Hepatitis c screening and linkage to care in an urban emergency department

Background: The Emergency Department (ED) is a potential high-yield site in healthcare to reach patients at risk for hepatitis C virus (HCV) infection. HCV is the most common chronic bloodborne pathogen affecting almost 2% of the population in the United States. If the current rates of HCV identification remain constant, it is estimated the HCV-related morbidity and mortality will quadruple over the next decade. We report on a targeted, opt-out HCV screening and linkage-to-care (LTC) protocol implemented in an urban ED. Methods: In August 2018, we implemented an automated HCV screening protocol in the ED through the EPIC electronic medical record (EMR) system based on risk factors for HCV. Adults born from 1945 through 1965 and/or those with a history of intravenous drug abuse were included in the screening protocol. A best practice advisory (BPA) alerted providers to the protocol, prompting a HCV antibody (Ab) test for patients whom a complete blood count (CBC) was ordered. Blood was drawn in patients who authorized testing. Positive HCV Ab tests triggered an additional BPA, prompting a HCV ribonucleic acid (RNA) test. A LTC team was established to follow up positive HCV RNA patients until they attended their first visit with a hepatology clinic or another qualified provider to discuss their HCV infection. The data analysis is inclusive of data obtained between August 2018 through November 2018. Results: HCV Ab tests were performed on 3314 patients, an average of 829 per month, after implementing this automated EMR-based screening protocol. This is an increase of more than 11-fold compared to the average of 72 HCV Ab tests per month prior to implementation of the protocol. The HCV positive antibody rate was 11 %. Of the 366 positive HCV Ab tests, 176 had HCV RNA tests performed (48%). A total of 111 were confirmed positive for active HCV infection for an overall RNA positivity rate of 63%. A total of 49 patients with active HCV infection were linked to care (44)%. Conclusion: Targeted opt-out HCV testing can be successfully implemented in an ED setting. Reflexive HCV RNA testing for positive HCV Ab tests would likely improve LTC rates. EMR based HCV screening protocols can help identify active HCV infections and link patients to care. These protocols can potentially prevent one of the major causes of chronic liver disease and cirrhosis in the United States