Key Players

Who needs to be on board to implement HIV testing in the ED?

Emergency department leadership and staff are clearly essential to the HIV testing team, but working relationships outside and inside the hospital are critical, too. These will ensure adequate resources, organizational capacity, and linkage-to-care processes that can make or break a successful program.

Here we identify many players you might approach and suggest their potential contributions and concerns. Once engaged, your essential players must come to consensus on objectives, operations, and indicators of success. An early goal must be to identify and address their practical and political concerns and clearly define their roles and responsibilities.

Emergency Department

Leadership

Emergency department leaders are the clinical and administrative directors of the ED. These include medical chiefs, formal and informal physician and nurse leaders, administrative directors, and residency and fellowship directors. ED leaders can create a supportive environment for HIV testing. They can champion the effort among hospital administrators and ED staff. They can elicit buy-in among staff who would be responsible for the program and help secure human resources to oversee and execute the program.  ED leaders, particularly in high-prevalence settings, have acknowledged that knowing a patient's HIV status can promote accurate diagnosis and treatment of patients in the ED. These leaders are concerned with  increased burden on their staff and the disruption of service flow in the ED. Piloting HIV testing on a small scale will help demonstrate the likely effect (or lack thereof) of HIV testing on ED operations.

Clinical Staff

Clinical staff could perform some or all aspects of HIV testing. While many would favor knowing their patients' HIV status, in practice, they might give HIV testing low priority because of the patient's presenting condition and history or because they are simply too busy. Clinical staff may be concerned about the time required for informed consent and counseling, especially when the ED is overburdened and understaffed. They might more readily support a parallel, nonintrusive testing service in the ED rather than incorporating testing into routine care.

Registration and Triage

These staff can be the patients' first point-of-contact for HIV testing in the ED by providing information, offering the test to patients, or taking specimens in triage. Registration and triage staff can be an integral component of the program when the goal is universal testing. They can build awareness and create the expectation among patients that they can get tested and get their results. Of course, registration and triage can be chaotic environments. Additional responsibilities for HIV testing may be perceived as an increased burden on staff. See Operational Flow for more information on how to use registration and triage staff.

Laboratory

Support from the hospital laboratory director is critical. If the tests are performed at the point of care, the lab director's role may be pure oversight, depending on who in the ED is monitoring quality and performance.

At a minimum, lab directors are concerned about and legally responsible for proper test administration and interpretation of test results, so they will need to work with the ED to establish procedures for performing the test, storing test kits, and assuring quality.

Some labs may prefer to run all tests from the lab, requiring additional staff resources as well as expedited processes for delivering results in a timely manner. Tests that are not run through the lab or overseen by the lab are not recorded in patients' medical records; this has implications for the clinical use of results and perhaps for ongoing tracking.

Health Department

State and local HIV/AIDS directors and their staffs are key partners in the planning, development and ongoing support of ED-based HIV testing. They are interested in how to best allocate scarce HIV testing resources and must balance competing interests and politics.

Initiator

In many places, the health department has initiated the discussion with hospital leaders. They present the opportunity for HIV testing and its potential impact on identifying patients with unknown HIV, improving care for that patient at that ED visit, and presenting the opportunity for earlier care outside the ED for HIV-infected patients. They can also provide data to help inform decision making regarding implementation of HIV testing efforts, including the specific models or approaches that might be most appropriate to the population and/or prevalence.

An important part of this early discussion is cueing in to the ED's concerns that may present barriers. Questions to drive this discussion may include:

• What are the ED's specific concerns about introducing routine HIV testing? These concerns may include consent and counseling requirements, burden of ED staff, interruptions in patient flow, and costs.   
• What needs to happen to address those concerns? Sometimes the answer is as simple as clarifying any consent and counseling requirements or presenting the evidence on feasibility and cost. Or you may need a pilot test to demonstrate impact.
• What is essential to the program design if it is going to work in this ED?
• Who in the hospital would support this program? Who in the hospital would oppose it? Why?

Funding

Funding is the most direct way a health department can help launch HIV testing in an ED. While funding can open the door, though its not always available or sustainable. In addition to direct funding, health departments can help incubate a program by:

• Funding a pilot program in the ED, which may demonstrate to other potential funders the feasability and possible results of HIV testing in that ED
• Funding the incremental cost of developing the program, such as  salary support for hospital staff to develop a program and find alternative funding
• Working with the hospital to identify other sources of funding and resources, including local and private, that may be more sustainable over time

Technical Assistance

Health departments can provide nonfinancial support through technical assistance and capacity-building efforts; this includes:

• Free or low-cost rapid test kits
• Laboratory services for confirmatory tests and other tests such as CD4 and viral loads
• Assistance in interpreting public health codes in such areas as consent and counseling requirements
• HIV counseling training for ED staff
• Training for ED staff in administering HIV tests
• Training in and use of information systems to collect and track data from the program
• Placing HIV counselors in the ED to provide testing and counseling
• Equipment, such as mobile carts
• Partner notification and referral services
• Referral resources
• Disease intervention services, such as patient follow-up and tracking
• Providing data to inform decision making about whether it is sensible to implement programs and, if so, which model might be most productive
• Assistance and support in linking with other community resources
• Identifying models and approaches to operationalize HIV testing
  

Infectious Disease and HIV Services

While the patients may learn their HIV status in an emergency department, they cannot receive their ongoing care there. Infectious disease and HIV services (either in the hospital or thourgh a community-based specialty care clinic) can pick up where the ED stops. The HIV or ID clinic located at or affiliated with the hospital will be where most HIV-infected patients are referred. The clinic will facilitate patients' ongoing primary and specialty care, as well as provide critical linkages to needed social and mental health services, both hospital and community-based. 

Chiefs and staff of the hospital's infectious disease department and affiliated clinics need to be at the table early in order to lay out the process for linking HIV-infected patients to systems of care. One concern for the clinic may be having adequate resources to meet increased demand for services.

HIV Counseling and Testing Services

The hospital's infectious disease department may offer HIV counseling,  testing and referral (CTR) services either in the hospital or at a free-standing or dedicated clinic. They may have trained counselors that can support testing in the ED, either by staffing the testing program or by providing post-test counseling and facilitating the linkage-to-care component. Possible issues with the hospital's HIV CTR include limited operating hours and limited resources the ED and CTR programs may be tapping into the same pool of funding for HIV testing.

Other Hospital Players

Administration

Hospital administration can facilitate the securing of equipment and resources for HIV testing. Administration is primarily concerned with unfunded activities and the impact of HIV testing on ED operations. Explore reimbursement and funding possibilities as part of your initial strategy to gain administration buy-in. 

Academic Research

Some long-running programs were conceived and implemented as projects of the research department.  In other cases, the hospital's research department can provide technical support and oversight in developing systems to collect and analyze program data.  Researchers may also have an interest developing manuscripts for publication based on results from HIV testing in the hospital's ED. This would contribute more broadly to the limited evidence base for ED-based testing.

Risk Management

Risk management ensures that hospital policies and procedures comply with laws and standards of care. They are an important resource that can advise the creation of policy and process. Risk management may err on the side of caution to protect the hospital from liability. Informed consent, counseling, divulging preliminary positive test results, getting test results to patients, and partner notification and follow-up may be sensitive issues for risk managers. Work with your risk managers and health department for information and clarification on the legal issues.

Community-based Organizations

CBOs provide an array of services targeted to special populations in the communities they serve and provide well-known, trusted resources to their communities. They can complement and enhance hospital-based services with constituent-tailored services and can meet the specific and longer-term care needs of patients with HIV.  When competition for HIV testing funding is a concern, hospitals and CBOs may explore opportunities together to leverage these scarce resources. For example, they may enter into a contractual arrangement to share or deploy a pool of testing staff to their respective sites. 

Resources

• The Collaboration Primer: Proven Strategies, Considerations and Tools to Get You Started (PDF)
  G. Williams Torres and F.S. Margolin of the Health Research and Educational Trust
• Making HIV Testing a Routine Part of Medical Care: The State Health Agency Role, February 2005 (PDF)
  Issue Report from the Association of State and Territorial Health Officials
• Prevention for Negatives Collaboration Program Agreement (PDF)
  Example of a formal process agreement between the hospital and community-based agencies for HIV testing, counseling, and referral services. University of Medicine & Dentistry of New Jersey
• HIV Testing in Emergency Departments: A Primer on Issues and Strategies for Health Departments (PDF)
  A primer on issues and strategies for health departments from the National Alliance of State and Territorial AIDS Directors