Automated Opt-Out Hepatitis C Testing to Reduce Missed Screening Opportunities in the Emergency Department

Sperring H, Ruiz-Mercado G, Yun BJ, Twitchell D, Shah B, Schechter-Perkins EM. Automated Opt-Out Hepatitis C Testing to Reduce Missed Screening Opportunities in the Emergency Department. Am J Public Health. 2024;114(11):1228-1231. doi:10.2105/AJPH.2024.307783

This study evaluated the impact of implementing automated opt-out hepatitis C (HCV) screening in the emergency department of an urban academic medical center, compared to a previous opt-in model. Over a nine-month period, HCV testing increased by 502%, and the identification of active HCV infections rose by 212%. The increase in testing likely included more patients without traditional risk factors, but overall more cases were detected. The study also found that linking patients to outpatient care improved after the opt-out intervention, from 21.1% to 27.5%. Opt-out screening was effective in reducing missed opportunities for diagnosing HCV, easing clinician workload, and helping patients access necessary treatment. The study suggests that EDs should consider opt-out HCV screening models, but also highlights the importance of ensuring adequate resources for follow-up care, as treatment gaps still exist, especially in Medicaid and commercially insured populations

Identifying Data:

26YOF

Date & Time of Encounter: 10/14/24 1430

Chief Complaint: RUQ pain x 4 days

HPI:

26YOF G4P1 w/ no PMH, s/p CSD x1 (2023); presents c/o RUQ pain x 4 days. Pt reports constant, non-radiating RUQ “pressure” with intermittent sharp pain that is provoked by eating. Pt states pain is 9/10 severity at worst but 7/10 at time of this interview. Pt is also reporting constipation and more frequent belching since onset of symptoms. She notes h/o constipation and reports taking psyllium at home without relief. She is able to pass gas normally and reports normal appetite, last oral intake was lunch today at about 2pm. Denies N/V/D, blood in stool, fever, urinary symptoms, CP, SOB. LMP 9/29/24. Endorses positive family history of gallbladder disease, states her mother is s/p cholecystectomy.

Past Medical History:

Present illnesses – Denies

Past medical illnesses – Denies

Childhood illnesses – Denies

Immunizations – Up to date, including annual covid and flu

Screening tests and results – Last annual 4/2024. G4P1, Pt sees gyn for routine pap screenings.

Past Surgical History:

CSD 2023, uncomplicated

Past injuries or transfusions

Denies

Medications:

Denies

Allergies:

Denies

Family History:

Father: alive, HTN and DMT2

Mother: alive, s/p cholecystectomy

Denies known family history of cancer

Social History:

Pt is married and lives with her husband and child. She works as a school teacher.

She is a non-smoker. Reports alcohol intake socially, ~1-2 drinks per week.

Denies recent travel.

Reports a well-balanced diet with daily fruits and vegetables. 

Reports moderately active lifestyle, exercising at least 30 minutes 3-4 days/week

Reports sexual activity with her husband only. 

ROS:

• General/Constitutional:
  • Denies fever, diminished appetite, fatigue.  
• HEENT:
  • Denies ear pain, sinus congestion, sore throat. 
• Respiratory:
  • Denies wheezing, cough, sputum, shortness of breath.
• Genitourinary:
  • Denies painful urination, frequent urination, abnormal discharge.
• Gastrointestinal:
  • Reports RUQ abdominal pain, frequent belching, and constipation. Denies diarrhea, nausea, vomiting. 
• Skin:
  • Denies pain, warmth, erythema.
• Cardiovascular:
  • Denies chest pain, dyspnea on exertion, palpitations.
• Musculoskeletal:
  • Denies arthralgias, myalgias, back pain.
• Neurologic:
  • Denies dizziness, headache. 
• Psychiatric:
  • Denies anxiety or depressed mood.

Physical:

Vitals: 

Temp: 98.0

HR: 95bpm

Oxygen sat %: 99% RA

RR: 16

Ht: 5ft 3in,

Wt: 138

BP: 102/70

Pain scale: 7/10

BMI: 24.44

General: 

Well-nourished, neatly groomed hispanic female, A&Ox4, that looks younger than her stated age, dressed appropriately for the weather. Pt appears slightly uncomfortable laying on her side in the ED bed.

Skin, Hair and Nails:

Skin is warm & moist, good turgor. No jaundice. No visible tattoos or markings.

Eyes:

Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white and non-icteric, cornea clear, conjunctiva pink.

Nose:

Symmetrical with no masses, lesions, deformities, or trauma. 

Neck:

Trachea midline. No masses, lesions, scars, or visible pulsations noted.

Lungs:

CTA B/L, no adventitious breath sounds

Heart:

Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4.  No splitting of S2 or friction rubs appreciated.

Abdomen:

Slightly distended, but soft. RUQ tender to palpation, Murphy’s sign is positive. Abdomen is otherwise nontender, no guarding or rebound noted. One well-healed horizontal surgical scar across the lower abdomen. Bowel sounds normoactive in all four quadrants. No striae or pulsations noted. No hepatosplenomegaly or CVA tenderness.

Assessment

26YOF G4P1 s/p CSD x1 (2023); presents c/o RUQ pain and constipation x 4 days. Pain is provoked by eating, Murphy’s sign is positive on exam; I suspect biliary tree disease. Pt endorses h/o chronic constipation, no LLQ tenderness on exam, so lower suspicion for SBO or diverticulitis. Pregnancy test negative, no lower abdominal/suprapubic tenderness, so low suspicion for gyn pathologies. 

DDx:

1. Cholelithiasis/Cholecystitis
2. Duodenal ulcers
3. Hepatitis
4. Bloating
5. SBO

Plan

-CBC

-CMP

-Lipase

-UA

-Urine HcG

-RUQ U/S

My recent site evaluation with Professor Mohamed was an enriching experience that underscored the importance of continuous learning and collaboration. During the session, I had the opportunity to learn about bifurcate uteruses through a fascinating case presented by my classmate Hannah. This case expanded my knowledge of reproductive anatomy and underscored the complexities we may encounter in various clinical settings.

I also presented my journal article on implementing opt-out hepatitis C virus (HCV) testing in the emergency department. Professor Mohamed expressed strong support for the article, noting its potential impact on patient outcomes. He even mentioned plans to share it at his next staff meeting, with hopes of advocating for opt-out HCV testing at the ED where he practices. It was incredibly rewarding to see my research have such a positive reception and to know it could influence future protocols to improve HCV detection and care.

This evaluation highlighted the value of bringing evidence-based practices into our rotations and the power of shared learning. Professor Mohamed’s feedback was encouraging and has motivated me to continue engaging with research that could have a real impact on patient care.

During my emergency medicine rotation, I gained valuable insight into the unique challenges and nuances of working in a fast-paced, high-acuity environment. This rotation allowed me to work alongside a variety of knowledgeable preceptors who were enthusiastic to show me their unique approach to managing acute conditions. Their varied styles and expertise helped me refine my clinical judgment, especially in the face of the unpredictable situations that occur in a community emergency department.

In addition to my preceptors, one of the most rewarding aspects of this experience was working interprofessionally with the dedicated nurses, administrative staff, and social workers who make up the emergency department team. I came to appreciate how essential collaboration is in emergency medicine, particularly when treating vulnerable populations. A highlight of this rotation was learning about the role of the engagement team, which provides tailored support for unhoused patients, addressing not only their immediate medical needs but also connecting them with long-term resources and care.

Additionally, I was fortunate to spend two weeks in the trauma/critical care department, where I had hands-on opportunities to perform a range of procedures. This experience not only strengthened my technical skills but also taught me the importance of clear communication and composure when working with critically ill patients. This reinforced the need to balance swift, effective intervention with compassion for patients and their families.

Overall, this rotation deepened my understanding of emergency medicine and the skills required to provide comprehensive care in challenging circumstances. I am grateful for the opportunity to have learned so much from a dedicated team and to have been part of such meaningful work.