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Critique of a ​Clinical Review Article --Facilitator’s Form

1. Which strategic objective is addressed by the clinical article topic?

2. Provide an introduction of why you chose this topic/article. Why or what is the unit
issue/practice issue that inspired you to choose this topic?

University of Colorado Health (UCH) emergency department has an existing HIV


screening process that is only utilized by the nursing staff during 40.3% of patient visits.
My unit specific, value added project revolves around rewording the screening questions,
re-educating the nursing staff, and, hopefully, increasing screening compliance. I chose
this article because the UCH screening process was modeled off of this study.
Additionally, they were able to screen 28,506 patients, finding 1,718 high risk patients,
testing 551 patients, and finding seven new diagnoses. In our first year, we screened
approximately 40.7% of all patients in the main emergency department and made 14 new
diagnoses with 13 successful linkages to care in the UCH HIV clinic. We have room for
improvement and an opportunity to screen more patients, potentially making more
diagnoses, and initiating early treatment.

a. Describe your literature searching process. Used CINAHL or PubMed or Other


database

Because this process is already in process and this study was the basis for the
screening process, I did not search for this particular article. Further literature
review to examine HIV screening in the ED, CDC guidelines, and Denver HIV
risk score was conducted via University of Colorado Health Sciences library
CINAHL/Ebsco host databases.

b. What is the Level of Evidence for ​this​​ article and/or where does this article fall in
the ​Colorado Patient-Center Inter-professional Evidenced-Based Practice Model​?

According to the leveling system from ​Evidenced-Based Practice in Nursing and


Healthcare: A Guide to Nest Practice ​(2nd ed.) (Melnyk & Fineout-Overholt,
2011), this study is level IV, evidence from well-designed case-control and cohort
studies. This article was based on a quasi-experimental, prospective, before and
after design, without randomization. The Oxford evidence-based medicine scale,
that addresses diagnostic based studies, rates this study as level 1b in that it was a

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cohort study (establishing risk factors and health outcomes), and was a clinical
decision rule tested within one clinical center (Howick, et al., 2011).

Within the Colorado patient-centered interprofessional evidence-based practice


model, the patient is the center of all decision making. When reviewing valid and
current research, early recognition and treatment has shown to improve outcomes
and decrease cost of care (Centers for Disease Control and Prevention [CDC],
2018). This study moves evidence into practice by evaluating ​cost effectiveness
via reduced number of tests required in the targeted phase versus the non-targeted
phase. Additionally, this study exemplifies utilization of ​risk data​ by categorizing
and assigning values to each risk characteristic (men who have sex with men and
injection drug use) as well as epidemiologic factors (age, racial/ethnic minority
populations).

3. Identify the quality of the references cited within the article.


a. Are they within 5 years of the date of publication? Yes - X No - ☐
Does that matter for this topic? Yes - X No - ☐
b. Evaluate the ​Colorado Model of Patient Centered EBP​ and or ​Level of Evidence
of the references. Are the articles listed in the references lower levels of evidence
or are there level 1 and 2 articles cited?

Most of the reference articles are level I, based on meta-analysis of all


relevant randomized controlled trials (RTC) to create nationwide CDC and White
House guidelines and and goals of treatment and diagnosis. There was one
surveillance study and one cost analysis that did not clearly fit into the provided
levels of evidence. There is one level II: evidence obtained from a well designed,
randomized RTC. There is one level VII: evidence based on the opinion of
authorities and/or reports of expert committees. There is one level IV: evidence
from well-designed case-control study.

c. Are there other references from professional organizations that establish


guidelines such as, but not limited to, AHRQ, CDC, international standards,
ANA, AORN, and ONS? Identify these sources on the ​Colorado Model of Patient
Centered EBP​.

CDC guidelines are referenced multiple times. This article also utilizes the
White House Office of National AIDS policy, national HIV/AIDS strategy for the
United States. Within these articles American Academy of HIV (AAHIV) and the

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Agency for Healthcare Research and Quality (AHRQ) are referenced. Within the
Colorado patient-centered interprofessional EBP model, these guidelines fall
under mentorship (quality improvement and risk data), organizational support
(based on international, national, and local standards), facilitation, and leadership
(cost-effective analysis).

4. Evaluate the readability of the article. Does it keep your attention and the content flow in
an orderly fashion?

This article is very readable and flows between sections easily. As is the case with
most studies, the results section is dry, however the authors clearly state the limitations
and outcome goals. Additionally, the discussion section is robust including previous data,
national guidelines, and a succinct conclusion.

5. Discuss the relevance of this article to your practice, unit, unit leadership, or profession.
Include inter-professional considerations, if applicable.

My unit based project is to increase the population of emergency department


patients who are screened using the HIV screening tool, thereby increasing new
diagnoses and linkages to care. The screening questions originally were based on this
study.
I plan to rearrange the screening questions from least invasive to most invasive, as
they were asked in the original article. I am also proposing a rewording of the questions,
a re-education of the nurses, and the addition of linkage to outpatient care for PrEP
prescription and counseling for those patients who screen HIV negative but are
considered to engage in high risk behaviors. This article will help to educate our nurses
about the potential positive consequences of these questions and the basis for why we
implemented them.
Interprofessional considerations include the physicians, the social work team, and
the outpatient HIV linkage to care team, as well as, the new addition of the outpatient
PrEP team. Because this is a nurse driven protocol, the HIV test can be ordered via
pathway, without the attending. However, the attendings do need to be notified and are
included in disclosing HIV positive results to the patient. The social work team is
involved if the patient is diagnosed after-hours. The outpatient teams are already involved
and invested in this program.

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6. Identify any limitations to the article. Discuss how this impacts your impression of the
article content.

A limitation of this article is that it only covers a four month period. We have
been screening patients for approximately 16 months and have had 15 linkages to care.
Additionally, because the hospital studied started this program greater than 8 years ago, a
follow up study would be helpful for other emergency departments to evaluate long term
follow up, financial, and CD4 outcomes. This does not discount from the original content
but looks forward to follow up studies and outcomes.

7. Provide a one paragraph written summary of the article content.

In the article, Comparison of Enhanced Targeted Rapid HIV Screening Using the
Denver HIV Risk Score to Non-targeted Rapid HIV screening in the Emergency
Department (Haukoos, et al., 2015), a clinical prediction tool was utilized to identify high
risk HIV patients (based on history of intravenous drug use, sexual practices, age,
ethnicity) for testing. This was compared to a nontargeted, pre study, HIV screening
where all patients in the ED between the ages of 13 and 65, who were clinically stable,
were “opt-in” consent to HIV testing.
The primary outcome of the study was comparing how many confirmed HIV
diagnoses per those tested were made in the ED in the two different groups. Secondary
outcomes included CD4 count at time of diagnosis, viral load at time of diagnosis, and
successful linkage into medical care. Though the same number of HIV positive patients
were identified, there were significantly less test run, leading to a decrease in cost.

8. Describe how this article impacts your practice or unit: define a measurable outcome for
costs, patient outcomes, LOS, pain score, cost, or others.

Again, this article was chosen because it was the basis for the initiation of the
Denver HIV Risk Score with targeting testing in the University of Colorado Health
Emergency Department. Because there has been low compliance in asking the questions
and screening the patients, there is a missed opportunity for early diagnosis and treatment
of at-risk patients. The measurable outcomes include increasing the percentage of patients
who are asked the risk score questions by educating the nursing, physician, and social
services teams about the potential positive outcomes. While the cost to the unit will not
be an outcome measured after this journal club or after implementation of my unit based
project, multiple CDC, AAHIV and AHRQ resources have shown that early detection
and treatment of HIV leads to decreased costs and decreased morbidity and mortality.

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References

Centers for Disease Control and Prevention (CDC)(2018). ​HIV.​ retrieved from:
https://www.cdc.gov/hiv/

Haukoos, J., Hopkin, E., Bender, B., Sasson, C., Al-Tayyib, A., & Thrub, M. (2013). ​Comparison
of Enhanced Targeted Rapid HIV Screening Using the Denver HIV Risk Score to Nontargeted Rapid HIV
screening in the Emergency Department. ​Annals of Emergency Medicine,​ 2013, 61(3): 353-361.

Howick, J., Chalmers, I., Glaszious, P., Greenhalgh, T., Heneghan, C., Liberati, A., … Thornton,
H. (2011). The 2011 Oxford CEBM Levels of Evidence (Introductory Document). ​Oxford
Center for Evidence-Based Medicine. R ​ etreived from:
http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford

Melnyk, B. & Fineout-Overholt, E. (2011). ​Evidence-based practice in nursing & healthcare: a


guide to best practice. ​Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

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