the perfect text, and this book is no exception. It is not as comprehensive as some of the other available references on the market, and a subset of readers may not embrace the novel approaches inherent to the presented algorithms. In addition, it is surprising to note that the discussion on “the best way to confirm placement of an endotracheal tube in the trachea,” included in the chapter entitled “Airway Devices and Techniques,” is too casual and possesses a reference list that ignores a number of rather important citations. The same complaints could be carried over to the discussions on “how do prehospital providers confirm and maintain intratracheal placement of the ETT” in chapter 13 and the chapter on “Aspiration: Risks and Prevention.” Both sections certainly lack depth and, yet again, an appropriate selection of references.These criticisms, however, should not overshadow the text’s value to both junior trainees and veteran anesthesiologists alike. Well written, functionally organized, and implementing algorithms that may be complementary to the established knowledge base of the majority of readers, Management of the Difficult and Failed Airway receives our highest recommendation for any practitioner interested in improving his or her knowledge of airway management.*Advocate Illinois Masonic Medical Center, Chicago, Illinois.ramez.salem-md@advocatehealth.com

Emergency psychiatry in the 21st century: critical issues for the future

Throughout decades of deinstitutionalization, the primary purpose of psychiatric emergency facilities has been defined as rapid referral of patients, triaging those who need 'emergent' care for their mental or emotional problems from those who do not. However, a merely triage-based conceptualization of the psychiatric emergency room does not take into account the ever increasing number of patients, the low accessibility of specialized services, the high need for early recognition of mental problems, or the need toward a more continuous provision of care. In this paper we aim to address some contemporary problems of emergency psychiatry, and then we try to outline some issues that may be of importance in the future of the psychiatric emergency room.

Managing Colorectal Cancer: The General Practitioner’s Roles

Colorectal cancer (CRC) contributes significantly to the morbidity and mortality of Australians. The introduction of the National Bowel Cancer Screening Project (NBCSP) has focused attention on the role of the general practitioner (GP) in screening for CRC. However, the role of the GP post-diagnosis has not been well-documented in Australia. This study aimed to identify and compare the roles of GPs in CRC management in Australia. Fifteen GPs practising in urban, rural and remote north Queensland were interviewed to explore self-reported roles in CRC management. All GPs reported having a role in diagnosis, referral, follow-up and palliative care. Treatment was provided by remote GPs only. GPs also reported acting as an advocate for their patient, providing post-operative care and co-ordinating care. Their care was influenced by the geographical location of their practice and also their relationship with the specialist. GPs with the strongest relationships with the specialist felt most confident in providing care for their patients and were able to ensure rapid referrals. The role of the GP in CRC management is substantial regardless of location. Improvements in the relationships between GPs and specialists could lead to better communication and greater shared care opportunities.

Development and Implementation of a Model to Improve Identification of Patients Infected with HIV Using Diagnostic Rapid Testing in the Emergency Department

Infection with the human immunodeficiency virus (HIV) continues to expand in nontraditional risk groups, and the prevalence of undiagnosed infection remains relatively high in the patient populations of urban emergency departments (EDs). Unfortunately, HIV testing in this setting remains uncommon. The objectives of this study were 1) to develop a physician-based diagnostic rapid HIV testing model, 2) to implement this model in a high-volume urban ED, and 3) to prospectively characterize the patients who were targeted by physicians for testing and determine the proportions who completed rapid HIV counseling, testing, and referral; tested positive for HIV infection; and were successfully linked into medical and preventative care. An interdisciplinary group of investigators developed a model for performing physician-based diagnostic rapid HIV testing in the ED. This model was then evaluated using a prospective cohort study design. Emergency physicians identified patients at risk for undiagnosed HIV infection using clinical judgment and consensus guidelines. Testing was performed by the hospital's central laboratory, and clinical social workers performed pretest and posttest counseling and provided appropriate medical and preventative care referrals, as defined by the model. Over the 30-month study period, 105,856 patients were evaluated in the ED. Of these, 681 (0.64%; 95% confidence interval [CI] = 0.60% to 0.69%) were identified by physicians and completed rapid HIV counseling, testing, and referral. Of the 681 patients, 15 (2.2%; 95% CI = 1.2% to 3.6%) patients tested positive for HIV infection and 12 (80%; 95% CI = 52% to 96%) were successfully linked into care. A physician-based diagnostic HIV testing model was developed, successfully implemented, and sustained in a high-volume, urban ED setting. While the use of this model successfully identified patients with undiagnosed HIV infection in the ED, the overall level of testing remained low. Innovative testing programs, such as nontargeted screening, more specific targeted screening, or alternative hybrid methods, are needed to more effectively identify undiagnosed HIV infection in the ED patient population.

Rapid access referral in East Kent

Rapid access referral in East Kent