Bring EPT to Your ED
This process can be complicated, but if planned well can create a steam-lined protocol that will make doing the right thing to do, the easy thing to do.
Implementing EPT is a big step that EDs can take towards advancing health equity. Because EPT involved treating a the partner who was not a patient in your ED, figuring out specific pathways to institute will take a multidisciplinary team with clinicians, administration, legal, nursing, pharmacy, informatics, faculty, residents all coming together to figure out what can work at your site.
Potential EPT Workflows
Every ED will find a local answer to what works best for allocating tasks to accomplish EPT. Here are some suggested samples.
Teach Your Colleagues
Help educate your colleagues and potential prescribers by asking for time during your next EM department meetings for a 10 minute presentation on EPT. Please check with your health department and hospital guidelines to modify this slideshow as appropriate to your local setting.
Engage your colleagues
Meet with key stakeholders (medical directors, nursing, pharmacy, EHR builders, informatics officers, hospital legal counsel) to determine what orders and policies work best for your group.
For patients identified as positive in follow-up, work with your medical director and follow-up office (nurse/ PA/ NP/pharmacists) to create straightforward protocols for offering EPT once lab-confirmed.
Unfortunately, EPT is not a process that will happen on its own in the ED. But by learning about EPT and becoming a departmental champion, you can take the critical first step in moving EM closer towards improving the sexual and reproductive health of our patients.
Talk with your Medical Directors
Medical Directors and key informants in emergency departments shared perspectives on facilitators and barriers to EPT. Generally, public health and protecting vulnerable populations was acknowledged as core to the EM mission, however, numerous barriers caused hesitation. These barriers included stigma, awareness issues, competing demands, medicolegal liability, and concern for patient safety. Departmental champions and clear delineation of task responsibilities through team-based care could help to overcome these challenges.
Public Health: Emergency medicine has a complicated relationship with public health
EM supports vital access
"We're kind of the glue that pulls together this broken fragmented system. If the patient doesn't have a place where they can go to receive one's care and it's kind of a one off thing, they land in an urgent care center or emergency department. So it's really important for us to think about how to provide comprehensive care in that context, and comprehensive care would include EPT."
STI are not an EM problem
"No one goes into emergency medicine to stamp out STIs"
ED are sentinels for Infectious diseases
“I think this [COVID crisis] is a serious canary in the coal mine, we should really be paying more attention to pandemics and infectious diseases and trying to nip them in the bud when we have the opportunity to do so. And I think STIs are a great example of that."
Stigma: Cultural stigma around sex causes emergency medicine providers to avoid discussion of sexual health.
Providers are uncomfortable with sexual health topics
"I'd say there's cultural discomfort with talking about sexuality and there can be jokes and exaggerations. "I had to click that three partners thing five times."
Patients are embarassed to discuss sexual health
"70% of people who come to the emergency department come with this guise like, "I think I have an STI." They whisper it to you when you walk into their room, the door is closed."
Process gap: Awareness of new EPT pathways is challenging but can be overcome by streamlined processes
Necessary details present roadblocks to full understanding
"I don't know even know how you'd call in an EPT prescription... Then if you print it, how do you get it to the patient? Do you have to mail it? Do you write a prescription? We don't even have prescription pads anymore ...,
Processes cannot be burdensome given competing demands
"It was more about, "is it easy for me to do?" Like, "I agree with this, but if it takes me 10 minutes to figure out on a shift, I'm not going to do it."
Division of labor facilitates task completion
"The pharmacy team in Epic, we get all the culture results and we review them kind of continuously throughout the day. That's part of our protocol we work usually with the APPs to do the prescriptions and follow up and stuff like that."
Ambiguity of fiduciary relationship: Non-traditional care process presents medicolegal, safety, and EMR concerns
Perception of incomplete liability protection
"We're not well-protected. Even if the litigation goes nowhere, the fact is if you get sued, it takes a good 40 to 60 hours of your time."
Patient situations may lead to concern for intimate partner violence
"Wait, are they going to tell my partner?" Because there are questions about infidelity and multiple partners, and it gets really, really complicated for safety. "
Empiric EPT may lead to over treatment
“I think there's this perception that it might compound diagnostic inaccuracy. So if you're making a judgment call for the patient in front of you, ...now you're asking that patient to distribute potentially to partners that you don't feel as confident about."
EMR system is harder to change than it seems
"We've learned that nothing in Epic is easy I'll just be like, "No, I just need this, " and he's like, "You don't understand, that is like 40 hours of work for someone to do,"
Champions can be effective in overcoming EPT barriers through leadership, institutional longevity and bandwidth
Organizational hierarchies can create bottlenecks to system change
"I'm just a cog in the wheel. I'm a medical director, I have a chair, we have a vice chair… I have influence but not authority and that's just the way it is."
Champions are more effective if focus is narrow
"Medical directors are terrible champions often unless they're truly passionate about stuff, and most have too many competing priorities to be passionate about any specific thing."
Power to change processes is tied to role
"Well, yeah. I mean, a lot of it is a role. You're right, like being a leader, having a leadership role in the department, and in the system, is helpful in that we can champion these really important causes"
For more details of a qualitative study regarding EPT medication kit design:
McBride K, Goldsworthy RC, Fortenberry JD. Formative design and evaluation of patient-delivered partner therapy informational materials and packaging. Sex Transm Infect. 2009;85(2):150-155. doi:10.1136/sti.2008.033746
Consider take-home EPT medications
According to the 2015 CDC STD Guidelines, medications in hand are preferrable to prescription EPT.
"Providing patients with appropriately packaged medication is the preferred approach to PDPT because data on the efficacy of PDPT using prescriptions is limited and many persons do not fill the prescriptions given to them by a sex partner. Medication or prescriptions provided for PDPT should be accompanied by treatment instructions, appropriate warnings about taking medications (if the partner is pregnant or has an allergy to the medication), general health counseling, and a statement advising that partners seek medical evaluation for any symptoms of STD, particularly PID."