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Operational Flow: When in the visit?
The time to test during a visit depends on staff availability and informed consent requirements. Generally, there are five points in the ED visit during which HIV testing can take place in whole or in part. For the broadest reach, HIV testing should be available at multiple points of contact during the visit, and multiple personnel should be accountable for their roles in the HIV testing process. Testing should be available 24 hours a day, seven days a week. When this is not feasible, aim to offer testing when patient volume is high, such as afternoons and evenings and weekends. Below we describe examples of implementation of HIV testing at triage, at registration, in waiting areas, at bedside, and at discharge. Each description includes a discussion of potential concerns or operational challenges. Where possible, we provide strategies to address challenges.
Triage
Ambulatory patients will first meet with a triage nurse, who conducts a general intake of chief complaint, vital signs, and some medical history. This initial point of contact provides the opportunity to:
- Inform the patient that an HIV test will be made available at that visit;
- Provide pretest information and obtain consent;
- Document in the chart than an HIV test is accepted or declined;
- Take the specimen when taking other vital signs.
Operational Concerns. Lengthy informed consent or activities outside the scope of what is typically done at triage risks creating a bottleneck in patient flow. Streamlined pretest information processes, such as using informational handouts, and opt-out testing may minimize the time the triage nurse spends on HIV testing. For more information, go to Informed Consent.
top of this pageRegistrar
Patients will sign in with the registrar either before or after seeing the triage nurse. Registration can best serve as an opportunity to inform patients of the availability of HIV testing during their visit. For example:
- The registration clerk can be responsible for informing patients of the availability of an HIV test during their ED visit.
- If patients would like an HIV test, they notify the registration clerk to note in their chart.
- Signage or HIV test brochures can be made available at the registration desk. These materials might include:
- Tear-out informed consent forms that a patient signs and gives to the person administering the HIV test.
- A card that patients may hand to providers to "silently" indicate they would like a test.
Operational Concerns. Registration can see high volumes of patients at a time, so registration staff are limited in terms of how much time they can spend conveying information to patients about HIV testing. The information they provide should be easily presented, such as brochures, signage, or handouts. Registration staff should be included in educational sessions on the rationale and processes for testing in the ED so they are able to answer or direct any questions that patients may have about HIV in general and the testing process at the facility specifically.
top of this pageWaiting Room
The waiting room presents an opportunity both to convey information about HIV testing and to actually conduct the test. Patients can spend a significant amount of time in the ED waiting to see a provider; in this sense they may be a "captive audience" for HIV testing. If separate signed informed consent is required for HIV testing, take advantage of patients' waiting time to provide pretest information.
Conveying information about HIV testing in the waiting room may include:
- Signage and brochures such as:
- Tear-out informed consent forms that a patient signs and gives to the person administering the HIV test
- A card that patients may hand to providers to "silently" indicate they would like a test
- Rolling video or kiosks to provide the information necessary for informed consent
Operational Concerns. Testing patients in the waiting room entails the availability of staff and space. Potential solutions include:
- Setting up an outpost in the ED waiting room for counseling and testing staff from the hospital, the public health department, or community-based organizations to obtain informed consent, take specimens, run tests, and deliver results
- Dedicating ED staff dedicated to offering and administering HIV tests which may include a rotation of nurses, physician's assistants, or dedicated counselors
- Finding a quiet space for a chair and a curtain to ensure privacy. This approach would need to mitigate the perception that this is the HIV area.
Testing in the waiting room will also require a protocol for completing the testing process with patients who are called in for treatment while they are being tested.
top of this pageBedside
Patients may be tested for HIV by a provider or a counselor at the time they are being treated for their chief complaint. This can be implemented in a number of ways:
- The provider (nurse or physician) offers the test to the patient and takes the specimen.
- The provider refers the patient for HIV testing and a counselor administers the test.
- The counselor approaches the patient for HIV testing in between the provider's treatment.
Ideally, patients will have been informed of the availability of HIV testing prior to being approached by a provider or a counselor at bedside.
Operational Concerns. The priority at the provider encounter will be treating the patient's chief complaint. If the provider is the primary source for offering and administering the test, it may not happen when workloads are heavy. If additional counseling staff are used, they will need to communicate with the provider about when to see the patient. Both ED staff and counselors will need to negotiate rules for when counselors can approach patients during their treatment in the ED. In addition, it is challenging to ensure privacy when beds are separated only by curtains. Some counselors report that using low voices and standing in close proximity to the patient is sufficient to ensure privacy.
top of this pageDischarge
The major opportunity at discharge is ensuring that patients that were tested received the results of their test. Anecdotally, after a long ED visit, patients are unwilling to stay additional time for an HIV test. The lesson learned is to take advantage of patients' waiting time.
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