Who in the ED will perform the various functions associated with HIV testing? The intensity of each of these functions will vary according to what testing approach is used and what resources are available. For many, existing staff can be tapped from internal and external sources, including the emergency department, other departments in the hospital, health departments and even community-based organizations. This section describes how multiple sources of staff can fulfill the various functions of HIV testing in the ED. We include a discussion of possible tradeoffs for each.
Ideally, oversight will be provided by a manager in the ED, such as an attending
physician, nursing director or manager, or ED administrative manager, even
if the program is an outpost operation of the health department or other organization. These
leaders can demonstrate immediate credibility with the ED staff and leadership.
The person providing program oversight will be a key person in the implementation
of the program and will design, execute, and troubleshoot the testing program.
They may be supported by a project coordinator for day-to-day administration
Administration of HIV Tests
There are a number of staffing possibilities, ranging from posting HIV counselors or other specially trained testing staff in the ED to using "indigenous," or pre-existing ED staff, in which nurses, attending physicians, residents, and other ED clinical staff incorporate HIV testing into their routine delivery of care. A third possibility is a team-based approach in which indigenous and supplemental staff together provide HIV testing to patients.
Indigenous ED Staff
Using indigenous staff to perform HIV testing can facilitate a more seamless integration of HIV testing into ED services. ED staff are already present and can incorporate testing into the rest of treatment. A potential drawback to relying on ED staff, particularly when universal testing is the goal, is that they may view HIV testing as an optional, add-on service that can be skipped when workloads are heavy. Informed consent requirements primarily contribute to providers' perceived burden of providing HIV testing to patients. An indigenous model can work when targeted testing is provided. A fully integrated model - one in which ED staff provide expanded screening to all patients - may require additional policy changes such as an opt-out approach and general medical consent.
Supplemental Counseling Staff
Supplemental counseling staff can be an important resource addition for HIV testing in the ED, especially when separate informed consent and pre-test counseling are required. ED staff report they could more fully support HIV testing in their ED, as long as there are additional staff to do it. In addition, ED staff report they quickly see the value of HIV counselors in the ED, because they can call on these counselors to perform HIV tests in cases when they suspect HIV infection or in cases of occupational exposure.
Counseling staff may be hired directly by the ED, or they may come from the hospital's HIV counseling, testing and referral (CTR) services, social services, the health department, or community-based organizations. Students such as nursing, medical, public health, and social work students, even undergraduates, are another possible source. Concerns with students include their limited availability, competing priorities, and high turnover, which can translate into high recruitment and training costs. While some programs report good outcomes with students, others maintain that the staff providing the counseling and testing services need to be dedicated professionals. The use of supplemental staff raises the question of integration. ED staff will need to be educated about the presence of the counselors, their role, and how to work with them. These "external" staff will need to be fully integrated members of the ED team to foster communication and seamless operation.
The use of supplemental staff raises the question of integration. ED staff will need to be educated about the presence of the counselors, their role, and how to work with them. These "external" staff will need to be fully integrated members of the ED team to foster communication and seamless operation.
Another consideration in counselor models is that results may not get entered into the patient's medical record because counselors, depending on their credentials, may not have access to those records.
Team-based approaches make use of indigenous and supplemental staff. These include the physician referral model, in which clinicians will call in trained counselors when a patient needs an HIV test. Some sites with targeted approaches use the physician referral model. One way this model has been implemented is a pager system in which the physician pages the on-call counselor in the hospital's CTR department.
Counselor-facilitated models are another approach. In such a model, a counselor identifies patients for testing, completes all pretest information requirements, and then advises the provider that the patient would like an HIV test. The provider then steps in to administer the test and deliver results to the patient. One pilot study of this approach found that more patients accepted testing when it was first discussed with a counselor rather than a physician.
Data Collection, Analysis, and Reporting
Reporting will fall under the project director's domain of responsibility and entails collecting and analyzing data on process and outcomes and submitting reports to key stakeholders. See Measuring Progress for more information on data collection and measuring progress. The hospital's research department can help in setting up data collection systems and analysis support.
All ED staff will need to be educated about the rationale, goals, and implementation of HIV testing in the ED. Staff administering HIV tests will need additional training and competency testing in performing the test and interpreting results. See Training Staff for more information on training requirements. Training can be provided by the project oversight staff, the health department, or staff educators in the hospital.
Quality Assurance Oversight
The hospital laboratory director will provide quality assurance oversight if rapid tests are being performed under the lab's CLIA waiver. In some cases it can be public health laboratory if the ED is operating as a satellite testing site of the health department. See Choosing a Test for more information on quality assurance requirements.
This is a staff person of the HIV or infectious disease clinic who facilitates the entry-to-care of HIV-infected patients identified in the ED. This person will interact on a regular basis with either the testing program director or his/her designate to set appointments and provide feedback on the referral process and to track the number of patients who keep their follow-up appointments. See Linking to Care for more information on this process.
Policy Development / Fiscal Management
These are services that can be provided or supported by the hospital's compliance and financial departments, respectively.