Published by: Lee Wilbur on 12/1/2010 9:46:09 AM
Did you know that over 25 percent of those infected with HIV are UNAWARE that they are infected, yet they are responsible for over 54 percent of new HIV infections? Did you know that studies have now shown that traditional risk-based testing for HIV is relatively ineffective at detecting this newly infected population that is responsible for so many forward transmission cases? Did you know that approximately 30 percent of those currently infected with HIV will eventually fall out of care? Did you know that the Centers for Disease Control released recommendations in 2006 instructing all ambulatory care centers and emergency departments to perform universal HIV screening for all eligible patients between the ages of 13 – 64 years?
This is why it is imperative for Public Hospitals to be the leaders in the detection of new HIV patients and the integration back into definitive care for those that have fallen out of care. Below, let me share how we are working to do just that at Wishard Health Services in Indianapolis, Indiana.
Let me briefly introduce myself. My name is Lee Wilbur, MD, and I am an attending emergency physician at Wishard Health Services and an associate professor of clinical emergency medicine at Indiana University School of Medicine. I serve as the medical director for the Wishard Emergency Department HIV Program. Our HIV program was created in 2008 when we first learned of the 2006 CDC recommendations instructing institutions, such as ours, to perform universal HIV testing for all eligible patients. The motto of Wishard is to Advocate, Care, Teach, and Serve. Our institution has been providing exceptional medical care to the city of Indianapolis for over 150 years and the vision of our HIV testing and integration initiative is central to the mission of our public access institution.
I want to use this post to briefly inform the reader (1) Why your institution should do this; (2) Introduce our protocol while demonstrating how it can be applied to many different hospital systems; and (3) Discuss how you may begin this process in your institution if you believe that this is important as a public access institution.
We discussed the ‘why’ a hospital system should consider performing universal HIV testing and re-integration into care in the comments above. Although I cannot detail all the barriers that you are likely to face in starting a program such as ours, let me outline the central themes that assured our success to date. First and foremost, you must believe that this mission is important for your institution. Second, you must identify an individual who is willing to be the ‘champion’ of this cause. Third, that leader must continuously ask this question of his/her team at every juncture along the way: “How can we achieve this with limited to no resources?” rather than succumbing to the more common barrier of initiation: “We would be able to do this if only we could start with ‘x’ amount of resources”. The composition of your team is critical. The program manager is the hinge to success or failure of a program such as this. Once you have this in place, barriers will be seen not as ‘barriers’ anymore…rather as ‘opportunities’.
How we do it. When a patient is registered in our Emergency Department (ED) upon entry, our electronic medical record system instantly queries the patients’ electronic medical record to determine if they are eligible for HIV testing, based upon the 2006 CDC criteria. Next, a certified HIV counselor invites the patient into the HIV testing office located behind our triage station to perform a rapid antibody test using an oral swab. The patient is released back into the waiting room until the test results are known…typically around 20 minutes. If the patient is non-reactive, the computer system will no longer identify them as eligible again for one calendar year. If the patient is reactive however, the HIV counselor will instruct the nursing staff to draw a confirmatory Western-Blot test prior to the patients’ discharge from the ED. The counselor will schedule the patient for a follow-up appointment with our team’s program manager. At this visit, the program manager will give the results of the Western-Blot to the patient and schedule them for an urgent appointment with the Infectious Disease clinic.
Your institution can do this. When we started in 2008, we had a great idea but we had zero funding, zero space to perform testing, zero certified testers, and no one else in our state doing the same work. A belief in the mission, a remarkable amount of patience, and multiple collaborations got us to where we are today. Since 2008, we have acquired over $500,000 in cumulative extramural funding, tested nearly 8000 patients, integrated over 40 patients into definitive care, and formed collaborations with our health departments, hospital administration, many community-based organizations, the National AmeriCorps program, and various academic departments within the Indiana University School of Medicine.
What we learned is that the institution should do AS MUCH AS POSSIBLE for the patient during the initial visit that they are capable of, rather than relying on multiple referrals. Make sure you always consider how each new protocol change or idea will impact a patient navigating this process. The real keys to success are to keep your team focused on the mission, assure that the protocol is patient-centered, and that you centralize as many of the services, normally found in the community, back into your institution. The medical literature consistently shows us that with each new referral the compliance to therapy drops off exponentially. This is why we decided to draw the confirmatory HIV test when they are still in our ED, why we make an appointment for them to receive their confirmatory results, and why we make the appointment for them with the Infectious Disease clinic. Our counselors understand the disease and what it is like to receive this diagnosis when you least expect it. Still to this day, we have a 100 percent follow up rate with our Program Manager and integration into Infectious Disease. This was all achieved by a simple idea in the midst of many telling us that it was not possible. Hence, why I’m telling you that ‘your institution can do this’!
The future. I mentioned that approximately 30 percent of those with HIV have fallen out of care, normally defined as not having a CD4 count drawn (an indication of HIV illness severity and response to therapy) in the previous 6 months. I want to advocate that our role as a public access hospital is to help in this process and reduce this number. First, we must learn more about this population. We know that many will have mental health and/or substance abuse issues, but does that mean that they are lost? Our informatics system can be programmed to query the medical record to identify all the patients that register in our Emergency Department if they have HIV or not. For those with HIV, we plan to approach these patients with our HIV counseling staff to determine if they are ‘in care’ or ‘out of care’. For those who are determined to be ‘out of care’…we hope to assess reasons why they have fallen out of care while integrating them back into Infectious Disease using our original model. In addition, we plan to expand our services gradually into our nine community health centers affiliated with Wishard Health Services. With this strategy, we hope that our institution will continue to serve our community through our mission to advocate, care, teach, and serve.
Lee Wilbur, MD, FAAEM
Medical Director, HIV Program at Wishard Health Services
Associate professor of Clinical Emergency Medicine at Indiana University School of Medicine