In its latest report on the incidence of sexually transmitted diseases (STDs), the CDC reported the number of cases reached an all-time high for a sixth consecutive year.
The agency indicated there were more than 2.5 million cases of chlamydia, gonorrhea, and syphilis reported in 2019. Further, the data show there was a 30% increase in reportable STD cases between 2015 and 2019.1
While STD clinics and primary care clinicians detect and treat many of these cases, there is no question EDs play an outsize role in caring for patients with STDs, particularly among disadvantaged populations. However, evidence suggests many EDs are not using all the tools at their disposal to facilitate treatment and curb transmission.
In particular, researchers note most EDs have not embraced expedited partner therapy (EPT), a practice that involves providing patients who have been diagnosed with an STD with prescriptions/treatment for their partners as well as themselves.
In one study, researchers found only 19% of academic EDs reported using EPT. Even when the option was available, many clinicians did not realize the practice was legal in their states.2 This was the case even though EPT is supported by the CDC as well as multiple professional organizations, including the American College of Emergency Physicians.3
Advocates of the approach stress this gap represents a clear opportunity for improvement in ED care, pointing to studies that show EPT is effective at both curbing the spread of STDs and preventing reinfection rates.4
Rachel Solnick, MS, MSC, a clinical lecturer in the department of emergency medicine at the University of Michigan, says EPT has existed for more than a decade, primarily in clinic and public health settings. She contends EDs should adopt the practice, considering the high number of patients presenting to EDs who could benefit from EPT.
However, she notes ED medical directors frequently cite the logistical complexity of implementing the practice as a barrier. “We all use electronic medical records now and that creates a little bit of a challenge in terms of how you actually write a prescription ... for someone who is not in the patient’s chart at all,” she explains.
Many states have worked around this problem by passing laws that allow clinicians to write a prescription even if the patient’s partner is not physically there. Other ED providers simply write the prescriptions for patients’ partners on paper. “There have been a number of workarounds, but more than those issues is just the fact that a lot of people don’t even know about EPT,” Solnick shares.
In the wake of COVID-19, with interest high in transmissible diseases, Solnick believes the timing is right for the emergency medicine community to adopt EPT, especially when it is explicitly legal in most states.5 “South Carolina was one of the last states in which [EPT] was prohibited, and it just changed that in the last few months.6 Now, in every state in the U.S., EPT is either likely permissible or it has specific laws supporting the practice,” Solnick shares.
For clinicians interested in learning about the potential for EPT in their EDs, Solnick advises bringing departmental leadership on board with the practice. Then, establish a clear written policy regarding EPT.
“People will be more supportive of [EPT] if they feel there is a policy that is supporting them,” Solnick suggests. “Having it written down as something that the ED does so that people don’t feel like they are going rogue when they are offering EPT would be very helpful.”
Some clinicians may find their systems already instituted a policy in support of EPT. That was Solnick’s experience when she came to the University of Michigan.
“I found that we actually had a policy here since 2016. It is just that we weren’t really aware because it wasn’t something that we were in the practice of doing,” she explains.
Since then, Solnick has delivered brief presentations about EPT and its importance to staff. “I think it is important for everybody to understand when a department adopts a policy,” she adds.
Experts note it is important for ED leaders to think creatively about how they can most effectively implement EPT. For instance, Gabrielle Jacknin, PharmD, BCPS, clinical specialist and lead pharmacist at the University of Colorado Hospital in Aurora, explains the EPT policy in place there is primarily driven through pharmacy services.
“When the providers see a patient that they decide to treat for an STD, they are able to offer partner prescriptions at that time and can physically write a prescription,” she explains. “We have a 24/7 physical pharmacy attached to our ED. They are able to write a prescription on a prescription pad and give it to the pharmacy with the patient’s information for the partner’s information or as an anonymous prescription without the partner’s information. Then, that can be picked up at the time of discharge.”
Usually, a positive STD result will flow into the inbox for the pharmacy group. The pharmacists will call the patients about the positive results.
“Then, the standard of care is to offer the partner prescriptions at that time,” Jacknin says. “The pharmacists are the ones who write the prescriptions, and about 50% to 60% of patients elect to have their partner treated.”
Jacknin says the ED sees about 110,000 patients a year, and the pharmacists receive seven to 10 positive STD cultures every day. That means there are many conversations happening about EPT.
Most partner prescriptions are paid for through Medicaid or a commercial insurer. When insurance is unavailable, the prescriptions are provided through a hospital program that provides certain medications to high-risk patients.
This approach to EPT removes any logistical burdens from the treating clinicians, and it is a natural extension of how many pharmacists are acting already.
“Pharmacists are calling patients with positive results in general, especially ED pharmacists. There is a precedent for this to be on their radar,” Jacknin says.
However, she acknowledges not all EDs maintain physical pharmacies on site. Providing the medicines to partners would need to follow a different pathway for those facilities.
Jacknin’s advice to other EDs interested in developing a similar approach is to start with a stakeholder meeting that includes whoever is handling the callbacks for STD results through the ED, a representative from the physician leadership group, and someone from pharmacy. Come equipped with the knowledge of what is required in terms of state laws and hospital regulations. Determine how to best execute EPT given the resources available.
Jacknin is unsure why more ED-based pharmacists have not branched into providing partner prescriptions for STDs, but it has worked well in the ED at the University of Colorado Hospital.
“It seemed like a very obvious step at our site, which is why we added it here,” she says. “We are fortunate to have a physical pharmacy here, too, so that made it very seamless for us to be able to prescribe.”
REFERENCES
- Centers for Disease Control and Prevention. Reported STDs reach all-time high for 6th consecutive year. April 13, 2021.
- Solnick R, Fleegler M, May L, Kocher K. Expedited partner therapy can stop sexually transmitted infections. ACEP Now. May 18, 2021.
- American College of Emergency Physicians. 2020 council resolutions.
- Ferreira A, Young T, Mathews C, et al. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev 2013;2013:CD002843.
- Centers for Disease Control and Prevention. Legal status of expedited partner therapy (EPT). Last updated April 2021.
- Centers for Disease Control and Prevention. Legal status of EPT in South Carolina. Status as of Feb. 1, 2021.
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