Providers Offer HIV Testing to All Emergency Department Patients in an Inner City Hospital, Improving Access to Testing and Subsequent Care for High-Risk Populations

Problem Addressed

• Drawbacks of counselor-driven model: As part of a process developed to meet Centers for Disease Control and Prevention (CDC) and state HIV counseling requirements, Metropolitan Hospital Center in New York City historically employed an HIV counselor who circulated in the ED, asking select patients if they were interested in  HIV testing; then the counselor would administer an oral swab test and communicate the results to the patient. This relatively informal system did not ensure that all eligible patients were invited to take the test. In fact, evidence shows that testing strategies that focus only on patients in certain demographic groups or those with HIV-associated diseases fail to capture a significant number of infected patients.¹
• Unrealized benefits of routine testing, particularly in ED: The value of widespread HIV screening is widely acknowledged; in fact, in April 2009 the Infectious Disease Society of America and the American College of Physicians released a joint policy statement calling for universal opt-out HIV testing to routinize testing for all sexually active adults, pregnant women and at-risk newborns.² However, routine testing is still not offered in most hospitals, including in New York State.³ Demonstration projects promoting HIV screening in hospitals and EDs found that a high percentage of patients did not know they were infected; because these patients were rarely seeking HIV testing when screening was offered at these sites, many infections were identified earlier than they would have been.⁴ The CDC recommends that HIV screening should be conducted in health care settings where other diagnostic and screening tests are performed routinely, such as EDs.⁴ However, while EDs represent an excellent opportunity to increase the number of people who learn their HIV status, the potential of this setting remains largely untapped.⁵ According to a 2004 survey, only 57 percent of hospital EDs provided HIV tests (typically in cases of occupational exposure or at provider discretion), but routine HIV testing was negligible.⁶
• Populations at high risk of HIV are typically those who seek care in the ED: HIV disproportionately affects populations who may not have a regular source of care or have poor access to care; an estimated 45 percent of HIV-infected individuals lack health insurance, and 30 percent are covered by Medicaid. EDs, which treat large numbers of underinsured and uninsured individuals, may be the only source of care for many people with or at risk of HIV.⁶ Metropolitan Hospital Center caters to underserved, mostly minority communities in upper Manhattan and the south Bronx, with roughly 60 percent of patients being Hispanic and 35 percent African American. Low income, minority patients often have limited access to preventive care.  

Description of the Innovative Activity

• Inquiry about status and invitation to test: Patients can view an HIV testing video that plays continually in the ED waiting room. The ED triage nurse, prompted by a mandatory field in the EMR's nursing assessment form, asks all patients aged 13 years and older who are not having an acute health emergency if they know their HIV status. If not, they are invited to be tested via a blood draw during their visit to the ED. For those who agree, the triage nurse enters the order in the EMR and gives the patient literature on HIV and an informed consent form.
• Consent and counseling process: A registered nurse (RN) accesses the patient’s record electronically, receiving the testing order along with information about other medical care needs. The RN obtains the signed HIV test consent form (required by New York State law) and answers any questions the patient may have. If necessary, the RN can refer the patient to the HIV counselor on staff for additional counseling.
• Testing process: As a routine part of care, the RN draws the blood specimen, orders the HIV test online along with any other laboratory tests needed, and sends the specimen to the hospital’s stat laboratory. The laboratory technician processes the specimen and enters the result online, usually within 1 hour. The ED physician reads the test result online and receives a call from the laboratory technician if the result is positive.
• Posttest counseling: If test results are negative, the physician informs the patient of the result and provides and documents posttest counseling about HIV prevention. For those who test positive, the physician informs the patient of the test result, provides and documents posttest counseling about HIV, and refers the patient to the HIV counselor for more in-depth counseling, case management, confirmatory HIV testing, and treatment referrals.
• Automated prompts for repeat testing: The HIV questions are required fields in the EMR so a patient is asked at each ED visit if they know their status and if they would like to be tested.
• Cultural competent services: All HIV counselors and many nurses are bilingual (speaking English and Spanish), and some are trilingual. The hospital also uses a telephone interpretation service (available in 150 languages) and onsite medical translators when needed.
• Similar processes elsewhere in hospital: The hospital offers testing through similar programs in many other departments, including the medical and psychiatric inpatient units, primary care, family planning, prenatal care, labor and delivery, and dental medicine.

Contact the Innovator

Results

• Initial doubling in number of patients tested: Before the program, roughly 200 patients were tested monthly in the hospital's ED. During the first 2 months after implementation, this figure doubled to approximately 400.
• Sustained 50-percent increase: The average number of patients tested each month subsequently fell to 300, a level that has been maintained since the end of 2007. This drop is due to the fact that the ED treats many repeat patients who, thanks to the new process, have recently been tested and thus do not need a test at every visit.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining senior leadership support: The nurse-led, provider-driven model was discussed at the hospital’s HIV leadership meeting, a monthly gathering of the hospital CEO, medical director, HIV program director, and chiefs of all relevant service areas, including ED nursing. All participants agreed on the necessity of this program.
• Designing the new process: The director of ED nursing met with front-line ED staff to introduce the concept and obtain input. Nurses noted that they did not have time to perform the oral swab test and then monitor it for 20 minutes; as a result, the team agreed to add HIV analysis to blood tests, because most ED patients require a blood draw anyway. The director of ED nursing and front-line staff representatives designed the process whereby the triage nurse would introduce the HIV test to the patient, while the RN would obtain consent and draw the blood. The goal was to incorporate the process into existing workflows so that it would add only minimal additional time.
• Amending EMR: The EMR's nursing assessment form was adjusted by hospital information technology staff to prompt the ED triage nurse to inquire about HIV status and offer testing and to allow the RN to easily add HIV testing to the laboratory orders for blood testing.
• Training nurses: The HIV counseling staff provided informal training to the nurses regarding basic HIV counseling, including responses to frequently asked questions, so that nurses would be comfortable offering the test to patients, obtaining consent, and answering general questions.
• Attempting a “hybrid” model: At first, the hospital tried a hybrid model in which the counselor offered oral swab tests to patients during normal business hours, with use of the nurse-led model being offered at all other times. However, to maximize the number of patients offered testing and to provide a more consistent and less confusing work process for nurses, the nurse-led model was eventually adopted at all times.

Resources Used and Skills Needed

• Staffing: The new testing process requires no new staff, as existing nursing, laboratory, and counseling staff incorporate tasks into their daily routines. Counseling staff duties have shifted as a result of the program—as noted, they no longer invite patients to take the test and administer the rapid HIV test, but rather serve as a resource for nurses during the testing process and provide follow up services for patients who test positive.
• Costs: No new costs were incurred in the development or operation of this initiative.

Funding Sources

New York City Department of Health and Mental Hygiene

Getting Started with This Innovation

• Enlist leadership support: Hospital leaders can articulate the rationale for the new process and thus help secure buy-in from front-line staff.
• Maintain full-time HIV counselor to support ED nurses: ED nurses are typically very busy handling a myriad of care needs and thus may initially resist adding counseling responsibilities to their workloads. To overcome this resistance, emphasize that the HIV counselor is still on staff to serve patients who require more than minimal counseling needs. Nurses will be more comfortable if they know they can call on the counselor to handle patient questions and concerns.
• Hire for cultural competency: Nurses and counselors who speak the language and understand the needs of the population being served will be more likely to convince patients of the need for testing. 

Sustaining This Innovation

• Use automated systems to sustain compliance: Metropolitan Hospital Center’s EMR facilitates the testing process by incorporating prompts and automating test ordering. These automated systems help to ensure compliance over time.