Assess Your Readiness

Purpose: This tool is designed to help you begin considering some of the major elements in launching an ED HIV testing program. We provide links relevant to sections in this guide for further information.

Engaging Key Stakeholders

Who needs to be on board?

Successfully implementing ED HIV testing requires that key players support the program, understand its need, and know how it will affect patient care in their daily practice. Factors that can help engage key stakeholders include:

• ED leaders support the effort.
• ED physician or leader champions the effort.
• Additional resources are provided, such as staff to conduct the testing or obtain funding.
• ED leadership and clinical staff have a public health orientation—that is, they see public health as part of their mission.
• Hospital CEO is aware of and supports the effort.
• HIV testing in the ED is part of a broader health improvement and prevention effort by the hospital or health system.
• Pilot tests are conducted to assess the idea and demonstrate impact.
• The ED serves a population that is at risk for HIV.

Factors that may make key stakeholders reluctant to support ED HIV testing include:

• Concerns about patient flow.
• Little awareness of the need and relevance of HIV testing in emergency medicine.
• Reliance on ED providers for most aspects of the testing process.
• Difficulty in demonstrating direct clinical benefit.
• Competing priorities in treating patients' chief complaints or other public health issues that may be more pressing for an individual patient.

To engage key stakeholders, consider the following questions:

• Who will champion HIV testing in the ED? Can this person convince ED leadership and clinical staff of the importance and relevance of HIV testing in the ED? Will he or she be able to ensure that the ED adopts the program? Will he or she be able to speak about the program to both internal and external audiences to build broad awareness and support?
• Who needs to be informed and to buy in to having an ED-based HIV testing program in your institution? Does anyone require additional information or data to make the case for HIV testing in this ED?
• Who has resources or important perspectives to contribute to the effort?
• Who needs to be involved in program design and decision making?
• Have they been contacted?
• Do they have specific expectations about the program?
• What are their concerns?

This chart serves as a tool for you to identify key stakeholders and track engagement and communication:

Key Stakeholder Engagement	Informed/ Buy-in	Resources / Perspectives	Design/ Decision Making	Contacted?	Expectations	Concerns
ED Leadership
ED Physicians
ED Nurses
ED Registration and Triage
Laboratory
Health Department
Infectious Disease Leadership and Clinical Staff
HIV Counseling and Testing Services
Hospital Administration
Academic Research Department
Risk Management
Community-based Organizations
Social Services
Mental Health Leadership and Staff
Who else?

Next Steps:

• For each area that has not been contacted, when do you plan to do so?
• For any concerns, is there information or resources that would diminish those concerns? Plan to make presentations to provide this information. See Making the Case.
• Think about how the program design can address and incorporate key players' viewpoints and contributions, so that the program's benefit is experienced quickly, even if on a small scale. See Operational Flow.
• What resources—human, financial, space, and equipment—are currently available among stakeholders to support implementation? What are the gaps and who will address them?

For more information on potential roles and perspectives, go to Key Players.

Legal Considerations

Patient Selection

What patient population do you aim to reach with HIV testing in the ED?

• All patients in the ED?
• All patients in a particular area, such as urgent care or fast track?
• All patients with unknown HIV status?
• Anyone who wants a test?
• Patients presenting with sexually transmitted infections (STI)?
• Patients who present with symptoms, risk behaviors, or medical histories that may indicate HIV infection/AIDS?
• Other?

The goal of the effort, along with the characteristics of the patient population, HIV (and other STI) prevalence, and the human and financial resources available for HIV testing, will inform which testing approach is the most practical for your ED.  For more information on testing approaches, click here.  For guidance on how to set up your program so you can measure your progress and success, go here.

Testing Approaches	May require additional staffing	Pilot recommended	Requires linking to care	Better for limited resources	Communities with <1% prevalence	Communities with >1% prevalence
Diagnostic testing
Targeted testing
Screening or universal testing

To ensure a smoother start and consistent running of the program over time, consider the range of financial, legal, operational, and staffing issues and address those issues early. Leave room to be flexible and adapt to unexpected issues. Program characteristics that may facilitate implementation include:

• Clearly defined roles and responsibilities for specific staff members.
• Staff dedicated to HIV testing.
• Oversight by ED-based project manager.
• Consistent funding source.
• Easy access to a pool of dedicated staff (e.g., medical/nursing students, HIV counselors).
• Testing functions coordinated with typical staff duties (e.g., nurses draw specimens, lab runs all tests, physicians deliver test results).
• HIV testing made part of standard operations (e.g., all patients are offered an HIV test at triage and this is recorded in the medical record and executed by medical staff).
• ED providers oriented to the testing program and given guidelines and protocols on when testing is to be offered.

Characteristics that can impede implementation include:

• Limited space in the ED to accommodate additional staff.
• Limited staff capacity in laboratory to run tests.
• Turnover of supplemental staff dedicated to HIV testing.
• Real and perceived burden on providers to obtain informed consent.
• Real and perceived requirement to obtain informed consent.
• Providers' belief that HIV testing is an ancillary activity, secondary to treatment of chief complaints.
• Reliance on presence of counselor.
• Lack of method to follow up with patients who initially decline.
• Reliance on individual providers.
• Busy periods in ED and quick turnover of fast-track patients.
• Ongoing need for staff training.

Financial Issues

• What major costs do you anticipate?
• Do you have resources--financial and other--to cover these costs?

Legal Considerations

Legal Considerations

• Do you know your state's laws regarding consent, confidentiality, testing, and reporting requirements?
• Does your hospital have additional or conflicting policies, practices, or requirements?

For information on your state's laws, go here  For options on consent requirements, go here.

Flow, Staffing & Choosing a Test

Where in the ED will testing occur? Will the lab or ED or other staff administer the tests? Who will inform patients of test results? For more information, go here.

Which staff members will be involved in testing? How will you build awareness and acceptance among ED providers of the value and availability of HIV testing in the ED? What training and cultural competency are required? For more information, go here.

Will you use rapid or traditional tests? Who will be responsible for quality control? For more information, go here.

Delivering & Documenting Results

What information or counseling is provided to a patient when a test is negative? What about when a test is reactive (preliminary positive)? For more information, go here.

What are the documentation and reporting procedures or requirements? For more information, go here.

Linking to Care

If a confirmatory test is positive, how will the ED link the patient to care? Processes and characteristics that can help facilitate linkage to care include:

• Infectious disease providers are proactively involved in the ongoing design, implementation, and evaluation of testing efforts.
• Disease investigation specialists from the health department are actively involved in tracking patients who are lost to follow-up.
• Same-day or standing appointments are offered at the referral clinic.
• Referral clinic is located in the hospital or on the hospital campus.
• Infectious disease provider assumes responsibility for linkage to care.
• HIV counseling and care providers are actively involved in posttest counseling and discussion of treatment and care options when a preliminary positive result is given.
• Confirmatory test specimen is drawn at the time a preliminary positive test result is given.
• Counselors accompany patients to clinic.

Processes and characteristics that impede linkage to care include:

• Those with the resources and expertise for linking patients to care are absent from planning and decision making about HIV testing in the ED.
• No referral site is part of or located near the testing site.
• No one is clearly accountable for ensuring that patients enter care.
• No or little patient contact information is provided in the ED.
• Data on patients linked to care are not collected or tracked by the ED testing program.

For more information, go here.

Sustainability

If a program is begun as part of a research project or pilot test, how will you sustain it when the original project or test ends? Factors that can ensure sustainability include:

• Funding for ED HIV testing comes from state and local pools of HIV prevention and care funds.
• Program is demonstrated to be cost efficient.
• Partnership is established with local health department which can provide test kits, training, lab, and funding.
• Program costs are absorbed by existing hospital budgets, such as supplies and laboratory.
• Public health, ED, laboratory, and infectious disease departments contribute infrastructure and resources to the testing process.
• Program staff participate in HIV planning councils/advisory groups.
• Data are collected to monitor and promote track record.

Factors that threaten sustainability include:

• Budget is cut at the federal level for HIV prevention and care.
• Nonrenewable funding sources support program.
• Testing is part of research study and attached to certain investigators and grants.
• Priority shifts for public health interventions or research conducted in the ED.
• No clear accountability or ownership of the testing process exists.
• Testing process is part of a parallel effort and is not integrated into ED operations.
• Program relies on one person to champion the effort after it has launched.