O1007: Seize the Opportunity - A Quality Improvement Initiative to Improve Screening for HIV and Syphilis in Adolescents Presenting to a Community Hospital Emergency Department

Purpose/Objectives: The demographics of the Human Immunodeficiency Virus (HIV) epidemic have changed. In 2018 45% of 13–24-year-olds living with HIV were undiagnosed and are disproportionately overrepresented compared with all other age groups. In a survey of Emergency Department (ED) providers caring for patients suspected to have sexually transmitted diseases (STD), only 10% encouraged testing for HIV in the ED. Only 13% of sexually active high schoolers reported being tested. In a survey of sexually active young adults, 54% had never been tested; the two most common reasons were not believing themselves to be at risk (67%) and their doctor not having suggested it (41%). The CDC recommends routine HIV testing between the ages of 13 and 64 in all settings unless declined (opt-out screening) and calls for reducing barriers to testing. Early identification is crucial to viral suppression and preventing transmission. Discussion of testing also provides opportunities for risk counseling. Evidence shows that routinizing testing can overcome barriers to testing. Recently the American Academy of Pediatrics report highlighted issues of confidentiality and recommended HIV testing in all adolescents 15 years and older. The CDC also warns that syphilis cases continue to increase since historic lows in 2000 and encourages screening. Persons with HIV infection visit hospital EDs years before receiving a diagnosis but are not tested. We implemented a quality improvement project to improve the proportion of adolescents tested or offered testing for HIV (and syphilis) of all adolescents tested for gonorrhea and chlamydia (GC/CHL) by urine nucleic acid amplification, presenting to a community hospital pediatric ED.

Design/Methods: Our pediatric hospitalist group affiliated with a tertiary children’s hospital practices in a general community hospital with a pediatric ED. We calculated the proportion of HIV testing over a baseline 12-month period. We identified barriers using a driver diagram and designed PDSA cycles. Physicians were educated about CDC recommendations and encouraged to do a confidential interview with adolescents being tested for GC/CHL to offer HIV testing. We created an ED quick order set and removed all STD testing results from the after-visit summary. We also created smart phrases with language to document confidential sexual history, if HIV testing was offered, and contact information for follow up.

Results: The mean proportion of adolescents tested or offered testing for HIV (and syphilis) of all adolescents tested for GC/CHL per month increased from 12% at baseline to 79% after intervention.

Conclusion/Discussion: The ED visit is a missed opportunity to screen for HIV (and syphilis) in adolescents who may not seek testing routinely. Complex issues of confidentiality in adolescents and workflow make testing challenging in the ED. Using quality improvement methodology our study shows that interventions targeted to physician education and confidentiality barriers can improve proportion of adolescents offered testing.