Introduction: HIV infection rates are increasing among adolescents. Despite guidelines recommending annual HIV screening among sexually active adolescents, 3.6% of adolescents tested for other sexually transmitted infections (STI) in a pediatric emergency department (PED) were screened for HIV. The aim was to increase HIV screening to 90%. Methods: Interventions were designed to address 4 key drivers thought to be critical in reliably offering HIV testing. The primary outcome measure was the proportion of adolescents offered HIV testing among those being tested for common STIs. Statistical process control charts were used to measure performance over time and differentiate common versus special cause variation. Results: We instituted point of care (POC) HIV testing in the PED in January 2012. The proportion of STI tested patients offered HIV testing was increased to >87% and sustained this performance. Implementation of a clinical decision support tool had the highest impact. The majority offered testing agreed, and the most common reason for refusal was a recent negative test. We identified eleven HIV positive patients over 5 years. Eight were newly diagnosed, and 3 had prior positive tests but were not connected to care. All 11 were successfully connected to providers with HIV care expertise. Conclusions: POC HIV testing is feasible, acceptable, and sustainable in a PED setting. The implementation of targeted HIV POC testing in the PED increased the number of HIV tests being offered, the number of high-risk patients being screened, and the number diagnosed and connected to care.
Teaching trauma management Sir In reference to the article on teaching trauma management in the accident and emergency department (Williams et al., 1991), we are concerned that it may perpetuate the myth that junior staff can and indeed should continue to manage critically injured patients. Many studies have shown that preventable trauma deaths can be reduced from 20-30% to less than 5% with appropriate organizational and staffing changes (Cales et al., 1985; Kreis et al., 1986). The management of major trauma presents a complexity of diagnostic and therapeutic decisions, in addition to requiring skill in multiple invasive procedures that cannot reasonably be expected of junior staff. The ATLS Programme teaches a basic approach to initial trauma care but in no way confers expertise on the participants and is therefore no substitute for management by experienced senior staff. The suggestion that an abbreviated version of ATLS might represent any type of solution to the problem of trauma care by junior doctors is unrealistic. Major trauma is a disease which demands the immediate presence of trained and experienced senior medical staff. Trauma centres, so favoured in the U.S.A., may not be a practical or economic solution in the U.K. environment with its comparatively low rates of trauma. However, redressing the serious imbalance in the ratio of junior to senior medical staff (10:1) in U.K. accident and emergency departments illustrated by Williams would improve the care of all critical and injured patients, not just those with major trauma, and must therefore represent an essential strategy.
Letters to the Editor 383 helicopter were for secondary missions, the helicopter being deployed after the land ambulance had arrived at the scene.It is clear from the work with the West Midlands that the best effective deployment of an air ambulance is as a primary resource replacing a land-based ambulance resource. The only absolute measure of evaluating the emergency response care provided by the ambulance service will be a clearly demonstrated reduction in morbidity and mortality and this can only be shown with reference to formal trauma scoring in particular TRISS methodology.
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