Baseline Assessment of Nurses’ Experiences and Attitudes regarding Expanded HIV Testing in the Emergency Department at LIJ November 2014 Jenny Doyle,NSLIJ Bruce Rapkin, Albert Einstein College of Medicine 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 offer HIV testing is offered by triage RN or primary RN as well as provider (documented in EHR) Pre-test communication NYS DOH ‘Say Yes to the HIV Test’ poster in English and Spanish Consent procedureOpt-in, verbal consent Testing assay Alere Determine 4 th gen rapid Negative resultsNegative results given by Provider or Nurse. If results not provided when in ED, patient can call or return to ED for results. Positive results Preliminary positive results are disclosed by Provider or referred to internal HIV services Provider gives referral to DAC

Methods Einstein and NSLIJ designed a 9 question survey 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 Never Weekends Works Weekends Completed Survey 626 Incomplete Survey 19 26% of those who work some weekend shifts returned incomplete surveys as opposed to 14% of those who never work weekends.

Rates of Non-Response by Shift Never Works Overnights Works Overnights Completed Survey 248 Incomplete Survey 64 33% of those who work overnight shifts returned an incomplete survey as opposed to 20% of those who never work an overnight shift.

How Nurses Communicate Information about HIV to Patients What do you generally say when you provide patients with information about HIV?: “As part of our policy we are mandated to offer HIV documentation on why should you be tested. We are mandated to offer it to anyone between the ages of if you decide to be test it after reading the material please speak to the MD or the nurse who will care for you.” “Do you want to be tested for HIV we must ask everyone?” “NY state is offering free HIV testing for all patients. Would you like to take advantage of this service?” “Its the law we must ask. ” “We offer free HIV tests, would you like to take one?”

How Nurses Communicate Information about HIV to Patients, Continued The majority of nurses are incorporating the HIV offer when providing the patients with the required information about the test – 3 noted that the physician is the one who offers the test How the offer is worded varies: – Some mention the test is “offered to everyone” or that it is mandated – Some mention the test is free – Some just do a general ask

ED Nurses’ Self-Reported Behavior Regarding Expanded HIV Testing How often do you…. All or Most Times RarelyNever Provide eligible patients with info about HIV 47% 9%14% Defer until Later 28% 12%40% Document info was provided when it was not 26% 23%19% Judge who to provide info to 21% 16%23% Triage/Primary nurses are required to provide patients with information about HIV.

Differences in providing info about HIV by ED Shift Nurses who work morning shifts are significantly more likely to: – Provide eligible patients with information about HIV – Document that HIV information was provided when it was not discussed Nurses who work overnight shifts are less likely to: – Provide eligible patients with information about HIV – Document that HIV information was provided when it was not discussed

Additional Barriers Identified by Nurses  Procedural Issues  The way the staff present the question to the patient  Blood is drawn before doctors asks about HIV testing  Incorporating into existing work flow  Getting providers and patients to believe that the testing is necessary and incorporate into their routine  The test itself can be inconvenient and disrupt work flow

Additional Barriers Identified by Nurses, Continued  Patient Acuity  Patients are sometimes very agitated and psychotic – these patients are unable to be consented for HIV testing  Patient is too critical/altered/unconscious to consent  Patient Resistance  Patients are scared, embarrassed  Patient does not see need for testing  “I don’t need THAT, why would you think I have it”

How Barriers Affect EHT in the ED If results will not be available during off hours, nurses are more likely to use their judgment to determine who should be provided information about HIV

Who Should Provide the Patient with Information about HIV?

EHT and Roles in the ED Perceptions of who should provide the patient with information about HIV are not directly associated with staff behavior around providing the required information

Perceptions of Leadership Nurses were more likely to provide eligible patients with information about HIV if they perceive the following as committed to EHT: – Hospital Administration – ED Administration – ED Nurses Perception of ED Physicians commitment is not directly associated with staff behavior around providing information about HIV

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 26%14% Consents Needed for HIV Testing 26%9% Who to contact if patients request testing 35%12% The follow up process if patients test HIV+ 14%37% Answer questions about HIV/AIDS 21%5% Answer questions about the testing process 30%9% Talk to high risk adult patients about testing 35%7% Talk to parents about testing their child 23%26%

Knowledge of Expanded HIV Testing Nurses are more likely to provide patients with information about HIV if the feel : – Knowledgeable about NYS requirements for routine testing in the ED – Confident in their ability to talk to adult patients who are high risk When nurses feel confident in their ability to talk to parents/guardians, they are more likely to document that information was provided when it was not When nurses feel confident in their ability to discuss HIV/AIDS symptoms, they are more likely to defer providing information and return to it at a later point in time

Mode of Communication and Knowledge/Confidence Nurses are more likely to report feeling adequately informed about changes in department or institutional policies when they receive information via: – Updated policy manuals – notices Nurses who receive information about changes in policies via are more likely to report feeling confident/knowledgeable regarding: – NYS requirements for routine testing – What consents are needed for HIV testing – Who to contact if the patient requests HIV testing

Mode of Communication and Staff Behavior Mode of communication is not directly associated with staff behavior around providing the required information

Potential Areas for Action Areas to highlight for LIJ P&I Team: Should the “HIV offer” script be formally standardized? How can we ensure that the offer is really happening? Will strategies need to differ by shift? How can the top 3 self-reported barriers be addressed? Perception of administrative leadership is related to staff behavior – how can this be leveraged? 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?