Assessment of HIV-postexposure prophylaxis prescription quality after a training programme and assistance in decisions provided by a computer-based decision program: a cross-over study.

BACKGROUND: Among the tools for preventing HIV transmission, post-exposureprophylaxis (PEP) is an effective means after potential HIV exposure. OBJECTIVES: To evaluate aPEP training program and acomputer-baseddecision program (CBDP) using simulated patients in emergency department (ED) on the quality of PEP prescription. METHODS: This cross-overstudy, carried out from 7January2019 to 28June2019, included 20 ED physicians from 10 tertiary referral hospitals. Intervention consisted of two parts: Period Aassessed physicians' compliance with PEP prescription guidelines before and after atraining program, using 400 post-exposuremedical records (200 occupational and 200 non-occupational). Period Bconsisted of arandomized crossover study involving 40 simulated patients, with physicians using or not using aCBDP. Sensitivity, specificity, and accuracy of PEP prescription in accordance with the guidelines were assessed. RESULTS: In period A, alpha Cronbach was less than 0.7 whereas it increased after the training to be >0.7. Sensitivity increased, especially for occupational patients ranging from 51.8%-66.6% to 70.4%-90.1%, whereas specificity increased for non-occupationalpatients ranging from 15.5%-51.9% to 52.1%-75.3%. In period B, sensitivity, specificity, and rate of complete assessments significantly increased (p < 0.0001) after the initiation of CBDP. Rate of PEP prescription significantly decreased (p < 0.001) for all subcategories. CONCLUSION: Significant recommendations-discordantprescriptions, mainly overprescription, occurred for patients visiting ED for PEP. Training improved quality of PEP prescription but the reduction was modest. The availability of CBDP improved quality of PEP prescription and allowed for better data collection and reduction of PEP prescription.

Características de la exposición al VIH y factores predictores del tiempo de acceso a la profilaxis posexposición: estudio observacional prospectivo / Characteristics of human immunodeficiency virus exposure and predictors of time until access to postexposure prophylaxis: a prospective observational study

OBJETIVOS: La eficacia de la profilaxis posexposición al virus de la inmunodeficiencia humana (VIH) depende de un tiempo inferior a 4 horas entre la exposición y la administración del tratamiento. Este estudio evalúa los factores predictores del tiempo entre la exposición al VIH y la llegada a urgencias. MÉTODOS: Estudio observacional, prospectivo, realizado en el Hospital Universitario de Bichat (París, Francia). Se incluyeron todas las consultas en urgencias en 2016 y 2017 por exposición al VIH -ocupacional y no ocupacional-. RESULTADOS: Se incluyeron 1.475 pacientes, de los que 598 completaron una encuesta de seguimiento. El retraso ($4horas) entre la exposición al VIH y la consulta en urgencias se asoció con el tipo de exposición al VIH: trabajadores sanitarios, otras exposiciones y sexuales (p < 0,001). Se encontraron diferencias entre la exposición sexual y otras: conocimiento del circuito de PEP: 65,2% y 46,9% (p < 0,001), uso previo de PEP: 23,9% y 13,1% (p = 0,001), uso de alcohol: 36,2% y 18,5% (p < 0,001), uso de drogas: 34,6% y 8,6% (p < 0,001), y chemsex: 26,1% y 0% (p < 0,001).En la exposición sexual, los siguientes factores predicen el retraso: conocimiento y uso previo del circuito de PEP(p < 0,001) disminuyen el riesgo de retraso > 4 horas, y uso de drogas (p = 0,03) y chemsex (p < 0,001) lo aumentan; en la exposición ocupacional, el conocimiento del programa PEP lo disminuye y el uso de drogas lo aumenta(p < 0,001). CONCLUSIÓN:El retraso en la consulta posexposición al VIH es mayor en la exposición sexual. El conocimiento del programa de PEP y su uso previo determinaban un retraso menor. En la exposición sexual, el consumo de alcohol, drogas y chemsex, implican un retraso mayor, en especial en hombres que tienen relaciones sexuales con hombres

BACKGROUND AND OBJECTIVE: The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV)contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival. METHODS: Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or non occupational exposure to HIV in 2016 and 2017 were included. RESULTS: A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P< .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2%vs 46.9%, respectively), previous use of PEP (23.9%vs 13.1%), alcohol intake (36.2%vs 18.5%), drug use (34.6%vs 8.6%), and chemsex (sexualized drug use) (26.1%vs 0%) (P< .001, all comparisons).Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prioruse of the PEP pathway (P< .001), drug use (P= .03), and chemsex (P< .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P< .001). CONCLUSIONS: Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men

Characteristics of human immunodeficiency virus exposure and predictors of time until access to postexposure prophylaxis: a prospective observational study. / Características de la exposición al VIH y factores predictores del tiempo de acceso a la profilaxis posexposición: estudio observacional prospectivo.

OBJECTIVES: The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV) contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival. MATERIAL AND METHODS: Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or nonoccupational exposure to HIV in 2016 and 2017 were included. RESULTS: A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2% vs 46.9%, respectively), previous use of PEP (23.9% vs 13.1%), alcohol intake (36.2% vs 18.5%), drug use (34.6% vs 8.6%), and chemsex (sexualized drug use) (26.1% vs 0%) (P .001, all comparisons). Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prior use of the PEP pathway (P .001), drug use (P = .03), and chemsex (P .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P .001). CONCLUSION: Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men.

OBJETIVO: La eficacia de la profilaxis posexposición al virus de la inmunodeficiencia humana (VIH) depende de un tiempo inferior a 4 horas entre la exposición y la administración del tratamiento. Este estudio evalúa los factores predictores del tiempo entre la exposición al VIH y la llegada a urgencias. METODO: Estudio observacional, prospectivo, realizado en el Hospital Universitario de Bichat (París, Francia). Se incluyeron todas las consultas en urgencias en 2016 y 2017 por exposición al VIH ­ocupacional y no ocupacional­. RESULTADOS: Se incluyeron 1.475 pacientes, de los que 598 completaron una encuesta de seguimiento. El retraso (4 horas) entre la exposición al VIH y la consulta en urgencias se asoció con el tipo de exposición al VIH: trabajadores sanitarios, otras exposiciones y sexuales (p 0,001). Se encontraron diferencias entre la exposición sexual y otras: conocimiento del circuito de PEP: 65,2% y 46,9% (p 0,001), uso previo de PEP: 23,9% y 13,1% (p = 0,001), uso de alcohol: 36,2% y 18,5% (p 0,001), uso de drogas: 34,6% y 8,6% (p 0,001), y chemsex: 26,1% y 0% (p 0,001). En la exposición sexual, los siguientes factores predicen el retraso: conocimiento y uso previo del circuito de PEP (p 0,001) disminuyen el riesgo de retraso > 4 horas, y uso de drogas (p = 0,03) y chemsex (p 0,001) lo aumentan; en la exposición ocupacional, el conocimiento del programa PEP lo disminuye y el uso de drogas lo aumenta (p 0,001). CONCLUSIONES: El retraso en la consulta posexposición al VIH es mayor en la exposición sexual. El conocimiento del programa de PEP y su uso previo determinaban un retraso menor. En la exposición sexual, el consumo de alcohol, drogas y chemsex, implican un retraso mayor, en especial en hombres que tienen relaciones sexuales con hombres.

Implementation of HIV-exposures triage strategy in emergency departments to improve nurse-triage for HIV-exposures: A pre- and post-intervention period study.

BACKGROUND: Health Education in the emergency department (ED) is one of the tasks that the HIV-exposure triage implementation needs to be considered. No triage training has been evaluated. METHODS: A prospective 3-years pre- and post-intervention study in an urban academic ED was realized. The intervention was a simulation-based training on triage rules for triage nurses. Triage is based on time between HIV-exposure and ED arrival (≤48 h: level 2 (urgent); ≥48 h: level 5 (non-urgent)). FINDINGS: A total of 2011 HIV-exposures were included; 15.1 per cent were well triaged in pre-intervention vs. 88 per cent in post-intervention period (P < 0.0001). Among well-triaged patients as level 2, the post-exposure prophylaxis prescription rate increased from 30.5 to 57.6 per cent (P < 0.0001). Time interval quality indicators (minutes) were: ED arrival-Triage Nurse 10.9 ±â€¯9.6 vs. 9.1 ±â€¯4.8 (P < 0.0001), ED arrival-Physician 56.3 ±â€¯26.0 vs. 49.9 ±â€¯36.0 (P = 0.0001), and ED arrival to Post-exposure prophylaxis first-dose 86.9 ±â€¯30.0 vs. 65.2 ±â€¯42.0 (P < 0.0001). CONCLUSIONS: These results suggest that time interval HIV-exposure to ED arrival can be used as a triage criterion. A continuous quality improvement program for PEP after HIV-exposure based on a nurse triage training program achieved the objectives of optimizing the triage performance by reducing the time to access the post-exposure prophylaxis first-dose.

Emergency Department influenza vaccination campaign allows increasing influenza vaccination coverage without disrupting time interval quality indicators.

To evaluate the impact of an influenza vaccination (IV) coverage (IVC) in a vaccination campaign of an Emergency Department (EDVC) and its impact on ED time interval quality indicators. We conducted a 4 year observational study, with an intervention during the 4th year. IVC was calculated during pre-and early-epidemic periods. During the final period, a 12 weeks EDVC was implemented. Physicians and nurses were trained and sensitized in the importance of vaccination, and their role in the prevention of severe forms of influenza was reinforced. The vaccine was proposed by physicians and nurses, and delivered by them. Repeated measures ANOVA is a validated method for related not independent groups ( https://statistics.laerd.com/statistical-guides/repeated-measures-anova-statistical-guide.php ). Overall, IVC was 987/3191 (30.9%) with an increasing trend from 28.8 to 33.2%. In the fourth period, out of 868 patients identified with IV indication, 288 had already been vaccinated (IVC 33.2%). After excluding patients presenting criteria of exclusion, IV was proposed to 475 patients: 317 (66.7%) accepted. The vaccination rate after patient's acceptance was 89.6% (288/317). At the end of the EDVC, influenza vaccination coverage was 572 (284 + 288)/868 (65.9%). The delay between arrival at the ED and seeing the triage nurse and physician as well as the overall ED length of stay were not modified during the study period and before and during EDVC. EDVC effectively doubled the influenza vaccination coverage, without modifying ED time interval quality indicators.

Patient's behaviors and missed opportunities for vaccination against seasonal epidemic influenza and evaluation of their impact on patient's influenza vaccine uptake.

OBJECTIVES: Influenza vaccination (IV) coverage remains low in France. Objectives were to assess patient knowledge and behaviors and missed opportunities for vaccination (MO) and their impact on vaccine uptake. METHODS: This is a prospective-observational study, including emergency department patients at risk for severe influenza. Patients were interviewed about their knowledge and behaviors. We evaluated the health-care voucher scheme (HCVS) and MO. RESULTS: 868 patients were included. Vaccine uptake was 33.2%, 42% of patients knew about the possible severity of influenza, 23% thought that they were not at risk for severe influenza, 39% knew that they have an indication for the vaccine, and 4.3% to 11.5% expressed reservations concerning IV side effects and effectiveness. HCVS was used by 44.3% of patients, but only 14.8% had been vaccinated. MO were reported by 484 patients (69.4%) declaring 1104 consultations and 148 IV propositions (86.6%). Predictors of vaccine uptake (p<0.0001) were: knowledge of serious and fatal influenza forms [OR 0.36 (CI95% 0.25-0.5)]; confidence in influenza vaccine effectiveness [0.38 (0.2-0.7)]; opposition to vaccines [0.22 (0.1-0.48)]; visit to general practitioner [4.53 (2.9-7.1)]; general practitioner proposed IV [2.1 (1.2-3.4)]. CONCLUSION: Our results indicate that high rate of missed opportunities, some patient behaviors and general practitioner visits may explain low influenza vaccine uptake, and that HCVS use is a complex process. Of interest, we found that the patient's knowledge of the potential severity of influenza is not sufficient to promote vaccine, suggesting that the information strategy must be adapted to each patient behavior.

Diagnostic performances of the Xpert® Flu PCR test and the OSOM® immunochromatographic rapid test for influenza A and B virus among adult patients in the Emergency Department.

BACKGROUND: New rapid influenza diagnostic tests (RIDT) are available but their clinical utility in adults has not been validated. OBJECTIVES: To evaluate the diagnostic performances of OSOM® Ultra Flu A&B a RIDT on viral strains of influenza A/B from the last epidemic season, and its feasibility by Emergency Department (ED) physicians and nurses. STUDY DESIGN: Of the 1099 patients admitted to the ED with suspected influenza, all having a nasopharyngeal swab tested by the Xpert® Flu PCR and then stored at -20 °C; 500 were selected at random and their samples were tested using the RIDT. Two experts reviewed ED and hospital medical records and all virological data to define influenza cases. Intra- and inter-observer variability were calculated. RESULTS: Of the 500 patients included 45% were ≥75 years, 122 (24.4%) presented with influenza based on clinical and virological criteria. PCR test performances (%) were Se 98.4 (95% CI 93.6-99.7), Spe 99.7 (98.3-100), PPV 99.2 (94.8-100) and NPV 99.5 (97.9-100); and RIDT performances were Se 95.1 (89.2-97.9), Spe 98.4 (96.4-99.4), PPV 95.1 (87.2-99.9) and NPV 98.4 (96.4-98). There was no difference in test performance between influenza A and B virus nor between the influenza A subtypes. Intra- and inter-observer variability of RIDT were 0.94 (0.89-0.99) and 0.96 (0.92-1). CONCLUSION: Our results show that the Xpert® Flu PCR and the OSOM® Ultra Flu A&B Test perform very well in diagnosing strains of circulating virus in adults and elderly. Our results also confirm the feasibility of this RIDT at point-of-care by ED staff.

Influenza virus infections among patients attending emergency department according to main reason to presenting to ED: A 3-year prospective observational study during seasonal epidemic periods.

OBJECTIVE: The role of influenza virus in patients presenting at ED during seasonal-epidemic periods has not previously been specified. Our objective was to determine its frequency according to clinical presentation. METHODS: This is a prospective observational study conducted during three-consecutive seasonal Influenza epidemics (2013-2015), including patients presenting i) community-acquired pneumonia (CAP); ii) severe acute symptoms (SAS): respiratory failure (RF), hemodynamic failure (HF), cardiac failure (CF), and miscellaneous symptoms (M); iii) symptoms suggesting influenza (PSSI). Patients were tested for influenza using specific PCR on naso-pharyngeal swabs. RESULTS: Of 1,239 patients, virological samples were taken from 784 (63.3%), 213 (27.2%) of whom were positive for the influenza virus: CAP 52/177 (29.4%), SAS 115/447 (25.7%) and PSSI 46/160 (28.8%) (p = 0.6). In the SAS group positivity rates were: RF 76/263 (28.9%), HF 5/29 (17.2%), CF 15/68 (22.1%), and M 19/87 (21.8%) (p = 0.3). Among the major diagnostic categories, the influenza virus positivity rates were: asthma 60/231 (26%), acute exacerbation of chronic obstructive pulmonary disease 18/86 (20.9%), HIV 5/21 (23.8%) and cardiac failure 33/131 (25.2%). The positivity of the samples has not been associated (p>0.1) nor the presence of signs of severity or admission rate in medical ward nor intensive care unit. CONCLUSIONS: Our results indicate that during seasonal influenza epidemics, Influenza virus-positivity rate is similar in patients attending ED for influenza-compatible clinical features, patients with acute symptoms including pneumonia, respiratory, hemodynamic and cardiac distress, and patients presenting for acute decompensation of chronic respiratory and cardiac diseases.