Operational FlowWhat are the "natural moments" for HIV testing in the ED?
In the pages that follow, we suggest opportunities during the visit and patient areas where EDs may incorporate HIV testing for patients. Our intent is to generate ideas about how HIV testing might work in your facility with minimal disruption to the existing operational flow. Please consider this information in the context of your ED's selected approach.
After reading these pages, we encourage you to spend time observing your EDs' flow and services at various times of the day and various days of the week. This will inform the time and resources required to complete the testing process and help determine what steps are reasonable at what points of service. Observation will also help identify any unanticipated bottlenecks that may impede service.
While observing, consider these aspects of the ED's design:
- Is there an urgent care or fast-track setting?
- Is there an observation unit?
- Where do ambulatory patients wait to see the provider? Is there more than one location?
- At what points in the visit do patients wait for 30 minutes or more?
- Is the ED an open ward where there are many beds in one room, separated by curtains? Or are there private rooms?
- Are there any private rooms or spaces where sensitive results could be disclosed?
- Is there a STAT lab in the ED or other temperature-controlled space for storing and running rapid HIV tests at the point-of-care?
- Is there a place where testing staff can complete paperwork and have space to store materials?
Consider design and flow issues in conjunction with these program elements:
- What ED patients will likely receive HIV tests? What are the goals of the program?
- Will testing will be provided on an opt-out basis, or will a streamlined pretest counseling approach be employed?
- Which staff members are available to offer tests to patients, run HIV tests, and deliver results?
Which patient area? ED patients have varying levels of acuity, with primary complaints ranging from broken fingers to gunshot wounds. As HIV testing is voluntary, it is important that patients understand and consent to their HIV test. Urgent care (fast track) and observation medicine units (or 23-hour admits) provide practical areas of the ED in which to offer HIV tests to patients.
Urgent care or Fast TrackUrgent care or fast-track areas see a large volume of patients with minor, often nonemergent conditions. They may be located in the ED proper or in a nearby location. They often have their own waiting areas and are staffed by nurses and physician assistants. Urgent-care patients are typically ambulatory and alert—good candidates for HIV testing. However, quick turnover of patients can present a challenge. In some sites, urgent care patients are seen within 30 minutes. When using rapid tests, testing programs can take advantage of multiple opportunities for approaching and testing patients so that patients receive their test results during their visit.
ED's observation unitThe ED's observation unit houses patients who have been treated and stabilized but will not be admitted. The patients' stay may last a few hours, and they will be discharged within 23 hours of arriving in the ED. A patient's consciousness must be an important consideration in this setting.
Presenting Conditions and HistoriesWhen a targeted approach is employed, patients eligible for testing can be identified on the basis of self-reporting, social and medical history, and/or medical evaluation.
Historical Characteristics
Men who have sex with men (MSM)
Heterosexual with multiple partners
Exchange of sex for drugs or money
Injection-drug use
History of sexually transmitted disease
Unprotected sex with a partner who is HIV-infected or has risk factors for HIV
Homeless
Clinical Characteristics
Sexually transmitted diseases
Abdominal pain and vaginal discharge and/or dysuria in women
Testicular pain, dysuria, and/or discharge in men
Pneumonia
Tuberculosis
Severe gingivitis or peridonitis
Persistent oral candidiasis (thrush)
Unexplained chronic diarrhea (greater than one month)
Persistent fevers
Unexplained severe weight loss
Unexplained anemia, neutropenia, or thrombocytopenia (low blood platelets)
Persistent generalized lymphadenopathy (swollen lymph nodes)
Recurrent respiratory tract infections
Recurrent oral ulceration, herpes zoster, Bell's palsy, and a variety of dermatologic conditions
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.
TriageAmbulatory 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.
RegistrarPatients 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.
Waiting RoomThe 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.
BedsidePatients 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.
DischargeThe 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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