PEPSE* PRESCRIPTION IN THE EMERGENCY DEPARTMENT Dr Stephen Megarity Specialty Doctor Genitourinary Medicine RVH *Post exposure prophylaxis following sexual exposure

Aims of Project Analyse numbers and demographics of ED PEPSE prescription Assess adherence to BASHH guidelines - 2015 Identify and implement improvement strategies for PEPSE prescription in ED/Follow up of patients

Methods Retrospective case note review PEPSE prescription from 1 April 2015- 31 March 2016 in the Emergency Department - Royal Victoria Hospital, Belfast Use of Pharmacy records – PEP pack reorder forms ED Symphony System – Search criteria: “PEP, post-exposure prophylaxis, HIV prophylaxis, HIV, sexual assault, unprotected sex”

Data Collection 37 patient episodes identified in period between 1 April 2015 – 31 March 2016 PEP for other indications excluded – PEPSE only Case note review Identified 37 patient episodes using defined search criteria. May be an slight underestimation but should have collected the majority of prescriptions. Important to note that PEP for some indications was excluded – sexual assualt/occupational

Demographic information collected Age Postcode Time/Date of attendance Grade of Doctor Indication/Risk group HIV status of partner Sexually transmitted infections diagnosed While analysing data I thought it would be useful to identify the demographics of patients attending for PEPSE

Audible outcomes As per BASHH 2015 guidelines – Proportion of PEPSE patients having a baseline HIV test: aim 100% within 72 hours of presenting for PEPSE Proportion of PEPSE prescriptions that fit within recommended indications: aim 90% Proportion of PEPSE prescriptions administered within 24 hours of risk exposure: aim 90% Proportion of individuals completing 4-week course of PEPSE: aim 75% Proportion of individuals seeking PEPSE undergoing testing for STIs: aim 90% Proportion of individuals completing 8-12 week post-exposure HIV antibody/antigen test: aim 75%.

Patient demographics

Patient demographics 37 patients Mean age of 28.2 years (range 18-51) Male – 36 Patients (97%) Female – 1 Patient 84% of patients MSM

Address 2 patients - England Majority of patients from Greater Belfast area. 2 patients from England who were visiting. 2 patients - England

Day of Attendance With GU services closed Saturday and Sunday, the spike in attendance at the weekend is not unexpected. The increased attendance on Monday is in keeping with what we see in GUM.

Time of Attendance Again, a spike of patient episodes towards late afternoon/evening when GU services more difficult to assess. This is of course when ED starts to get busy with GP referrals/unwell patients backing up. The awareness and training of ED staff is therefore important to allow them to easily and accurately assess patients for PEP. This will allow a more efficient for PEP seeking patients as well as allowing the ED staff to attend to unwell patients also using their department.

0RAL/PROTECTED VAGINAL Indication DOCUMENTED TYPE OF SEX NUMBER RECEPTIVE 14 ANAL 10 INSERTIVE 4 VAGINAL ORAL 1 ORAL/PROTECTED ANAL 0RAL/PROTECTED VAGINAL UNABLE TO RECALL OTHER 28/37 for ‘anal sex’ Other – laceration to toe in Sauna

1 msm 2 csw 3 hiv contact 4 endemic country

12/37 claim an HIV positive contact

I thought this information would be useful to see what level of experience the ED doctor would have. Unfortunately most staff did not document their grade. Of those that did – majority were non consultant grade and quite junior staff. The majority of doctors there are f2 doctors - this is their 2nd year post graduate and likely first experience of PEP/ED.

Auditable Outcomes

HIV Test ? % Proportion of PEPSE patients having a baseline HIV test: -aim 100% within 72 hours of presenting for PEPSE HIV Test ? % YES* 81% (n=30) NO 19% (n=7) *3 Patients no baseline HIV test in ED but attended GUM within 72hours

Proportion of PEPSE prescriptions that fit within recommended indications: -aim 90% As Per Guidelines % YES 84% (n=31) NO 16% (n=6)

Proportion of PEPSE prescriptions administered within 24 hours of risk exposure: -aim 90%

Proportion of individuals completing 4-week course of PEPSE: -aim 75% Complete 4 weeks? % YES 59% (n=20) DNA 41% (n=14) EXCLUDED* 3 * 2 Outside NI/ 1 stopped in GUM

Proportion of individuals seeking PEPSE undergoing testing for STIs: -aim 90% Attend GUM % YES* 63% (n=22) NO 37% (n=13) OUTSIDE NI 2 *GUM attendance only - Some patients may have sought STI testing in Primary Care

Proportion of individuals seeking PEPSE undergoing testing for STIs: -aim 90% Attend GUM % YES* 63% (n=22) NO 37% (n=13) OUTSIDE NI 2 *GUM attendance only - Some patients may have sought STI testing in Primary Care

Proportion of individuals seeking PEPSE undergoing testing for STIs: -aim 90% Attend GUM YES* NO OUTSIDE NI STI? YES** 9% (n=2) NO 91% (n=20) **2 cases - GC *GUM attendance only - Some patients may have sought STI testing in Primary Care

Lost to Follow up This was interesting as I expected all those not attending for follow up would be from locations outside of Belfast.

Proportion of individuals completing 8-12 week post-exposure HIV antibody/antigen test: -aim 75%. Window HIV % YES 51% (n=18) NO 9% (n=3) DNA 40% (n=14) OUTSIDE NI 2

Areas For Improvement Baseline HIV testing PEPSE prescription meeting BHIVA indications Completing 4 week course STI testing Window HIV/BBV tests

Areas For Improvement Baseline HIV testing PEPSE prescription meeting BHIVA indications Completing 4 week course STI testing Window HIV/BBV tests

Areas For Improvement Baseline HIV testing PEPSE prescription meeting BHIVA indications Action ED Teaching sessions Introduction of PEP assessment proforma

Areas For Improvement Baseline HIV testing PEPSE prescription meeting BHIVA indications Completing 4 week course STI testing Window HIV/BBV tests

Areas For Improvement Baseline HIV testing PEPSE prescription meeting BHIVA indications Completing 4 week course STI testing Window HIV/BBV tests Action GUM follow up

Implementation (a) Action ED Teaching sessions Introduction of PEP assessment proforma ED Teaching sessions – 1st session provided October 2016 ED PEPSE proforma development – near completion In order to address these issues I have offered ED teaching sessions to target junior and middle grade staff. These will be most beneficial at staff changeover times. First session was delivered in October of this year. I am working with ED to finalise a PEPSE assessment proforma

This is a draft copy of the proforma This is a draft copy of the proforma. Main benefits are questions to prompt for info needed for accurate risk assessment. The checklist prior to dispensing PEP reminds the doctor of the baseline HIV testing/bloods and to prompt discussion about follow up

Implementation (b) Action GUM follow up Introduction of email referral system – e-referral with consent of patient Contacted within 72 hours for follow up to be arranged by Triage Nurse 6 month Pilot Scheme Improving attendance at GUM clinic following PEPSE presciption is important to allow STI testing/vaccine administration/education/full risk assessments. This group of patients, particularly those who frequency acquire PEP are patients we need to be seeing in GUM. To address the low GU attendance rates one of the ED consultants and myself worked together to decide what system would work best to improve follow up. Email referral systems seem to work well in ED with other specialties so we went down this line. An email account specifically for PEPSE follow up has been created and a system for offering patients appointment put in place in GUM. - 6 month pilot in first instance

Future Plans Continue and expand education programme with ED Implement ED PEP assessment proforma Audit in 2017 to assess pilot referral system Education of ED staff is an area that needs more attentions and I will continue to provide teaching for ED staff. Hopefully adherence to guidelines and baseline testing will be further improved with the proforma. PEPSE prescription will be audited in the new year to see if this quality improvement strategies have made a difference.

Acknowledgements BHSCT Pharmacy Department RVH Emergency Department