Evaluation of opt-out inpatient HIV screening at an urban teaching hospital.

This study evaluated opt-out inpatient HIV screening delivered by admitting physicians, and compared number of HIV tests and diagnoses to signs and symptoms-directed HIV testing (based on physician orders) in the emergency department (ED). The opt-out inpatient HIV screening program was conducted over a one year period in patients who were admitted to the 386-bed University of California San Diego (UCSD) teaching hospital. Numbers of HIV tests and diagnoses were compared to those observed among ED patients who underwent physician-directed HIV testing during the same time period. Survey data were collected from a convenience sample of patients and providers regarding the opt-out testing program. Among 8488 eligible inpatients, opt-out HIV testing was offered to 3017 (36%) patients, and rapid antibody testing was performed in 1389 (16.4%) inpatients, resulting in 6 (0.4% of all tests) newly identified HIV infections (5/6 were admitted through the ED). Among 27,893 ED patients, rapid antibody testing was performed in 88 (0.3%), with 7 (8.0% of all tests) new HIV infections identified. HIV diagnoses in the ED were more likely to be men who have sex with men (MSM) (p = 0.029) and tended to have AIDS-related opportunistic infections (p = 0.103) when compared to HIV diagnoses among inpatients. While 85% of the 150 physicians who completed the survey were aware of the HIV opt-out screening program, 44% of physicians felt that they did not have adequate time to consent patients for the program, and only 30% agreed that a physician is best-suited to consent patients. In conclusion, the yield of opt-out HIV rapid antibody screening in inpatients was comparable to the national HIV prevalence average. However, uptake of screening was markedly limited in this setting where opt-out screening was delivered by physicians during routine care, with limited time resources being the major barrier.

Clinical judgment versus the Pneumonia Severity Index in making the admission decision.

The Pneumonia Severity Index (PSI) is a validated risk assessment tool for patients with community-acquired pneumonia (CAP). Guidelines endorse outpatient treatment for patients deemed low risk, but experience shows that such patients are frequently hospitalized. We investigated the limitations of the PSI as a triage tool by examining outcomes in patients whose disposition from the Emergency Department differed from that predicted by the PSI. PSI scores were calculated by retrospective chart review for all adults with CAP presenting to the Emergency Department of a university medical center. Disposition was classified as consistent with the PSI when low-risk patients were discharged and high-risk patients were admitted. Charts of low-risk patients whose disposition was inconsistent with the PSI were abstracted for documentation of comorbidities contributing to the admission decision, as well as length of stay and level of care. There were 174 patients with CAP who met inclusion criteria, and 32% had a disposition inconsistent with the PSI. Eighty-six percent of the inconsistencies involved low-risk patients admitted to the hospital, and 41% of all low-risk patients with CAP were hospitalized. Hypoxia contributed to the decision to admit in 48% of these patients. Average length of stay was 5.2 days, and 78% of patients remained in the hospital > 48 h. Hypoxia was the most frequent factor contributing to admission of low-risk patients with CAP. Low-risk inpatients had a significant length of stay, suggesting that clinical judgment appropriately superseded the PSI in these cases.