Increased rates of rapid point-of-care HIV testing using patient care technicians to perform tests in the ED
American Journal of Emergency Medicine 32 (2014) 651-654
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: locate/ ajem
Brief Report
Increased rates of rapid point-of-care HIV testing using patient care technicians to perform tests in the ED
Daniel J. Egan, MD a,?, Jolene H. Nakao, MD, MPH b, Patricia M. VanLeer, MD b, Rituparna Pati, MD, MPH c,
Victoria L. Sharp, MD c, Dan E. Wiener, MD b
a Department of Emergency Medicine, NYU School of Medicine, New York, NY
b Department of Emergency Medicine, Mount Sinai St. Luke’s Hospital, Mount Sinai Roosevelt Hospital, New York, NY
c Department of Medicine, Mount Sinai St. Luke’s Hospital, Mount Sinai Roosevelt Hospital, New York, NY
a r t i c l e i n f o
Article history:
Received 18 September 2013
Received in revised form 20 November 2013 Accepted 21 November 2013
a b s t r a c t
Background: Various emergency department (ED) HIV testing models are reported in the literature but may not all be sustainable. We sought to determine whether changing an ED rapid HIV testing program from counselor-based to ED technician-based resulted in more testing.
Methods: We evaluated data from an ED rapid HIV testing program. Triage nurses offered testing to patients. In 2009, counselors performed rapid testing weekdays from 10:00 AM to 6:00 PM. In 2010, ED technicians were trained to perform the test and replaced counselors. We compared the numbers of tests performed during the same 6-month periods in 2009 and 2010. Study personnel abstracted results through medical record review.
Results: A total of 241 oral tests were performed in 2009 compared with 1483 in 2010, representing slightly more than a 6-fold increase. In 2010, there was a steady increase in testing month by month. Incorporating patient volume, testing rates increased from 1.3% to 8.1%. Oral testing yielded no positive test results in 2009, but 7 individuals (0.47%) tested newly positive during the testing period of 2010. Of those with a documented CD4 count within 100 days of the positive result, 4 of 5 had CD4 counts less than 200.
Conclusions: We present a novel approach to HIV testing using existing staff within the ED. This new ED technician-based model led to large increases in rates of testing.
(C) 2014
Introduction
In 2006, the Centers for Disease Control and Prevention formalized recommendations for opt-out HIV testing in all health care settings, including high prevalence settings such as emergency departments (EDs) in regions with a prevalence of undiagnosed HIV greater than or equal to 0.1% [1]. In 2007, the American College of Emergency Physicians supported this recommendation in a policy statement [2]. On September 1, 2010, New York State amended its HIV testing legislation, requiring all EDs to offer an HIV test to each patient between 13 and 64 years of age presenting for care. The new law also allowed the use of verbal rather than written informed consent in settings using rapid testing technology.
Numerous ED HIV testing models have been presented in the literature, including those requiring outside sources of funding and additional support staff. [3-8] The use of outside staff and the need for
* Corresponding author. Department of Emergency Medicine, 462 First Ave, Suite A345, New York, NY 10016.
E-mail address: [email protected] (D.J. Egan).
additional financial support may hinder the sustainability of testing when funding sources run out. In contrast, using internal resources and existing processes may remove barriers and increase rates of testing. The requirement and implementation of Screening tests in the ED can be challenging because practitioners are already pressured to treat multiple acutely ill patients in overcrowded departments. Models of testing that minimize barriers in the testing process and burdens on staff may be more sustainable. A systematic review of ED HIV testing models in the literature called for reports on outcomes of novel structured programs different from the traditional testing models already described [3].
The leadership team of the ED HIV testing program at St Luke’s Roosevelt Hospital Center (SLRHC), composed of stakeholders in both emergency and HIV medicine, met in late 2009 and began a planning process of replacing the traditional counselor-based HIV testing system with a new model using existing ED staff (ie, patient care technicians) to perform the point-of-care rapid oral HIV test. The change was motivated by low rates of testing in the ED. We compared the number of tests performed during a counselor-based model to the number performed with an ED technician-based model. To our knowledge, we present the first data in the literature on using ED technicians for Point-of-care testing.
http://dx.doi.org/10.1016/j.ajem.2013.11.051
652 D.J. Egan et al. / American Journal of Emergency Medicine 32 (2014) 651-654
Materials and methods
St Luke’s Roosevelt Hospital Center is a 2-site, university-affiliated hospital in Manhattan, New York City. We evaluated data from the St Luke’s site, a level 1 trauma center with an annual volume of 110000 patients and a primary training site of an emergency medicine residency program. HIV testing began at SLRHC in 2006.
We performed an observational study comparing the number of tests performed under the counselor-based testing model from March 1 through August 31, 2009, with the number performed under the newly instituted technician-based model from March 1 through August 31, 2010. We used the same 6-month period in each year to account for possible seasonal variation. Furthermore, we did not extend our comparison past this 6-month window given that verbal
400
350
Number of Tests
300
250
200
150
100
50
0
Absolute Number of HIV Tests by Month
Month
2009 Counselor-Based
2010 Technician-Based
rather than written informed consent was allowed in September 2010 with the modification of the HIV testing law in New York State, which would have confounded our analysis.
During both portions of the study period, triage nurses were instructed to offer an HIV test to patients presenting to the ED. As part of usual departmental protocol, triage nurses were scripted to ask, “Would you like a free HIV test?” upon patient triage. Tests were free because the kits were funded by a grant from the New York City Department of Health. When a patient responded “yes,” this response generated a flag in the electronic medical record. In 2009, that flag was recognized by the counselor stationed in an office adjacent to the ED. When the counselor arrived, he or she obtained written informed consent for testing from the patient and performed a point-of-care oral HIV test (Oraquick Advance Rapid HIV-1/2 Antibody Test; Orasure Technologies, Inc, Bethlehem, PA). An HIV counselor was present only from 10:00 AM until 6:00 PM Monday to Friday. Off-hours, clinicians followed the same consent procedure but sent blood samples to the laboratory for rapid testing.
With the change in testing model on February 1, 2010, the patient’s provider recognized the electronic medical record flag and obtained written consent from the patient, after which a technician conducted the rapid point-of-care test used by the counselors. All ED technicians were trained in oral point-of-care HIV testing by nursing leadership. grant funding that was previously used to support a counselor was applied toward hiring one additional ED technician for each shift that overlapped with the counselors’ previous schedule. The additional ED technician had the same duties as the others in the department: performing all ED point-of-care HIV testing, electrocar- diograms, urine pregnancy testing, point-of-care glucose testing, basic phlebotomy, and Patient transport. Although technicians and rapid HIV testing were available 24 hours a day in this new model, we evaluated data only from days and times during which a counselor would have been present (Monday through Friday, 10:00 AM-6:00 PM) in the previous model in order to allow for a parallel comparison.
Similar to the counselor’s schedule and availability of the 2009 model, social work support and post-test counseling for positive results was available on site through our Center for Comprehensive Care (CCC) HIV care center from 9:00 AM until 5:00 PM on weekdays. Therefore, there was no significant change in the total number of hours during which formal counseling was available between study periods. During off-hours, the ED provider delivered positive results, fulfilled the role of counselor, and referred the patient to the CCC the next business day.
During both study periods, social workers in the CCC used
Fig. 1. Absolute number of HIV tests performed by month during each study period, 2009 and 2010.
and analyzed using basic descriptive statistics. We used the z test to compare proportions. The institutional review board of SLRHC approved this study.
Results
A total of 241 HIV tests were performed in the 2009 study period compared with 1483 in 2010, representing a slightly more than 6-fold increase. In addition, throughout the 2010 testing period, there was a steady increase in testing month by month, with 110 tests conducted in March 2010 compared with 292 in August 2010 (Fig. 1). The number of patients aged 13 to 64 years presenting to the ED between the hours of 10:00 AM and 6:00 PM Monday through Friday during the 6-month study periods decreased from 2009 to 2010: 18627 visits in 2009 and 18383 in 2010. Hence, our testing rate increased from 1.3% (95% confidence interval, 1.1%-1.5%) of patient visits in the 2009 study period to 8.1% (95% confidence interval, 7.7%-8.5%) in 2010, representing a statistically significant difference in proportion (P b .001; ? = .05). Furthermore, the proportion of patients testing during each month increased significantly between 2009 and 2010 for all 6 study months, with a P value less than .001 for all months (? = .05; Fig. 2). In August 2010, the final month of the study period, 9.3% of patients were tested. In both years, 60% of patients tested were female. Median age of testers was 29 years in 2009 and 31 years in 2010. Absolute numbers of tests increased dramatically from 2009 to 2010 in all age categories (Fig. 3). Oral testing yielded no positive test results in 2009, but 7 individuals (0.47%) tested newly positive during the observed period in 2010. Of those with a documented CD4 count within 100 days of the positive result, 4 of 5 had CD4 counts less than 200. Of the 2 individuals with no
HIV Tests as a Percentage of total ED visits by Month
Percent of visits with test performed
12%
10%
8%
6%
telephone outreach to newly positive patients who did not present 4% for follow-up to either confirm linkage-to-car at another location or 2% encourage follow-up at the CCC.
Investigators abstracted data from the daily electronic reports 0%
produced as part of the routine protocol of our HIV testing program. Number of ED visits was obtained by query of the ED Electronic
2009 Counselor-Based
2010 Technician-Based
Medical Record program (EmSTAT, Afoundria, Austin, TX). Data were entered into Microsoft Excel (Microsoft Corporation, Redmond, WA)
Fig. 2. HIV tests performed as a percentage of total ED visits by month during each study period, 2009 and 2010.
D.J. Egan et al. / American Journal of Emergency Medicine 32 (2014) 651-654 653
450
400
Number of Persons
350
300
250
200
150
100
50
0
<15
years
HIV Testing by Age
15-24 25-34 35-44 45-54 55-64 >=65
years years years years years years
Age
2009 Counselor-Based
2010 Technician-Based
in the ED, although this has yet to be seen, as reimbursement data have not yet been published in the literature.
Our program has shown that an HIV testing model using existing ED technicians is feasible. Although the data are beyond the scope of this article, our novel program is still functioning effectively as of September 2013, with even higher testing numbers than before. Our model did rely on the addition of an ED technician in order to assist in the performance of testing. Although this adds cost to the department, we propose that the benefits of increased testing, including earlier Diagnosis and referral to care, and a larger workforce for all elements of point-of-care testing in the ED warrant that additional financial line.
Our model does require the involvement of providers in the department to counsel patients who test HIV positive. Although this
Fig. 3. Absolute number of HIV tests performed by age during each study period, 2009 to 2010.
documented CD4 counts, 1 was from a city far outside SLRHC’s catchment area and, on telephone follow-up, confirmed that he was linked to care closer to home. The second individual did not have a record of follow-up at the CCC despite living in the catchment area of the hospital and so would be considered lost to follow-up.
Discussion
Emergency department technicians are present in virtually all EDs and typically perform point-of-care testing. At our institution, their responsibilities include performing electrocardiograms, point-of-care urine dips, point-of-care urine pregnancy testing, basic phlebotomy, and fingerstick glucose testing. When developing a plan for remodel- ing our HIV testing program, we proposed a logical expansion of the skill set of our technicians to include another point-of-care test, the oral rapid HIV test. Technicians are integral to the care of the ED patients and are also already members of ED care teams.
In our hospital, the original testing model used trained HIV counselors at the bedside after an offer of testing by the triage nurse. This model required providers or nurses to page the counselor who would respond to perform a test. When this model was replaced by ED technicians performing the test, the numbers of completed tests increased dramatically. Emergency department volume during the 10 AM TO 6 PM period was relatively unchanged during the period, with a slight decrease in the 2010 study period of 234 patients. A small decrease of total ED volume occurred between the years of less than 10 patients per day, and we do not suspect that a decreased volume made providers more inclined to complete testing. We believe that nurses and providers began to embrace the concept of HIV testing as more routine in the ED by creating a testing model using existing staff members and eliminating the additional duty of needing to page a counselor. We do not have qualitative data to definitely show change in attitude around the testing change.
The Centers for Disease Control and Prevention, American College of Emergency Physicians, and now the United States Preventive services Task Force all endorse Routine HIV testing. Outside regulatory agencies make suggestions and often mandates for clinical practice, yet do not necessarily supply the funds to carry out protocol change. New York State EDs experienced this challenge beginning in September 2010, when the state law mandated the offer of an HIV test to all patients aged 13 to 64 years presenting for care. Other studies have reported innovative testing mechanisms which often require the use of staff outside core ED members such public health associates, trained counselors, or research assistants [9-12]. Some models have demonstrated success with the use of video consents and triage kiosk machines [4,7,8]. Some have also evaluated a hybrid use of both existing and supplemental staff in the ED [5]. Many of these methodologies, however, require additional funds. Insurance compa- ny reimbursement for testing may ultimately help support HIV testing
additional duty may add time to an already limited patient encounter, the frequency with which positive test results occur in most EDs is quite low-0.47% in our 2010 study period-suggesting that the addition will likely be negligible overall [13-16]. Depending on the setting, providers may exhibit resistance to testing because of their own perceived barriers to a testing program [17,18]. The allowance in New York State of verbal rather than written consent, beginning immediately after our 2010 study period, has already shortened the time demand and increased the ease of HIV testing in EDs.
Limitations
Our data are limited to a single site with ED technicians routinely performing many point-of-care testing duties, and our results may not be generalizable to other settings. Some centers may not have universal technicians for all point-of-care testing and may use individualized staff for specific procedures (eg, electrocardiograms). A more detailed comparison between the individuals testing in 2009 and in 2010 is beyond of the scope of this work; however, such an analysis may provide further insight into the characteristics of who tests under each model. Our data are also limited to a short period and does not demonstrate definitive long-term sustainability, although the testing program remains robust. We were unable to present a longer period due to the change in testing legislation, which removed separate written informed consent in September, 2010, which streamlined testing even further with the allowance of verbal consent. Including data after this point would have added a confounder to interpretation of the rates of testing.
Conclusions
We present a novel approach to rapid HIV testing in the ED using technicians already present in the department. We demonstrated a significant increase in rates of testing in the same 6-month period in 2 consecutive calendar years not related to increases in patient volume. Emergency departments struggling to create sustainable testing models without excess staffing costs may consider this novel, acceptable, and feasible approach.
References
- Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55:1-17.
- HIV testing and screening in the emergency department. Ann Emerg Med 2007;50
Haukoos JS, White DAE, Lyons MS, Hopkins E, Calderon Y, Kalish B, et al. Operational methods of HIV testing in emergency departments: a systematic review. Ann Emerg Med 2011;58:S96-S103.
- Calderon Y, Haughey M, Bijur PE, Leider J, Moreno-Walton L, Torres S, et al. An educational HIV pretest counseling video program for off-hours testing in the emergency department. Ann Emerg Med 2006;48:21-7.
- Hsieh Y-H, Jung JJ, Shahan JB, Pollack HA, Hairston HS, Moring-Parris D, et al. Outcomes and cost analysis of 3 operational models for rapid HIV testing services in an academic inner-city emergency department. Ann Emerg Med 2011;58: S133-9.
654 D.J. Egan et al. / American Journal of Emergency Medicine 32 (2014) 651-654
Hutchinson AB, Farnham PG, Lyss SB, White DAE, Sansom SL, Branson BM. Emergency department HIV screening with rapid tests: a cost comparison of alternative models. AIDS Educ Prev 2011;23:58-69.
- Merchant RC, Clark MA, Mayer KH, Seage Iii GR, DeGruttola VG, Becker BM. Video as an effective method to deliver pretest information for rapid human immunodeficiency testing. Acad Emerg Med 2009;16:124-35.
- Haukoos JS, Hopkins E, Bender B, Al-Tayyib A, Long J, Harvey J, et al. Use of kiosks and patient understanding of opt-out and Opt-in consent for routine rapid human immunodeficiency virus screening in the emergency department. Acad Emerg Med 2012;19:287-93.
- Walensky RP, Reichmann WM, Arbelaez C, Wright E, Katz JN, Seage GR 3rd, et al. Counselor- versus provider-based HIV screening in the emergency department: results from the universal screening for HIV infection in the emergency room (USHER) randomized controlled trial. Ann Emerg Med 2011;58:S126-132.e1-4.
- Brown J, Shesser R, Simon G, Bahn M, Czarnogorski M, Kuo I, et al. Routine HIV screening in the emergency department using the new US Centers for Disease Control and Prevention Guidelines: results from a high-prevalence area. J Acquir Immune Defic Syndr 2007;46:395-401.
- Hoxhaj S, Davila JA, Modi P, Kachalia N, Malone K, Ruggerio MC, et al. Using nonrapid HIV technology for routine, opt-out HIV screening in a high-volume urban emergency department. Ann Emerg Med 2011;58:S79-84.
- Calderon Y, Leider J, Hailpern S, Haughey M, Ghosh R, Lombardi P, et al. A randomized control trial evaluating the educational effectiveness of a rapid HIV posttest counseling video. Sex Transm Dis 2009;36:207-10.
- Calderon Y, Leider J, Hailpern S, Chin R, Ghosh R, Fettig J, et al. High-volume rapid HIV testing in an urban emergency department. AIDS Patient Care STDS 2009;23:749-55.
- Christopoulos KA, Schackman BR, Lee G, Green RA, Morrison EAB. Results from a New York City emergency department rapid HIV testing program. J Acquir Immune Defic Syndr 2010;53:420-2.
- White DAE, Scribner AN, Schulden JD, Branson BM, Heffelfinger JD. Results of a rapid HIV screening and diagnostic testing program in an urban emergency department. Ann Emerg Med 2009;54:56-64.
- Haukoos JS, Hopkins E, Conroy AA, Silverman M, Byyny RL, Eisert S, et al. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA 2010;304:284-92.
- Arbelaez C, Wright EA, Losina E, Millen JC, Kimmel S, Dooley M, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med 2012;42:7-14.
- Chen JC, Goetz MB, Feld JE, Taylor A, Anaya H, Burgess J, et al. A provider participatory implementation model for HIV testing in an ED. Am J Emerg Med 2011;29:418-26.