HIV, STIs and Viral Hepatitis Routine Screening Emergency Department Toolkit: Patient triage

Step 1: Patient triage | Step 2: Initiating standard screening protocol | Step 3: Testing and diagnosis | 

Step 4: Patient education and post-test counseling | Step 5: Linkage to Care

Frequently, sporadic visits to the emergency department might be a patient’s only interaction with the health care system and can lead to challenges in health record traceability and continuity of care. Obtaining medical records to guide the clinical decision-making process can pose a challenge, especially among patients who are uninsured and underinsured.

Additionally, patient discomfort with discussing sexual history negatively impacts access to care, disrupts important risk assessment conversations and often prevents test consent. Creating a trusted and welcoming environment for the patient and letting them play a larger role in the screening process by actively engaging them in the intake process in conjunction with automated support, can help give a better view of the patient’s screening needs and ultimately increase screening.

• Incomplete medical history stored across multiple care locations
• EHR excludes patient records from other health care systems
• Inconsistent demographic information
• Lack of space to ensure patient privacy
• Patient discomfort in discussing personal sexual history
• Staff discomfort in discussing personal sexual history with patients
• Distrust of institutional health
• Lack of awareness in the community about the need for screening
• Lack of knowledge on costs and affordability of screening
• Misconceptions about disease transmission
• Fear about finding out one’s status and the associated stigma in the community

1. Create a trusted and welcoming environment 

   1. Trust is earned through creating an environment and care team that is understanding of the patient’s needs: hire from the community, keep the screening team small and personal, and offer options to self-report. Concerns of privacy and patient comfort with discussing sexual health history can be particularly challenging in emergency departments where physical space presents a challenge, with emergency triage areas lacking the appropriate privacy for conversations about sexual history or consent. Hiring administrative and clinical staff that reflect the language, culture, race, sexuality and socio-economic status of communities that health settings intend to serve helps bridge gaps in communication at patient intake and helps “catch” opportunities for screening.

   2. Related resources

   • Tools to Create a Welcoming Environment: Included as a subset of resources in the National Coalition of Sexual Health’s Compendium of Sexual & Reproductive Health Resources for Healthcare Providers, users can find examples and resources on how to create a welcoming and safe environment for both teen and LGBTQ patients.
   • Target HIV Cultural Competency Resources: This webpage includes a collection of guidance, tools and trainings that clinicians can use to identify and address bias to improve communication with diverse patients.
   • Cultural Competence in Health and Human Services: This resource from the National Prevention Information Network defines what cultural competence is and how it applies to HIV, viral hepatitis, STI and TB prevention.

2. Involve patients in the screening process

   1. Proactive engagement with patients at intake, through written or tablet surveys, allows emergency departments to gather information that will expedite the screening workflow, enable privacy and help form a more robust patient record. Front desk staff should be trained to provide patients with self-assessments. Patient navigators can assist with self-assessments, if available. Enabling self- or automated risk assessment saves time in the workflow and prevents physician fatigue. Further assessment of clinical risk factors can be conducted by the physician at a later point, if the patient tests positive.

   2. Related resources

   3. Self or risk assessment templates: The following links provide you with examples of self or risk assessment templates that you can leverage in your practice.
   • HIV: Learn the HIV risk of different sexual activities when one partner is HIV positive and one partner is HIV negative (a discordant partnership).
   • STIs: Assess your risk with the CDC’s Prepare Before You’re There STI self-risk assessment quiz.
   • Viral hepatitis: Assess your risk with this Hepatitis Risk Assessment Tool from the CDC.

3. Collect comprehensive patient demographics and sexual history

   1. Developing a standardized method to collect patient demographics, including race and ethnicity data, and sexual history can not only help you understand the screening needs for your patient, but can also be a mechanism to help identify quality improvement initiatives related to population health and improve health equity at your organization. Patient discomfort and stigma surrounding sexual history negatively impacts access to care and oftentimes disrupts screening consent. Equipping clinicians in your organization with tools and resources to routinely capture this information in an accurate and sensitive manner will help increase screening.

   2. Related resources

   • Discussing Sexual Health with Your Patients: The resource from the CDC outlines strategies and tips for facilitating discussions with and asking patients sensitive questions related to sexual health.
   • A Guide to Taking a Sexual History: This CDC resource offers a framework for discussing sexual health issues to help clinicians complete the overall picture of their patient’s health.
   • GOALS Framework for Sexual History Taking in Primary Care: The GOALS Framework resource from the Clinical Guidelines Program of the New York State Department of Health AIDS Institute is designed to streamline sexual history conversations and elicit information most useful for identifying an appropriate clinical course of action.
   • Sexual Health and Your Patients: A Provider’s Guide: The resource from the National Coalition for Sexual Health was developed to help health care professionals better integrate sexual health conversations and recommended preventive services into routine visits with adolescents and adults.
   • HIV Prevention and Care for the Transgender Population: This CDC resource outlines information and tips for health care professionals to facilitate the disclosure of sexual history information from transgender patients where obtaining this information is particularly sensitive due to potential prior experiences of discrimination in health care.
   • AMA STEPS Forward: Collecting Patient Data – Improving Health Equity in Your Practice: This training module from AMA STEPS Forward highlights why it is important to collect patient race and ethnicity data and how you can establish standards for and train your staff to collect this data.

4. Define clear approach and team member roles for routine screening

   1. A lack of a clear protocol for routine screening, compounded by an overwhelming demand for care, causes staff roles to blur. A clear routine screening plan, streamlined by EHR support, can help clarify care team member roles. If it is feasible, having dedicated staff or volunteers to initiate point of care testing, allows clinicians to focus on confirmatory screening, treatment, and the chief reason for the visit.

   2. Related resources

   • Clinical algorithm flowcharts for screening: This set of documents translates screening guidance and clinical considerations from the USPSTF into a decision tree format to help outline steps in the testing continuum from beginning to end and allow you to help clarify team member roles at each step of the process.
     • Clinical algorithm flowchart for HIV screening (PDF)
     • Clinical algorithm flowchart for Chlamydia and Gonorrhea screening (PDF)
     • Clinical algorithm flowchart for Syphilis screening (PDF)
     • Clinical algorithm flowchart for HBV screening (PDF)
     • Clinical algorithm flowchart for HCV screening (PDF)
   • Streamlined testing cascade: This set of infographics outlines the testing cascade for each infectious disease in this toolkit, including opportunities to optimize screening, and can be used to help clarify care team member roles at each step as well as define a clear post-test protocol.
     • Streamlined testing cascade for HIV in Emergency Departments (PDF)
     • Streamlined testing cascade for STIs in Emergency Departments (PDF)
     • Streamlined testing cascade for HCV in Emergency Departments (PDF)

Disclaimer: This page contains resources supplied by third party organizations. Inclusion of these materials on this page does not imply endorsement of these resources or corresponding organization.

The toolkit is organized across the screening continuum and offers helpful resources and best practices for the emergency department care team.

Overview

Step 1: Patient triage

Step 2: Initiating standard screening protocols

Step 3: Testing and diagnosis

Step 4: Patient education and post-test counseling

Step 5: Linkage to care