Article

HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation

a b s t r a c t

Routine HIV testing in Primary care settings is now recommended in the United States. The US Department of Veterans Affairs has increased the number of patients tested for HIV, but overall HIV testing rates in VA remain low. A proven strategy for increasing such testing involves nurse-initiated HIV rapid testing (HIV RT). The purpose of this work was to use a mixed methodology approach to evaluate the 5-year sustainability of an intervention that implemented HIV RT in a VA emergency department setting in a large, urban VA medical center to reduce missed diagnostic and treatment opportunities in this vulnerable patient population. In- person semistructured interviews were conducted with providers and stakeholders. Interview notes were qualitatively coded for emerging themes. Quarterly testing rates were evaluated for a 5-year time span starting from the launch in July 2008. Findings indicate that HIV RT was sustained by the enthusiasm of 2 clinical champions who oversaw the registered nurses responsible for conducting the testing. The departure of the clinical champions was correlated with a substantial drop-off in testing. Findings also indicate potential strategies for improving sustainability including engaging senior leadership in the project, engaging line staff in the implementation planning from the start to increase ownership over the innovation, incorporating information into initial training explaining the importance of the innovation to quality patient care, providing ongoing training to maintain skills, and providing routine progress reports to staff to demonstrate the ongoing impact of their efforts.

Background

An estimated 20% of persons with HIV infection in the United States are unaware of their HIV serostatus, do not receive the necessary treatment, and may be unknowingly transmitting the disease to others [1]. In recent years, the Centers for Disease Control and Prevention and the American College of Physicians have recommendED shifting from risk-based HIV testing to once per lifetime Routine testing of all patients ages 13 years and older [2,3]. The US Department of Veterans Affairs (VA), the largest single provider of HIV services in the United States, has recently joined with these recommendations [4]. Even with the adoption of these recommendations, however, HIV testing in the VA is still relatively low [5,6].

* Corresponding author. Veterans Affairs West Los Angeles Healthcare Center, 11301 Wilshire Boulevard (111G), Building 500, Office 4681, Los Angeles, CA 90073. Tel.: +1 310 478 3711×48568, +1 818 809 6955 (Mobile); fax: +1 310 268 1928.

E-mail address: [email protected] (H. Knapp).

One strategy that has shown promise for increasing HIV testing in VA settings is the use of rapid testing administered by nurses, known as nurse-initiated HIV rapid testing (HIV RT). We have previously implemented HIV RT in traditional VA settings, including Primary care clinics [7,8].

To broaden the scope of our testing efforts within VA, we have also explored the potential for expanding HIV testing into nontraditional VA settings such as substance use disorder clinics where patients with high risk factors and potentially low access to primary care services may present [9]. In this same vein, we also implemented an HIV testing program in a VA emergency department (ED) setting [10]. A Quality Enhancement Research Initiative-HIV research and imple- mentation team was assembled consisting of 2 physicians, 1 registered nurse (RN), 2 PhD social scientists, and a health science research assistant, who then coordinated with an ED physician and ED nurse manager to derive a minimally obtrusive plan for introducing HIV RT into the ED. Emergency department nurses were trained to administer HIV RT. Considering that potential adverse effects of this intervention could not be fully anticipated, initially, nurses

http://dx.doi.org/10.1016/j.ajem.2014.04.043 0735-6757/

approached a random sample of approximately 10% of ED patients (those whose Social Security Numbers ended in 0) and offered the HIV RT. The only inclusion criterion was that patients had to be medically and psychologically stable enough to consent to HIV testing. Nurses administered the informed consent and test procedure, recorded the results in the patient’s electronic medical record, and verbally reported the test results to the patient’s physician, who would then provide the test results to the patient. After several weeks, when it was clear that this new procedure did not interfere with normal operations, the 10% rule was lifted, and all patients who had the capacity to give consent were offered testing.

During the first few months, the research assistant made twice- weekly visits to the ED to verify that there was an ample supply of test devices on hand and conferred with the nurses, verifying that tests were being administered per the established protocol. She also answered questions and recorded any feedback offered by the nurses. Monthly HIV testing rates were delivered to the ED leadership to provide feedback to staff highlighting their performance. After 6 months, the research team disbanded, enabling the ED leadership (ED champion physician and ED nurse manager) to take over the day- to-day operations of the implementation.

This effort was successful in integrating HIV RT into the ED setting on a regular basis. The purpose of the current project is to evaluate the 5-year sustainability of this effort.

Objective

The objective of this manuscript is to evaluate the long-term sustainability of a nurse-initiated HIV RT implementation in a VA ED in Los Angeles, CA, after training and 6 months of initial implementation support [10]. Quantitative testing rate data for the 5 years of this implementation are presented, followed by qualitative data gathered from staff interviews to contextualize the quantitative results.

Method

The researchers applied for and were granted institutional review board clearance to precede with the qualitative staff interviews using traditional confidentiality protocols. The researchers conferred with the ED stakeholders to discuss the rationale, goal of the research, and the specific interview questions; authorization and full support was given. The RN ED manager encouraged staff participation in the qualitative interviews and helped identify staff members who had a history of administering the HIV RT. Deidentified quantitative data detailing the ED HIV RT counts were gathered via database queries in computerized patient record system, per IRB authorization.

Staff interviews

We conducted individually administered semi-structured inter- views with eight ED staff members: the ED physician who served as the clinical champion throughout the project, the current ED nurse manager, and 6 RNs who perform HIV RT in the ED. Each interview lasted approximately 30 minutes.

The British National Health Service Sustainability Index (SI) model [11,12] was used as a guide to construct the semistructured interview questions. The SI model has been used extensively within the British National Health Service and has been used to assess sustainability potential of primary care mental health integration and mental health system redesign efforts within the Veterans Health Administration [13,14]. The SI model was also used in a previous evaluation by this team to assess the sustainability potential of HIV RT in a primary care clinic [15]. The SI is a quantitative rating scale covering 10 factors found to predict sustainability of new practices. See the Table for a list of factors. For each factor, the respondent is presented with 4 descriptive statements and chooses the statement that best describes

their change effort. Each statement corresponds to a numeric score with higher scores indicating better conditions for sustainability. A total score is calculated by adding all 10 factor scores together.

We chose to construct a qualitative interview for this study rather than using the quantitative scale as we were interested in more detailed descriptions of how the factors were operationalized for HIV RT in the hopes of developing actionable recommendations for other clinics. The interview was structured to cover 9 of the 10 factors of the SI. The factor “benefits beyond helping patients” was not covered as implementing HIV RT was not expected to “improve efficiency” or “make jobs easier” for the ED staff, although presumably, it may have had these effects for laboratory staff by decreasing the number of blood HIV tests that would otherwise have been run in the laboratory. The resulting interview was pilot tested for question clarity and to ensure that the targeted interview length of 60 minutes was not exceeded.

Detailed notes were taken during each interview. Content analysis was used to code participants’ responses into categories reflecting the SI factors and to identify illustrative quotes. For each SI factor, coded content was compared with the factor statements to determine how well the HIV RT implementation exemplified that factor. The Table lists the corresponding statement and whether the statement represents the highest possible rating, lowest possible rating, or a moderate rating (1 of the 2 intermediate statements).

Results

Quantitative HIV RT results

We queried our electronic medical record system to gather quarterly ED HIV RT figures spanning the first 5 years of this implementation (July 2008 to June 2013). Analyses revealed that a total of 2055 tests were conducted during this time frame with a quarterly mean of 102.75 (SD, 55.24). The bars (Fig.) represent the number of tests administered in each of the 20 quarters; the positive slope of the trend line (dotted) shows an average increase of 2.95 additional tests administered per quarter over the 5 years.

Qualitative interview results

Sustainability Index factors, the highest factor level attained by the HIV RT implementation, and illustrative quotes are presented in the Table.

The HIV RT implementation met the criteria for the highest level on only 2 SI factors: “credibility of benefits” and “fit with organiza- tion’s strategic aims and culture.” The staff felt that testing patients for HIV and communicating their test results to them had clear benefits of slowing the spread of the illness and getting patients into life- prolonging treatments. They also recognized the benefit of the HIV RT allowing them to communicate test results to patients in 20 minutes as they are able to allay patient’s fears and/or immediately order a confirmatory (Western blot) blood test as well as connecting them to treatment services. The staff felt that implementation of HIV RT fits with the strategic aims of their organization because of the recognized high risk level of their patient population. They also viewed themselves as a high-functioning team that is successful with quality-improvement efforts.

The HIV RT implementation was rated moderate on 4 of the SI factors: “staff attitudes toward sustaining the change,” “effectiveness of the system to monitor progress,” “clinical leadership engagement,” and “infrastructure for sustainability.” Although staff recognized the importance of HIV testing, they felt that they were simply mandated to do a specific number of tests per shift without having any input into how test administration would be integrated into their regular duties. Although it appears that there were monthly graphs available to clinic leadership to monitor HIV RT rates, this information was not communicated in any consistent or reliable manner to the staff, so

Table

Sustainability Index factors, highest factor level achieved, and illustrative quotes

SI factor Representative quotes Highest factor level achieved

Benefits beyond helping patients Not assessed by interview The change neither improves efficiency nor makes jobs easier. (Lowest)

Credibility of benefits “Treatment is essential. Lack of treatment leads to death. Also, they could be spreading to others and it’s not like you can tell (that they’re positive) by looking at them. Nobody here told me any of this, it’s just what I knew and already believed.”

“It’s good to be able to give a quick test if the patient is worried about something they did that might have put them at risk or if the patient knows that they’re at risk. It’s good because you can just swipe their mouth and let them know in 20 minutes and then talk to them about making some good decisions to help keep themselves healthy.”

Adaptability of the improvement process “We haven’t been doing it, it just slowed down,

then stopped.”

“Nobody’s training new staff, staff training stopped about 2-3 months ago.”

“The champion MD just recently departed so the staff is unsure if HIV RT is supposed to continue or not. (Training in place?) Yes, but I’m not sure how that works.”

Effectiveness of the system to monitor progress “The MD champion receives a monthly report and

distributes the report to the RN nurse manager.” “Occasionally, there’s a monthly report on the bulletin board, but it’s not there very reliably.” “There was one meeting with a graph. It would have been good to see outcomes more regularly to let us know if what we’re doing is really working.”

Staff involvement and training to sustain the process (Opinions values?) “No, they just gave it to us, they

never asked us. It’s just the RNs’ responsibility to do 5 tests per day. The charge RN just gave out the test to us and we knew we had to do one each per shift so we just did it.”

(Preparation?) “Nothing, just the training on how to do the HIV RT. We needed practice proposing HIV testing. It’s odd for the RN to do it, we weren’t sure

why we were doing it so what should I tell the patient?”

Staff attitudes toward sustaining the change “At the start it looked like extra work. It was okay

when things are slow but it’s hard to do 5 a day to keep the doctor away (referring to 5 per day quota). Now, it’s the same but we got used to it. It’s easy now, patients get excited about getting an HIV RT, they’re very enthusiastic about the test.”

“It was annoying at first, just an additional task to do. Also, the HIV RT was introduced at the same time as the rapid triponen test, but we got over it. Now we see the importance of HIV testing, so the attitude’s better. This just had to be done. It’s not an option, the supervisor said do it so we just made it happen. Over time, we got used to it.”

Senior leadership engagement “Executive administration did not express any opinion or encouragement one way or the other.” “No, we never even heard them talking about it, they’re still silent on this.”

(leadership support?) “I don’t recall seeing or feeling that. Only the people in the ER were encouraging, upper management never got involved with this. We just never heard anything from them.”

Clinical leadership engagement “Yes, my manager at the time had to roll it out so he had a vested interest, but his attitude was not really contagious. We just did what he said.”

“Yes, especially the lab, they’re very supportive. The lab made it important, accessible, easy to do, and emphasized cost effectiveness.”

“The new RN manager hardly ever mentions it. It’s not his baby, he wasn’t here when it got started, he’s only been here for about a year. He’s got other things to do.”

Fit with organization’s strategic aims and culture “Everyone cooperates with new processes. We

work as a team. It’s a good team here.”

“It’s a high priority because lots of patients are substance abusers or sexually active or might be embarrassed to go to a clinic for an STD test.” “HIV RT is more successful than most others

Benefits of the change are immediately obvious, supported by evidence and believed by stakeholders. (Highest)

The process is not able to adapt to other organizational changes, and there is no system for continually improving the process. (Lowest)

There is a system in place to identify evidence of progress and act on it, but the results are not communicated. (Moderate)

Staff have neither been involved from the beginning nor adequately trained to sustain the improved process. (Lowest)

Staff does not feel empowered by the change process but believes the improvement will be sustained. (Moderate)

Organizational leaders do not take responsibility for efforts to sustain the change process, and staff typically do not share information with or seek advice from leadership. (Lowest)

Clinical leaders take responsibility for the efforts to sustain the change process, but staff typically does not share information with or actively seek advice from the leader. (Moderate)

There is a history of successful sustainability, and improvement goals are consistent with the

organization’s strategic aims. (Highest)

Table (continued)

SI factor Representative quotes Highest factor level achieved (other implementation efforts) because it’s easy to do

when time is available. The problem is that when things are slow, there’s few patients to test and when things are very busy, we don’t have time to test anyone.”

Infrastructure for sustainability “You have to call the lab for them to bring the tests. Depends on when the lab brings them. They’re slow to respond and we don’t call them fast enough so it’s possible to just run low or run out. We used to take a look at how many were left every Friday and if it was low then we’d just call for a resupply but now nobody cares.”

“The charge RN used to hand out tests at the start of the shift and that doesn’t happen anymore. We check the crash-carts daily but the HIV RT checklist is gone. The HIV RT is only a day shift thing, but with low staffing and low priority for HIV RT, it just feel off.”

The level of staff, facilities, and equipment to sustain the change are not appropriate, although job descriptions, policies, procedures, and communication systems

are adequate. (Moderate)

they had no idea how well the implementation effort was functioning. Clinical leadership engagement appears to have been high on the part of the ED physician champion and the nurse manager; however, when these individuals left their positions and new leadership entered the clinic, the drive to sustain the testing was largely lost. The nurse manager had taken responsibility for making sure that RNs had test kits available and that established quotas were maintained. When management stopped providing this infrastructure on a regular basis, because the staff had never felt ownership over the testing initiative, they were happy to have 1 less task to complete as exemplified by the following quote: “Sometimes there are no kits for days at a time and everyone’s happy…oh, we don’t have to do it!”

The HIV RT implementation was rated low on 4 of the SI factors: “benefits beyond helping patients,” “staff involvement and training to sustain the process,” “adaptability of the improvement process,” and “senior leadership engagement.” Benefits beyond helping patients was not assessed by the interview and received a low rating because HIV RT was not expected to improve efficiency or make jobs easier for the ED clinic staff. Although staff felt they received good training in how to administer the HIV RT, they did not feel they received any training in how to approach patients regarding an HIV test, which caused them to feel less comfortable and more resistant to implementation. They also reported that they did not receive any routine ongoing training on HIV RT. The long-term success of this HIV RT implementation appeared to be highly dependent on 2 individuals (ED physician champion and ED nurse manager), and the implemen- tation was not able to adapt when they left. Because there was no senior leadership involvement, the implementation was left vulner- able to the loss of the clinical champions.

Fig. Registered nurse-administered HIV oral rapid testing in VA ED over 5 years (July 2008 to June 2013).

Conclusion

Given the relatively low overall rating on the SI, it is actually surprising that the implementation of HIV RT sustained as long as it did. It appears that the main factors supporting sustainability were the strong clinical champions and the mandate applied to the RNs. Once the clinical champions left the clinic and the mandate was no longer enforced, the staff was happy to allow HIV RT to lapse. Although the overall trend line of the quantitative test data remained positive, it is clear that the testing rate fell dramatically in the final 3 quarters of the assessment period. It is likely, given the results of the qualitative interviews, that further moni- toring would show a continued decline of testing rates.

The results for this ED contrast distinctly from the results of our previous evaluation of sustainability of HIV RT in a primary care clinic where sustainability potential was very high [15]. In contrast to the ED, the primary clinic interviews revealed that staff were involved in planning for the implementation process before implementation, staff understood the value of testing rather than viewing it as something they had to do because of a mandate, staff received substantial support and encouragement from senior leadership, processes were in place to ensure regular refresher training and training of new staff, systems were in place to communicate monitoring data to all clinic staff on a regular basis, and staff had consistent access to the equipment they needed to perform the tests.

An obvious limitation to the conclusions of this study as well as our previous study of sustainability of HIV RT in a primary care clinic is that each was conducted in 1 clinic and, therefore, represents a unique case study; the results of which may not be generalizable to other EDs or primary care clinics seeking to implement HIV RT. In addition, the staff members that agreed to participate in the interview may have opinions about the implementation of HIV RT, either more positive or more negative, that differ consistently from those that refused to be interviewed or did not respond to the interview request. Finally, we used the SI model to develop a qualitative interview rather than using the quantitative measure applied in previous studies. Although our desire to collect richer, more detailed information is a valid rationale for this approach, it limits the ability to compare our results with previous studies using the quantitative measure. In hindsight, it would have been desirable to collect both the quantitative SI ratings and the qualitative interview material.

Despite these limitations, we feel that the results of these 2 cases provide important lessons for sustainability of quality-improvement efforts. It is likely that HIV RT would have been more successfully maintained in the ED if more of the ingredients of sustainability had been incorporated into the implementation effort at the start. The

following suggestions may assist other clinics in building sustainability into their quality-improvement efforts:

  • Engage the line staff (in this case, the RNs) in the implementation planning from the start to increase ownership over the innovation rather than simply enforcing a mandate.
  • Incorporate specific information into initial training explaining why an innovation is important to the patients receiving care in the clinic.
  • Provide ongoing training to maintain enthusiasm for the innovation and maintain confidence in skills.
  • Provide routine progress reports to the line staff implementing the innovation to demonstrate to them the impact of their efforts.
  • Engage senior facility leadership in the project.

If, through these strategies, both the line staff and senior leadership develop a sense of commitment to and ownership over the innovation, chances of sustainability will likely be enhanced. For ED implementa- tion, these strategies would have provided “back up” for the enthusiasm of the clinical champions and increased the chances for continuity of the program when those champions left the clinic.

Appendix A. Greater Los Angeles VA ED – HIV RT Five Year Sustainability Interview Guide

(Briefing)

The Greater Los Angeles VA ED began offering nurse-administered HIV RT in July, 2008. The ED has continued to successfully conduct HIV RT over the past five years without any outside intervention. Our goal is to learn from you how this was accomplished, and publish the ingredients of your success story so that other facilities, both in- and outside the VA might be able to reproduce your methods to benefit patients at those sites.

(Staff Involvement – 1)

  • HIV rapid testing began in ED in July, 2008. When did you become involved in the HIV rapid testing program?
    • How were you involved?
  • Did you feel your opinions regarding the HIV rapid testing program were valued?
  • What was done to prepare for HIV rapid testing prior to the launch date (July, 2008)?
    • Looking back, is there anything that should have been done differently?
  • Did you feel that the training you received prior to implementation was adequate?
    • If not: What was missing? (Staff Attitude – 2)
  • What was your attitude toward the prospect of implementation HIV rapid testing when planning was just beginning?
  • How does that compare to your current attitude?
    • If any changes: What contributed to the change in your attitude? (Fit with Organization’s Strategic Aims and Culture – 1)
  • At the time of implementation, how high of a priority did you feel that HIV testing was for your facility?
  • Aside from HIV rapid testing, when it comes to attempting to implement new practices, how successful do you feel your facility or clinic is?
    • If applicable: Why do you think HIV rapid testing implementa- tion was more successful?

(Senior Leadership Engagement – 1)

  • Did you feel that senior leadership at your facility was supportive of implementation of HIV rapid testing?
    • If yes: How did they show their support?
    • If no: How did you know they were not?
  • Do you feel they are supportive of the program now?
    • If yes: How do they show their support?
    • If no: How do you know they are not? (Clinical Leadership Engagement – 1)
  • Did you feel that leadership in your clinic was supportive of implementation of HIV rapid testing?
    • If yes: How did they show their support?
    • If no: How did you know they were not?
  • Do you feel they are supportive of the program now?
    • If yes: How do they show their support?
    • If no: How do you know they are not? (Infrastructure for Sustainability – 2)
  • On a scale of 1-5 with 1 being not at all available and 5 being fully available, how available were the necessary resources (staff time, funding for test kits) for HIV rapid testing at the time of implementation?
    • If rated below 3: What was missing? How were necessary resources secured?
  • Using the same scale, how available are the necessary resources now?

(Credibility of Benefits – 3)

  • In your opinion, what are the benefits to patients (if any) of the HIV rapid testing program?
  • Did you recognize these benefits at the start of the program? (Adaptability of Improved Process – 2)
  • Since your involvement with HIV rapid testing began, can you think

of any changes that have been made in how the program runs?

    • If yes: Why were the changes made? Was it easy to make necessary changes?
  • How has the program maintained in the face of staff turnover?
  • Are there processes in place to ensure that new staff members are trained?

(Effectiveness of the System – 3)

  • Do you have procedures in place to monitor the program, for example, monitor the number of rapid tests performed each month?
    • If yes: How do you use this information? (Wrap Up)
  • Once HIV rapid testing got started, what was most helpful in keeping it going?
  • What got in the way or made it less convenient?
  • Based on your success here, suppose you were put in charge of implementing HIV rapid testing at a site that has never done it. What are the most important things they would need to do prior to launch?
  • What would they most need to know about maintaining HIV rapid testing over time?

That is the last of my questions. Do you have any questions for me before we end?

Thank you very much for taking the time to speak with me today. Your input will be very useful in assisting other clinics with implementing and sustaining HIV rapid testing programs.

References

  1. Centers for Disease Control and Prevention (United States). HIV surveillance– United States, 1981-2008. Morb Mortal Wkly Rep 2011;60:689-93.
  2. Centers for Disease Control and Prevention (United States). Revised recommen- dations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morb Mortal Wkly Rep 2006;55:1-17.
  3. Qaseem A, Snow V, Shekelle P, Hopkins R, Owens D. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med 2009;150:125-31.
  4. Veterans Health Administration. Testing for human immunodeficiency virus in Veterans Health Administration facilities; 2009 [Washington, DC].
  5. Halloran J, Czarnogorski M, Dursa E, et al. HIV testing in the US Department of Veterans Affairs, 2009-2010. Arch Intern Med 2012;172:61-2.
  6. Veterans Affairs Office of Clinical Public Health. HIV testing rates in VA 2009-2011;

    2012 [Washington, DC].

    Anaya HD, Bokhour B, Feld JE, Golden J, Asch SM, Knapp H. Implementing routine rapid HIV testing within the US Department of Veterans Affairs healthcare system. J Health Care Qual 2012;34(5):7-14.

  7. Anaya HD, Butler JN, Solomon JL, et al. Implementation of a nurse-initiated rapid HIV testing intervention at two high prevalence primary care sites within the US Department of Veterans Affairs healthcare system. J Sex Transm Dis 2013;40 (4):341-5.
  8. Conners EE, Hagedorn H, Butler J, et al. Implementation of HIV rapid testing in VA substance use disorder clinics. Int J STD AIDS 2012;23:799-805.
  9. Chen JC, Goetz MB, Feld JE, et al. A provider participatory implementation model for HIV testing in an ED. Am J Emerg Med 2011;29(4):418-26.
  10. Davies B, Tremblay D, Edwards N. Sustaining evidence based practice systems and measuring the impacts. In: Bick D, Graham ID, editors. Evaluating the Impact of Implementing Evidence Based Practice. Oxford: Wiley-Blackwell; 2010. p. 165-88.
  11. Mayer L, Gustafson D, Evans A. Sustainability. Leicester, England: British National Health Service Modernization Agency; 2004.
  12. Ford JH, Krahn D, Wise M, Oliver KA. Measuring sustainability within the Veterans Administration mental health system redesign initiative. Qual Manag Health Care 2011;20(4):263-79.
  13. Ford JH, Krahn D, Oliver KA, Kirchner J. Sustainability in primary care and mental health integration projects in Veterans Health Administration. Qual Manag Health Care 2012;21(4):240-51.
  14. In pressKnapp H, Hagedorn H, Anaya HD. A five-year self-sustainment analysis of nurse- administered HIV rapid testing in Veterans Affairs primary care. Int J STD AIDS 2014.

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