1. Using Nurses to Support Rapid ART Scale up in Zambia Mary Morris Nursing and QA/QC Coordinator Centre for Infectious Disease Research in Zambia (CIDRZ) University of Alabama at Birmingham Ministry of Health Zambia The University of Alabama at Birmingham

2. #1 Challenge: limited resources, unlimited patients

3. Lusaka 2,000,000 inhabitants Adult (15-49) HIV prevalence = 22% Prevalence among children ~ =6% Estimated number HIV-infected = 267,900

5. 267,900

7. The “ARVs in Vending Machines” Problem Zambian MOH reported clinical staffing levels in 2006: “slightly over 25%” (Partial) Solution: task shifting

8. Workforce Duties: Historical Initial consultation/clinical evaluation Ordering lab tests / radiology Assessment of ART eligibility Initial ART prescription Toxicity management Treatment failure management Referral to tertiary care Triage of returning patients Consultation for stable patients ART prescription refills Registration Phlebotomy Pharmacy dispensation Education and counseling adherence counseling Vitals, height, weight Doctors (MOs) Nurses Clinical Officers (COs)

9. Initial consultation/clinical evaluation Ordering lab tests / radiology Assessment of ART eligibility Initial ART prescription Toxicity management Treatment failure management Referral to tertiary care Triage of returning patients Consultation for stable patients ART prescription refills Registration Phlebotomy Pharmacy dispensation Education and counseling adherence counseling Vitals, height, weight Doctors (MOs) Nurses Clinical Officers (COs) Clinical Officers (COs) Nurses Peer Educators Workforce Duties: Revised

10. Advanced HIV nurse “triage training” Objectives: To train nurses to assist CO’s and MO’s in patient management To train nurses to care for stable patients on ART Evaluating new patients: Record the presenting complaint and take a patient history PMHx, Meds, ROS Draw screening labs Managing stable patients Review the chart to determine what routine labs, care, and counseling is required at each visit Interval histories Basic physical exam Order routine monitoring labs Maintain the ARV prescription Assess response to ART Assess for toxicities and clinical treatment failure Recognize and refer patients with abnormal findings

11. Triage training process 5 days of classroom-style didactics –Modification of IMAI training materials used with a combination of power point presentations, group work, and case studies. Pre and post tests –Those who score > 85% on post test progress to the clinical mentoring module

12. MondayTuesdayWednesdayThursdayFriday Chronic HIV care Eligibility for ART WHO Staging IMAI Acute Care Emergency care Cough/Difficulty breathing Review Headache/neurologica l problem Review Special considerations in children Disclosure Physical examination Vital signs and review of symptoms Anaemia/Undernutriti on Psychiatric problemsPediatric eligibility and prophylaxis Physical examination History taking, TB, Pregnancy, Family status Mouth examinationTreatment of common conditions Pediatric dosingPhysical examination ProphylaxisSTD and PIDSignificance of laboratory results Pediatric growth charts Post exposure prophylaxis ARV therapyFeverAdherencePCR testingPrevention ToxicitiesDiarrheaTreatment failurePregnant womenConfidentiality Skin problemsTreatment failurePregnant womenPost test and evaluation

13. Pre and Post test scores

14. Clinical Mentoring 1:1 Clinical mentoring with nurse trainers –Trained by Project HEART staff Minimum 100 hours –Most require 300 hours Must demonstrate competency –Clinical competency checklist

15. Checklist for Clinical ReviewPrePostComments Information to Review from the Chart Greet patient Check VS to ensure patient is stable. If not, refer to CO immediately Are latest labs recorded on summary sheet? If not, record. Are there any protocol labs that need to be ordered this visit? E.g. Has CD4 count been done in the past 6/12? Has HB been done in past 3/12 if on AZT? If anemia, is it treated? Are labs normal? If not, refer to CO and re-check Review CD4 counts and percentages. Does patient meet immunological or clinical failure criteria? Review problem list: Diabetes? Depression? Kidney Problems? Hepatitis? Review Patient Locator Form. Have children been tested? Review Current Medications and ARVs, including dosage and timing Review last three weights. Are they increasing or decreasing? If decreased by 2 kg and patient has other symptoms, refer to CO Review last clinical note to see if there is need for follow-up this visit Review Family Situation. Have children been tested for HIV?

16. Summary Nurses are a key component of the healthcare workforce General nursing training in Zambia does not teach patient management (or even physical examination) Most nurses need 3 months of intensive mentoring to become competent in caring for stable patients on ART Nurses can learn these skills, and once they do they do it well

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18. Clinical Officer HIV Training Training in adult HIV AIDS care (8 days) Training in pediatric HIV AIDS care (5 days) Clinical mentoring at dedicated training facility (3-4 weeks) Continuous mentoring conducted by MO’s –Rotating supervised clinical days –Weekly case conferences –Telephone and email consultation

19. Basic Nurse Training Adult and pediatric HIV and ART management –IMAI and patient management skills Counseling skills, psychosocial, referral, and adherence QA/QC Some go on to “triage training”

20. Peer Educators HIV-infected (mostly) members of the clinic community who work for the project Duties include –Group education –Counseling –Following up late patients –New: registering patients, vital signs

21. Task shifting in Lusaka Almost all ART care is provided by non-MD clinicians Clinical officers, nurses, and peer educators Optimal staffing for clinic with 3000 patients on ART –2 clinical officers, 5 nurses, 3 peer educators in AM –1 clinical officer, 3 nurses, and 2 peer educators in PM

22. Monitoring and Evaluation In order to monitor nurse managed care nurses record the PTID of all patients that they see. Mentors routinely review those files to assess the quality of care given. At present all nurses trained and their mentors are being assessed by a nurse practitioner from the US.

23. Staff trained 670 Nurses and Clinical Officers trained in adult HIV care and ART 340 Nurses and Clinical Officers trained in pediatric HIV care and ART 74 nurses trained in clinical “triage” –34 have completed mentoring program to manage stable patients on ART 28 peer educators have been trained in patient check-in / vital signs

25. Monitoring and Evaluation Quarterly performance reports generated for each site allow us to monitor trends in performance in each clinic. This can be attributed to improved knowledge and skills of nurses and improved data entry.