Background-The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all healthcare settings, including the emergency department (ED).

Objective We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff. Methods The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors—without other clinical responsibilities—assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured. Results From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P < .001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P < .001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P = .025). Conclusion Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.

Background Expanded HIV screening efforts in the United States have increased the use of rapid HIV tests in emergency departments. The reported sensitivity and specificity of rapid HIV tests exceed 99%. Objective To assess whether a reactive rapid oral HIV test result correctly identifies adults with HIV infection in the emergency department. Design Diagnostic test performance assessment within the framework of a randomized, clinical trial. Setting Brigham and Women's Hospital emergency department (Boston, Massachusetts) from 7 February to 1 October 2007. Patients 849 adults with valid rapid oral HIV test results. Intervention Rapid HIV testing with the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (OraSure Technologies, Bethlehem, Pennsylvania). Patients with reactive rapid test results were offered enzyme-linked immunoassay, Western blot, and plasma HIV-1 RNA testing for confirmation. Measurements Specificity and positive likelihood ratio. Results 39 patients had reactive results (4.6% [95% CI, 3.2% to 6.0%]). On confirmation, 5 patients were HIV-infected (prevalence, 0.6% [CI, 0.1% to 1.1%]) and 26 were non–HIV-infected (8 patients declined confirmation). The estimated rapid test specificity was 96.9% (CI, 95.7% to 98.1%). Sensitivity analyses of the true HIV status of unconfirmed cases and test sensitivity resulted in a positive likelihood ratio of 8 to 32. Western blot alone as a confirmation test provided conclusive HIV status in only 50.0% (CI, 30.8% to 69.2%) of patients at first follow-up. The addition of HIV-1 RNA testing to the confirmation protocol improved this rate to 96.2% (CI, 88.8% to 100.0%). Limitation Test sensitivity cannot be assessed because nonreactive OraQuick test results were not confirmed. Conclusion Although patients with a reactive oral OraQuick HIV screening test in the emergency department had an 8- to 32-fold increased odds of HIV infection compared with the pretest odds, the specificity of the test was lower than anticipated.

HIV screening studies in the emergency department (ED) have demonstrated rates of HIV test refusal ranging from 40–67%. This study aimed to determine the factors associated with refusal to undergo routine rapid HIV testing in an academic ED in Boston. HIV counselors offered routine testing to 1,959 patients; almost one-third of patients (29%) refused. Data from a self-administered survey were used to determine independent correlates of HIV testing refusal. In multivariate analysis, women and patients with annual household incomes of $50,000 or more were more likely to refuse testing, as were those who reported not engaging in HIV risk behaviors, those previously HIV tested and those who did not perceive a need for testing. Enrollment during morning hours was also associated with an increased risk of refusal. Increased educational efforts to convey the rationale and benefits of universal screening may improve testing uptake among these groups.

BackgroundIn the context of a randomized controlled trial (RCT) on HIV testing in the emergency department (ED) setting, we evaluated preferences for survey modality and data quality arising from each modality.MethodsEnrolled participants were offered the choice of answering a survey via audio computer assisted self-interview (ACASI) or pen and paper self-administered questionnaire (SAQ). We evaluated factors influencing choice of survey modality. We defined unusable data for a particular survey domain as answering fewer than 75% of the questions in the domain. We then compared ACASI and SAQ with respect to unusable data for domains that address sensitive topics.ResultsOf 758 enrolled ED patients, 218 (29%) chose ACASI, 343 chose SAQ (45%) and 197 (26%) opted not to complete either. Results of the log-binomial regression indicated that older (RR = 1.08 per decade) and less educated participants (RR = 1.25) were more likely to choose SAQ over ACASI. ACASI yielded substantially less unusable data than SAQ.ConclusionsIn the ED setting there may be a tradeoff between increased participation with SAQ versus better data quality with ACASI. Future studies of novel approaches to maximize the use of ACASI in the ED setting are needed.

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Purpose:Smartphone technology offers a multitude of applications (apps) that provide a wide range of functions for healthcare professionals. Medical trainees are early adopters of this technology, but how they use smartphones in clinical care remains unclear. Our objective was to further characterize smartphone use by medical trainees at two United States academic institutions, as well as their prior training in the clinical use of smartphones.Methods:In 2014, we surveyed 347 internal medicine and emergency medicine resident physicians at the University of Utah and Brigham and Women’s Hospital about their smartphone use and prior training experiences. Scores (0%–100%) were calculated to assess the frequency of their use of general features (email, text) and patient-specific apps, and the results were compared according to resident level and program using the Mann-Whitney U-test.Results:A total of 184 residents responded (response rate, 53.0%). The average score for using general features, 14.4/20 (72.2%) was significantly higher than the average score for using patient-specific features and apps, 14.1/44 (33.0%, P<0.001). The average scores for the use of general features, were significantly higher for year 3–4 residents, 15.0/20 (75.1%) than year 1–2 residents, 14.1/20 (70.5%, P=0.035), and for internal medicine residents, 14.9/20 (74.6%) in comparison to emergency medicine residents, 12.9/20 (64.3%, P= 0.001). The average score reflecting the use of patient-specific apps was significantly higher for year 3–4 residents, 16.1/44 (36.5%) than for year 1–2 residents, 13.7/44 (31.1%; P=0.044). Only 21.7% of respondents had received prior training in clinical smartphone use.Conclusion:Residents used smartphones for general features more frequently than for patient-specific features, but patient-specific use increased with training. Few residents have received prior training in the clinical use of smartphones.

Given the discrepancy between men and women's equal rates of medical school matriculation and their rates of academic promotion and leadership role acquisition, the need to provide mentorship and education to women in academic medicine is becoming increasingly recognized. Numerous large-scale programs have been developed to provide support and resources for women's enrichment and retention in academic medicine. Analyses of contributory factors to the aforementioned discrepancy commonly cite insufficient mentoring and role modeling as well as challenges with organizational navigation. Since residency training has been shown to be a critical juncture for making the decision to pursue an academic career, there is a need for innovative and tailored educational and mentorship programs targeting residents. Acknowledging residents' competing demands, we designed a program to provide easily accessible mentorship and contact with role models for our trainees at the departmental and institutional levels. We believe that this is an important step towards encouraging women's pursuit of academic careers. Our model may be useful to other emergency medicine residencies looking to provide such opportunities for their women residents. RÉSUMÉCompte tenu de l'écart qui existe entre les hommes et les femmes en ce qui concerne l'égalité des taux d'inscription dans les écoles de médecine mais l'inégalité des taux de promotion et de nomination à des rôles de direction, la nécessité d'offrir du mentorat et de la formation aux femmes en médecine universitaire s'impose de plus en plus. De nombreux programmes appliqués à grande échelle ont été élaborés afin de fournir du soutien et des ressources aux femmes en vue de leur perfectionnement et de leur maintien en médecine universitaire. Sont souvent invoqués, dans les analyses des facteurs qui jouent un rôle dans cet écart, le manque de mentorat et de modèles de rôle ainsi que les difficultés de s'y retrouver dans les organisations. Des études ayant démontré que la résidence constituait une étape cruciale dans la poursuite d'une carrière universitaire, il est nécessaire d'avoir des programmes novateurs et adaptés de formation et de mentorat, qui ciblent les résidentes. Reconnaissant les demandes concurrentielles des résidentes, les auteurs ont élaboré un programme qui vise à offrir aux stagiaires des possibilités de mentorat et d'établissement de relations avec des modèles de rôle, et ce, tant au niveau du département qu'au niveau de l'établissement. Les auteurs croient qu'il s'agit là d'une étape importante afin d'inciter les femmes à poursuivre une carrière universitaire. Le modèle décrit ici peut se montrer utile dans d'autres programmes de résidence en médecine d'urgence en vue d'offrir aux résidentes ce genre de possibilités.