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Challenges of Implementing HIV Screening in Emergency Departments – Lessons Learned . Christina Eaton, MPH Louisiana LPS. Making the CDC Recommendations Fit in the Emergency Department. “Opt-Out” and routine for all patients 13-64 years of age

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Challenges of implementing hiv screening in emergency departments lessons learned l.jpg

Challenges of Implementing HIV Screening in Emergency Departments – Lessons Learned

Christina Eaton, MPH

Louisiana LPS

Making the cdc recommendations fit in the emergency department l.jpg
Making the CDC Recommendations Fit in the Emergency Department

  • “Opt-Out” and routine for all patients 13-64 years of age

  • Part of routine clinical care in all health-care settings

  • Voluntary and similar to screening for other treatable conditions

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Is There Interest? Department

Is HIV Screening:


Cost Effective?

Worth our Time?

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8 Step Model Department

  • Pre-work

  • Framework

  • Patient Visit Process

  • Prep for Tracking Reactives

  • Setting Up/Adopting Screening Codes

  • Promote and Provide Training

  • Launch

  • Monitor

Buy in l.jpg
Buy -In Department

  • Within Hospitals

    • Administration

    • Laboratory

    • Infectious disease clinic

    • Behavioral health services

    • Legal Department

    • ED staff

  • State Medicaid programs

  • Medical schools/nursing schools

  • Professional Associations

    • State and county/parish medical societies

    • Nursing associations

    • Hospital associations

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Step 1: Pre-work Department

  • Determine which test will be used


  • Estimate the quantity needed for first 6 mo. of testing

    • (# unduplicated visits for patients 13-64)

  • Identify source for tests

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What Support from Health Department? Department

  • Single ED support or Several ED Programs?

  • Total or partial funding?

    • How sustainable is Health Department Funding?

  • Indirect support

    • Training staff

    • Marketing and Program Promotion

    • Assist with linkages

    • Develop implementation protocol

  • Step 1 pre work9 l.jpg
    Step 1: Pre-work Department

    • Appoint staff person to receive, manage, and coordinate test supplies

      • Identify medical team or dedicated staff that will perform tests

    • Determine whether HIV follow up care will be provided in-house of through referral

    • Specify referral agency(s), get name, phone & email contact of the person your staff calls when they want to make a referral

    Step 1 pre work10 l.jpg
    Step 1: Pre-work Department

    • Identify the role of Disease Intervention Specialists (DIS) in counseling or referral support

    • List how the state/local health departments will provide support

    • Schedule official start date

      • If multiple sites will you launch simultaneously or stagger

  • Identify staff member to trouble shoot any problems during launch

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    Step 2: Framework Department

    • Prepare an HIV Test Log and HIV Test Control Log

    • Determine how informed consent will be obtained

    • Adapt and print patient educational information

    • Prepare a tool for staff that will be discussing HIV testing to patients

    Step 3 the patient visit process l.jpg
    Step 3: The Patient Visit Process Department

    • Determine where in the Patient Visit Process routine screening will occur

    • Determine a process to respond to negative/reactive results

      • Create algorithm depicting the process for response

    • Western Blot Confirmatory Test Results

      • Determine process to respond to negative, indeterminate, and positive result

      • Create algorithm depicting the process for response

    Algorithm sample l.jpg
    Algorithm Sample Department



    Step 4 identify a point person to track reactives l.jpg
    Step 4: Identify a Point Person to Track Reactives Department


    I Want to get a

    Confirmatory Test

    Step 5 adopt hiv screening codes for reimbursement l.jpg
    Step 5: Adopt HIV Screening Codes for Reimbursement Department

    • As of Jan 1, 2008 providers can bill for rapid tests

      • Usual lab code for HIV (86701-86703) within the CPT system

      • Add modifier “92” for “Alternative Laboratory Platform Testing”

  • May 2008

    • American Academy of HIV Medicine (AAHIVM) releases

    • Coding Guidelines for Routine HIV Testing in Health Care Settings

  • OR Create your own codes

  • $




    Step 6 promote and provide training l.jpg
    Step 6: Promote and Provide Training Department

    • Leadership present its support for and expectation around routine HIV Screening

    • Profession-specific training

      • Triage/intake staff

      • ED Physicians, nurses

      • Laboratory

    Step 7 launch l.jpg
    Step 7: Launch Department

    Step 8 monitor l.jpg
    Step 8: Monitor Department

    How is the program working?

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    Caveats to Working with EDs Department

    • All EDs are different

    • All hospitals are different

    • The approach to each hospital/ED is different

    • The key players are different

    • Not all ED directors recognize risk of HIV in their area

    Challenge buy in l.jpg
    Challenge: Buy In Department

    • Best Practices

      • Identify a Champion within the Hospital and/or ED

      • Make sure key opinion leaders are

        • At your initial meetings

        • Involved in the planning process

      • Give key opinion leaders the “absolutely need to know” information

        • Do not overburden them

      • Make sure all shifts are on board with protocol

        • Expect a slow start

        • Watch volumes of tests

    Challenge funding financing l.jpg
    Challenge: Funding/Financing Department

    • Challenge: Opt Out?!?!

    • No Hospitals have successfully implemented an “opt-out” approach

      • “Routinely Recommended with Right of Refusal”

    • Opt – In is cheaper





    Monitoring l.jpg
    Monitoring Department

    • Monthly meetings with

      • Hospitals, core lab staff, infection control

    • Look at

      • Number of positives & indeterminates

      • Number of rejected samples & reason for rejection

      • How often a patient agreed to testing but did not receive the test

      • How often a patient did not receive a result (rapid or confirmatory)

    • Program overall

      • How is the program going from the perspectives of each discipline?

    Challenge hiv screening at point of care l.jpg
    Challenge: HIV Screening at Point of Care Department

    • Challenge of point of care includes

      • Overseeing the timing of the test

      • Monitoring the proficiency of the testers

    • Specialized staff are needed for POC

    • ED staff can be utilized if the lab is utilized

    Resources l.jpg
    Resources Department

    • Process Flow Charts

    • General Consent Form

    • Informed Consent Form

    • Data Process Form

    • Patient Information for a Positive, Negative, or Indeterminate Test Result

    • Performance Training Criteria Checklist

    • Patient Referral Form/Linkage to Care

    • Billing and Coding Guidelines for (OraQuick Advance)

    • Current State Regulations