Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one?

OBJECTIVES: Our primary objective was to investigate whether urine drug screen (UDS) results affected the medical management of pediatric psychiatric patients presenting to the pediatric emergency department (ED) for psychiatric evaluation and whether it affected the final disposition of these patients. METHODS: This was a retrospective chart review of patients who presented to an urban pediatric ED in Newark, NJ, with psychiatric or behavior problems for medical clearance before psychiatric evaluation between June 3, 2008, and June 3, 2009. Inclusion criteria were any patient between the ages of 0 to 20 years who presented to the pediatric ED and had a UDS performed. Exclusion criteria were if the UDS was obtained for a primary medical workup such as altered mental status, known or admitted overdose, or accidental ingestions, or no psychiatric consultation was made from the ED. Abstracted descriptive data include patient's age, sex, race, and insurance status. Visit-specific data include patient's reason for visit, results of the UDS, psychiatric diagnosis if any, history of substance abuse if any, and management decisions other than psychiatric evaluation after medical clearance. RESULTS: A total of 875 charts were identified from laboratory records; 539 of those patients presented to the pediatric ED for psychiatric evaluation. A total of 62 patients had at least 1 substance detected on the UDS and were referred to psychiatry. All of the patients who had presented for psychiatric evaluation, including those with a positive result on the UDS, were medically cleared with no documented change in management or medical intervention in the pediatric ED. CONCLUSIONS: Obtaining a UDS on patients who presented to the pediatric ED for medical clearance before psychiatric evaluation did not alter medical decision for clearance nor necessitate any change in management or interventions before psychiatric evaluation.

Implementing routine HIV screening in an urban pediatric emergency department.

OBJECTIVE: In 2006, the Centers for Disease Control and Prevention recommended that all outpatient health care settings offer routine, opt-out HIV screening for patients aged 13 to 64 years, except where the prevalence of undiagnosed HIV infection is known to be less than 0.1%. Most emergency departments (EDs) lack routine HIV screening. The objective of this investigation was to describe the results of the implementation of routine, nontargeted opt-in HIV screening for patients aged 13 to 20 years in an urban pediatric ED (PED) in a city in which 1 of 30 residents has HIV/AIDS. METHODS: This was a retrospective chart review from an urban, academic PED. The implementation of routine HIV screening in the ED was funded by the New Jersey Department of Health and Senior Services and planned independently of the study investigator. Patients aged 13 to 64 years were offered HIV screening by nursing staff, physicians, and/or HIV counselors. Patients who accepted were screened with rapid HIV fingerstick testing performed via Clearview HIV 1/2 STAT-PAK by HIV counselors as per the New Jersey Department of Health and Senior Services protocol. Data collected by the study investigator were done by chart review from October through December 2009, the first 3 months after implementation of routine HIV screening. Data were collected from patients aged 13 to 20 years presenting to the PED. Primary outcomes measured included the proportion of patients offered and accepted screening, newly diagnosed HIV cases, and the rate of linking newly diagnosed HIV patients to treatment. Demographic data collected included patient age, sex, and ethnicity. Results from the first 3 months of routine, nontargeted screening were compared with the HIV screening results of October through December 2008, during which time rapid HIV screening was provided to patients in the ED based on clinical indication. Patients who were not offered testing or who refused testing were measured by forms that were placed in every chart and collected by physicians. Emergency department census data were queried to identify the total number of patients seen in the ED within age range and time frame studied. RESULTS: Three hundred (11%) of the 2645 patients aged 13 to 20 years were offered routine HIV screening in the PED from October through December 2009. Two hundred twenty-four patients (74%) accepted HIV testing. No new cases of HIV were identified. There was an increase in acceptance of HIV testing that correlated with increasing age (P < 0.05). There was no significant difference between male and female acceptance rates (P < 0.05). Eleven (4.9%) of the patients accepting testing did not have testing performed because of unavailability of the counselor and/or the patient could not wait. Review of HIV testing performed in the PED from October through December 2008 showed 39 patients aged 13 to 20 years were tested. Routine testing increased the number of patients tested by 446%. CONCLUSIONS: Pediatric patients in this urban setting are very accepting of HIV testing. HIV screening is increased when routine screening is offered.