Is Expedited Partner Therapy Ready for Your Emergency Department?

 

JoshuaFaucherBy Josh Faucher, MD, JD // Edited by Michael Barrie, MD

 

 

A 24 year-old male presents to your rural ED’s fast-track area with purulent penile discharge and dysuria.  These have been present for the past week, and he recently began intercourse with a new female sexual partner.  They have not used barrier contraception.  He denies hematuria, fevers, genital lesions, or other associated symptoms; his physical exam is within normal limits other than purulent penile discharge.  Rapid urine testing is positive for Neisseria gonorrhea infection; the patient is treated empirically in the ED with one-time doses of ceftriaxone and azithromycin.  He denies any other recent sexual partners.  The patient’s sexual partner works full time but is uninsured, and in your rural area there are no local STD clinics that are easily accessible for partner follow-up.  Your patient asks if he can have a prescription to conveniently treat possible infection in his female partner at home, saving the time and cost of an additional ED visit or delayed outpatient follow-up.  Can you provide the sexual partner any treatment without seeing her directly as a patient?

Introduction

For reasons of access, cost, or convenience, patients with uncomplicated sexually transmitted diseases (STDs) are frequently encountered in the ED.   The Center for Disease Control’s 2015 Sexually Transmitted Disease Treatment Guidelines include a rather strong endorsement of expedited partner therapy (EPT; also known as patient-delivered partner therapy) for the sexual partners of such patients:

“Unless prohibited by law or other regulations, medical providers should routinely offer EPT to heterosexual patients with chlamydia or gonorrhea infection when the provider cannot confidently ensure that all of a patient’s sex partners from the prior 60 days will be treated.”1

EPT involves writing an additional prescription for treatment of these STDs either to be filled by the patient’s sexual partner, or for the patient to distribute themselves to identified sexual partners.  This can achieve treatment of probable STD infections in sexual contacts without requiring in-person follow-up.  The utility of this practice lies in the potential to quickly treat vectors of disease that might otherwise have protracted or missed follow-up, thereby efficiently preventing further spread of infectious disease or re-infection of your original patient.

Downsides when compared to the traditional referral and in-person evaluation method might include a loss of opportunity to counsel additional contacts about safe sex and risk factors for STDs, a loss of local culture data for information on susceptibilities and patterns of local infections, and possible adverse effects from ad-hoc provision of prescription drugs to patients not seen in person.  When EPT was originally promoted, the legal permissibility of prescribing antibiotics to unseen patients was also not yet clear.

The Scientific Evidence for EPT

The largest clinical trial comparing EPT against formal partner referral for preventing recurrence of both gonorrhea and chlamydia in women and heterosexual men appears to have been conducted by Golden and colleagues, published in the New England Journal of Medicine in 2005.2  The authors had just over 900 participants completing the study in each arm, but the challenges of getting a representative sample to look at this population is revealed by their loss to follow-up of over 30% of those originally randomized in the trial.  Persistent or recurrent gonorrheal or chlamydial infection at follow-up was less prevalent for subjects whose partners received EPT compared to standard referral, with a relative risk of 0.75 (95% CI 0.59 to 0.98).  Gonorrhea experienced a greater reduction in presence than chlamydia (73 percent compared to 15 percent, respectively).  Subjects provided EPT also reported more frequent receipt of treatment by partners and fewer sexual encounters with untreated partners than those provided partner referral.

While Golden’s results were promising, the confidence interval for the primary outcome was wide, and the sampling methods and loss to follow-up may have yielded a non-representative sample.  The author’s EPT method also included subjects who declined to contact their partners themselves, and where EPT was provided by clinic staff collecting contact information and anonymously contacting subject’s sexual partners.  Such practices might be outside the scope of resources in your emergency department, causing EPT to reach a smaller proportion of your patient’s partners than in this trial.

The CDC guidelines note that EPT has not been studied for treatment of contacts with trichomonas or syphilis, and also recommend that EPT not be provided for men who have sex with men (MSM) based on the limited available clinical evidence of effectiveness, and the >5% prevalence of undiagnosed HIV infection in partners of MSM diagnosed with gonorrhea or chlamydia.1 Some authors have explored EPT in this specific population, including Kerani and others in 2013.3 They compared EPT in combination with, and against, an online partner referral website, as well as standard partner referral, but unfortunately experienced severe difficulty obtaining adequate enrollment and halted their study early with only 53 total subjects.   The study arms had significant differences in both race/ethnicity of subjects and type of infection, despite randomization.  The authors found that EPT recipients had 54% more mean partners treated than those with standard partner referral, but the means ratio had a wide 95% confidence interval of 1.01 to 2.34.

Prescribing Within the Limits of the Law

The legal status of EPT varies based on the public health laws of each state, although the vast majority now supports the practice according to a CDC website outlining the legal status in each jurisdiction.4   When it comes to my home state of Ohio, the CDC outlines some preexisting case law that could be viewed as a legal threat to Ohio providers seeking to prescribe EPT.  A 2005 case from the Ohio Court of Appeals, Reed v. State Med. Bd. Ohio, details the courts rejection of a physician’s appeal of a state medical board decision to revoke her license.5 The case describes Dr. Reed’s prescription of a higher-than-usual doses of amoxicillin, along with multiple refills provided for as patient to fill so, as Dr. Reed said, “she could give them to her husband if she felt like it, which a lot of these people do”.  It’s not clear that the board’s decision to sanction a physician in this circumstance, which appears to be questionably justified prescribing, would clearly apply to the more widely accepted practice of EPT.  The case also details other grievances held by the medical board against Dr. Reed, such as prescribing controlled substances including Xanax, Darvocet, and Soma to patients exhibiting “drug-seeking behavior” without justifying her prescriptions with basic records recording any sort of history or physical.

Despite that case and others, the CDC states that EPT is legally recognized as permissible in Ohio, largely because of a specific statute authorizing the practice.  It came to life as House Bill 124, which was moved quickly through the Ohio state legislature in the fall and winter of 2015 (under the guide of two physician legislators, Sate Reps. Stephen Huffman and Terry Johnson)  before being signed by Governor Kasich and becoming effective on March 23, 2016.6  The bill specifically authorizes physicians and other providers to write EPT prescriptions with the patient’s partner named on the prescription, or with the words “expedited partner therapy” or letters “EPT” displayed on the prescription label.  It also provides immunity from civil liability, criminal prosecution, or professional discipline for providers prescribing EPT within the scope of the law.

A More Complete Perspective on EPT

Considering the whole picture, public health authorities have clearly embraced EPT as a useful tool to combat reinfection and spread of gonorrhea and chlamydia, and legal authorities in the majority of states have expressly authorized its use by physicians to combat STDs.  The scientific evidence for the practice could be stronger, and is limited to certain populations and conditions, but is held back by the difficulty of studying the practice in a vulnerable population around a sensitive subject.  While there doesn’t appears to be an specific evidence looking at EPT in emergency departments, this could be a useful tool in an area of the health care system where obtaining follow up for patients and their partners is an ever relevant issue, and you should consider the possible benefit EPT might have for patients (and their partners) in your ED.

References

  1. Workowski, KA, and Bolan, GA. Sexually Transmitted Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3):8-9.
  1. Golden, et al. Effect of Expedited Treatment of Sex Partners on Recurrent or Persistent Gonorrhea or Chlamydial Infection. N Eng J Med 2005;352:676-85.
  1. Kerani, et al. A Randomized, Controlled Trial of inSPOT and Patient-Delivered Partner Therapy for Gonorrhea and Chlamydial Infection Among Men Who Have Sex With Men. Sexually Transmitted Diseases 2013;38:941-46.
  2. CDC. Legal Status of Expedited Partner Therapy (EPT). CDC Sexually Transmitted Diseases website.  https://www.cdc.gov/std/ept/legal/.  January 9, 2017.  Accessed April 8, 2017.
  3. Reed v. State Med. Bd. Ohio, 833 N.E.2d 814 (Ohio Ct. App. 2005).
  4. House Bill 124. The Ohio State Legislature website.  https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA131-HB-124.  March 23, 2016.  Accessed April 8, 2017.

 

Conference Review 2-15-17 ETOH/Nutrition and Billing/coding

Thank you to Maggie Krebs, MD for making these conference reviews!

EtOH and Nutrition

Review pathophysiology, diagnosis and treatment alcohol-related nutrition deficiencies.

  • Alcoholics are at risk for many nutritional deficiencies due to decreased nutrient intake via diet, decreased absorption and decreased hepatic storage.
  • Classically at risk for B12, folate, thiamine deficiency
  • B12 deficiency à megaloblastic anemia
  • Thiamine deficiency à Wernicke encephalopathy
  • Alcoholics also have decreased absorption of vitamins K, A, D, E and are also at risk for hypoK, hypomag, hypoCa
  • Diagnosis – obtain serum B12, folate, thiamine
  • May obtain serum levels but probably low yield especially in acutely drunk binge-drinkers
  • Classically, treatment in the ED is a banana bag but again, probably low yield in binge-drinkers who are otherwise healthy
  • Thiamine deficiency treatment 100 mg daily

Review pathophysiology, diagnosis and treatment of Wernicke Encephalopathy and Korsakoff Syndrome.

  • Wernicke Encephalopathy thiamine deficiency causing AMS, ocular dysfunction, ataxia
  • Korsakoff syndrome – memory impairment and confabulation
  • Thiamine is a cofactor in the Krebs cycle, deficiency leads to decrease in enzyme activity à lactate accumulation in the brain and serum à biochemical lesions can be seen in many different parts of the brain. Petechial hemorrhage can be seen in mammillary bodies
  • Treatment 500 mg IV TID x3 days, then 250 mg IV/IM daily
  • For one time dose of dextrose/glucose, do not need to worry about administering thiamine first

Review pathophysiology, diagnosis and treatment of ethanol withdrawal.

  • Pathophsyiology: Chornic EtOH use causes down-regulation of GABA receptors (inhibitory) and upregulation of NDMA receptors (excitatory). Withdrawal à inadequate activity of inhibitory receptors and excessive activity of excitatory receptors à hallucinations, seizures, hyperadrenergic state
  • Diagnosis: hypertension, tachycardia, tremors, diaphoresis, vomiting, headache, hallucinations, seizures (utilized in CIWA; downfall is scores can be intentionally manipulated via subjective complaints to get benzos)
  • Treatment benzos (Ativan, Valium, longer acting Librium), phenobarbital
  • Can consider precedex
  • Refractory seizures à intubation, propofol

 

 

Billing/Coding

Review the basics of EM documentation focusing on how to document a level 5 note.

  • History of present illness – need 4 elements from the following: location, quality, duration, severity, timing, context modifying factors, associated signs and symptoms (use CODIERS or OPQRST)
  • Need 2/3: past medical, family and social history

Focus on the scoring components of the MDM section and understand what elements to focus documentation time on

  • 2/3 categories (problems, data, risk) need to be high or extensive to bill as a level 5

Understand how an observation stay is billed and the importance of switching a patient to observation status as soon as possible

  • Requires a stay of at least 8 hours to bill as obs(expected less than 48h)
  • Decreased door to dispo times
  • If admission to obs order placed before mignight, can be difference between a same day or 2 days obs charge (2 day obs charge more than 1 day)

Learn to document clinical impression per ICD-10 guidelines and review general EM code reimbursement levels.

  • precise anatomic location is important (including R vs L)
  • Where: geographic location important
  • Why: Circumstances/activity surrounding
  • How: injury related to work, military, altercation etc.

Conf Review – Patient Safety, Observation Care

Thanks Chad Garthe for these conference reviews!

Patient Safety and Quality Improvement

Patient safety and a shared culture incorporates everyone from doctors, nurses, and medical technitions to take responsibility for patient safety. This responsibility is shared between everyone providing care for the patient.

If you encounter a situation that you believe to be unsafe à SAY SOMETHING

Be comfortable to speak up even in front of superiors

Use maneuvers to excuse yourself from the patient’s room to express concerns

You can report patient safety concerns on One Source even after they happen

Quality Improvement:

Finding a good QI project would be something you have difficulty with in the department on a daily basis. There are endless opportunities for QI in the ED.

Root Cause Analysis- evaluate the root cause to an issue/problem in order to identify the root cause and set up intuitional barriers to prevent future issues/problems

Six Sigma

DMAIC Phase Steps

Define Phase: Define the project goals and customer (internal and external) deliverables

Measure Phase: Measure the process to determine current performance; quantify the problem

Analyze Phase: Analyze and determine the root cause of the defects

Improve Phase: Improve the process by eliminating defects.

Control Phase: Control future process performance

 

Observation Care

Rationale is to provide an extended stay in the emergency department for reassessment of a patient at a later time or to wait for a diagnostic test (i.e MRI, Cardiac Stress Test, Physician Consultation).

Lower admission rates

Provide cost effective care for the patient

Specific protocols: Several protocol are instituted to provide better care for the patient

Go to Order Set à Type CDU à Order-set for specific protocols can be found here

ED Observation for TIA

Definition TIA: Transient Ischemic Attack, hemiplegia or dysarthria for a period of time with complete resolution of symptoms thought to be ischemic in nature.

Appropriate for Observation Appropriate for Inpatient Admission
Sx w/i 72 hours and ABCD2 > 3 Pt with > 1 symptomatic episode in 24 hour period
Sx w/i 72 hours and ABCD2 0-2 w/ no outpatient workup in the next 2 days Crescendo of symptoms
Sx w/i 72 hours and ABCD2 0-2 w/ likely focal ischemia New onset atrial fibrillation
  TIA w/ >70% known stenosis of the carotid artery

 

Benefits of Inpatient Admission:

More observation time

Better management of patient’s with multiple co-morbidities

Benefits of CDU/Observation stay:

Less cost with similar outcomes (Nair et al)

Faster

More efficient and less costly (Ross et al)

ABCD2 Score

ABCD2 0 +1 +2
Age > 60 No Yes N/A
BP > 140/90 mmHg No Yes N/A
Clinical Features Other symptoms Speech disturbance w/o weakness Unilateral Weakness
Duration of Symptoms <10 minutes 10-59 minutes > 60 mintues
History of Diabetes No Yes N/A

 

– Estimates risk of stroke after a TIA

– The largest prospective study of using the ABCD2 score in the emergency department found that the score performed poorly (low sensitivity for identifying low risk patients, low specificity for identifying high risk patients).

– Multiple studies have shown that as the ABCD2 score increases the risk of a subsequent stroke also increases.

– Patients with a low baseline risk of stroke (≤ 2%) with a low ABCD2 score (0-2) are at low risk for having a stroke within the next 7 days (0.4-0.8%).

– The ABCD2 score was developed in the outpatient (non-emergency department) setting. It has been shown to have lower accuracy when used by non-specialists (primary care or emergency physicians). The ABCD2 has less impact on risk stratification when applied in settings where the patients were at low baseline risk of stroke.

Chest Pain Observation

Risk stratify patient’s based on the HEART Score

HEART Score – Predicts Major Adverse Cardiac Event (MACE) in the next 6 weeks

HEART Score 0 +1 +2
History Slightly Suspicious Moderately Suspicious Highly Suspicious
EKG Normal Nonspecific repolarization disturbance Significant ST-Depressioni
Age < 45 45-65 > 65
Risk Factors* No risk factors 1-2 risk factors > 3 risk factors
Troponin < normal limit 1-3x normal limit > 3x normal limit

 

*Risk Factors Include: Hypercholesterolemia, HTN, DM, Smoking, Positive Family History, Obesity

HEART Score MACE
0-3 0.9-1.7%
4-6 12-16.6%
7-10 50-60%

 

Please note that HEART Score should never make the decision for you rather give you evidence to support your disposition.

Thorough Chest Pain Rule-out includes EKG, Troponin, Physician risk stratification, Provocative heart test

 

 

Contraindications

Absolute

  • Acute MI within 2 days, or

active unstable angina

  • Symptomatic severe aortic

stenosis

  • Decompensated heart failure
  • Aortic dissection
  • Acute myocarditis or

pericarditis

  • Uncontrolled arrhythmias
  • Acute PE

Relative

  • Left main disease
  • Severe uncontrolled

hypertension

  • Hypertrophic obstructive

cardiomyopathy

  • High degree AV block