Baseline Assessment of Nurses’ Experiences and Attitudes regarding Expanded HIV Testing in the Emergency Department at Albany Medical Center November 2014 Lisa Sutton, Abigail Gallucci- Albany Medical Center Bruce Rapkin, Iliana Garcia -Albert Einstein College of Medicine

Summary of HIV Testing Process (at time of survey distribution) CharacteristicDescription Eligibility criteriaPatients years old, unless unable to consent or medically unstable HIV Test offerHIV testing offer was a mandatory part of the electronic nursing assessment. If the patient indicated that they had never been offered a test, then they were asked if they wanted to be tested for HIV during the ED visit and response was documented in the EMR* Pre-test communication Seven points of testing addressed by linkage specialist or provider* Consent procedureOpt-in, written consent* Testing assayDepending on staff availability either a rapid point of care test -or- a standard blood draw* Negative resultsPatients had to return to ED for results* Positive results Standard blood draw: Staff follow up with patient after ED visit and refer to HIV medicine for confirmatory testing* Rapid test: Staff follow up with patient during the ED visit and refer to HIV medicine for confirmatory testing* * NOTE: The above processes have been modified since distribution of the baseline survey

Methods Einstein and AMC designed questionnaire to assess staff attitudes, practices, and knowledge of EHT among nursing staff Survey was distributed to all ED nursing staff via survey monkey by the Nurse Manager Survey was open for a two week period All responses were anonymous Responses were analyzed using descriptive statistics, Pearson correlations, and verbatim feedback

*Shifts are not mutually exclusive

Rates of Non-Response by Shift Works WeekendsNever Weekends Completed Survey 2411 Returned Blank Survey % of respondents who sometimes work weekends did not complete the survey, compared with 8% of respondents who NEVER work Weekends

ED Nurses’ Self-Reported Behavior Regarding Expanded HIV Testing There is currently a question on the ED assessment that asks “Have you ever been offered an HIV test or been tested for HIV”: How often do you…. All or Most Times RarelyNever Ask at Intake37% 24%18% Defer until Later8% 32%22% Skip the Question25% 33%25% Do not Document3% 11%74% Judge who to Offer32% 14%32% Offer an HIV Test44% 14%16%

Differences in asking about EHT by ED Shift Nurses who work evenings or night shifts are significantly less likely to ask about HIV assessment upon intake. Nurses who work weekends on the day shift state that they are most likely to defer asking until a later time. Nurses who work weekends overnight neither ask nor defer the question. Nurses who work on many different shifts overall state that they are more likely to use their judgment to determine who should be asked.

Barriers to EHT Encountered in the ED

Additional Barriers Identified by Nurses Need for Training, Materials and Support – Trained personnel – information to hand out to patient – Paperwork can be confusing – clarity of which testing is done – Lack of education of providers Competing Demands – I'm dealing with patients’ other issues – Patients with very urgent/emergent issues

Procedural and Philosophical Problems Procedural Issues Extra forms to complete. Would be nice just to have the conversation with the person and order the test in the computer I don't want to have to arrange follow up Forgetting to ask Family Present in the ED Disagreement with EHT in the ED – Not all complaints require drawing blood, making for an additional patient stick – Not an emergency unless there is risk for recent exposure – not pertinent to visit, why should we provide everything

How Barriers Affect EHT in the ED Nurses are less likely to ask about EHT at intake and more likely to skip the question if: – They perceive the consent process is too time consuming – They are concerned testing may be costly to patients – They believe it takes too much time to make arrangements if someone tests positive – They are concerned about getting results in a reasonable time on weekends or evenings. Nurses who perceive lack of access to follow-up HIV/AIDS care are less likely to offer a test, even among patients who have never been tested.

Who Should Be Responsible for Asking About EHT in the ED?

EHT and Nurses’ Roles in the ED Nurses who believe that the triage nurse should be responsible for inquiring about EHT are more likely to skip the question at intake. Conversely, those who believe it is the responsibility of the primary nurse to inquire are less likely to skip the question and less likely to base inquiry on their judgment about who needs testing.

Perceptions of Leadership Nurses who perceive that the Emergency Department is committed to expanded HIV testing state that they are less likely to inquire about the test. Perceptions of Hospital Administration are not directly associated with staff behavior around HIV testing.

Staff Confidence in their Knowledge and Ability to Conduct EHT in the ED Knowledge about/Ability to… Very Confident Not Confident NYS requirements for HIV testing in the ED 35%24% Consents Needed for HIV Testing 32% Who to contact if patients request testing 32%18% The follow up process if patients test HIV+ 24%41% Answer questions about HIV/AIDS 47%6% Answer questions about the testing process 26%24% Talk to high risk adult patients about testing 44%9% Talk to parents about testing their child 21%35%

Knowledge of Expanded HIV Testing Nurses are more likely to ask about EHT, more likely to defer and less likely to skip if: – They feel confident in their knowledge about NYS testing requirements – They know what consents are needed for testing – They are aware who they need to contact if a patient does desire testing – They are confident that they can answer questions about HIV testing

Potential Areas for Action Areas to highlight for AMC P&I Team: Differences in staff practices emerged by shift. What could be driving that and how can it be addressed? Top 3 barriers related to procedural issues regarding time and resource required for EHT Perceptions of staff roles varied. How are roles being communicated and reinforced? Nurses report feeling least confident in the follow up protocol for preliminary positives and in their ability to talk to parents. How can this be addressed?