DistanceBased Telephone Consultation: Experience of the National HIVAIDS Clinicians Consultation Cen

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Distance-Based Telephone Consultation
Experience of the National HIV/AIDS Clinicians
Consultation Center

• Warmline, PEPline and Perinatal Hotline
• Ronald Goldschmidt MD, Jess Fogler MD, Hazel
  Georgetti, Shannon Weber MSW
  
• San Francisco General Hospital
• University of California
• San Francisco

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Objectives

• Describe these national services
• Services offered
• Problems encountered
• Discuss educational and research value of
  distance-based clinical consultation
  
• Explore how this model fits into services
  provided through the Ryan White Care Act
  
• Discuss ideas about further linkages between the
  NCCC and other components of the RWCA
  

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NCCC

• Warmline -1993 46,ooo calls to date
• PEPline -1997 52,ooo calls to date
• Perinatal Hotline -2004 5oo calls to
  date
  
• 98,500 calls to date
• Currently 1000 calls/month
• Warmline calls- 85 from medically underserved
  areas
  
• Service project, not research project
• 1,850,000 annual
• HRSA is principal funder
• CDC provides some supplemental funds

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NCCC Staff

• Physicians 15
• Family Medicine
• Jess Fogler, Megan Mahoney, Ann Harvey, Grace
  Dammann, Robin Serrahn
  
• Internal Medicine
• Jason Tokumoto, Amy Kindrick, Amy Garlin, Lisa
  Gooze, Gifford Leoung, Meg Newman, Rich Aranow,
  Jose Eguia, Jackie Tulsky
  
• Ob-Gyn consultant
• Deb Cohan

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NCCC Staff

• Physicians - 15
• Clinical Pharmacists - 5
• Betty Dong, Helena Tang, Cristina Gruta, Nancy
  Nguyen, Parya Saberi
  

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NCCC Staff

• Physicians - 15
• Clinical Pharmacists - 5
• Evaluator- open
• AETC Liaison- Halley Cornell
• Perinatal Coordinator- Shannon Weber, MSW
• Project Manager- Hazel Georgetti

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National HIV Telephone Consultation
Service (Warmline)

• For questions about HIV/AIDS clinical care

800/933-3413 Monday - Friday 8 am to 8 pm EST
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Warmline Call Scenario

• A 49-year-old HIV man has a history of
  injection drug use. He takes zidovudine,
  lamivudine and lopinavir/ritonavir and states he
  has been adherent to treatment for the past four
  years. The viral load was undetectable until last
  month, but now has increased to 8000 copies/mL.
  The patients CD4 count has remained stable
  between 320 and 390 cells/?L.
• Should the antiretroviral regimen be changed?
  What factors would you consider in making the
  choice?

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Warmline Callers Current HIV Patient Load
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Warmline

• Clinical management- 170/mo
• Mostly ARV
• Especially complicated ARV strategies
  (resistance, etc.)
  
• State of California (SOA) Resistance Panel
• Prevention- 150/mo
• Non-occupational PEP (post-exposure prophylaxis)

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Warmline Clinical Management Call Topics
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Warmline Caller Patient Race
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Warmline Caller Satisfaction Survey, 2005Scale
Likert 1 - 5
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Warmline

• Issues
• Assessing caller competency
• Figuring out the real questions
• Guidelines vs clinical experience/clinical
  practice
  
• Reporting and Research obstacles
• Outcomes research
• Measuring complexity
• Time per call
• ARV resistance
• Warmline as sole source of consultation
• - rural, lost at sea
• Liability (NB- Virginia prison doctor)

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National Clinicians Post-Exposure Prophylaxis
Hotline (PEPline)

• (888) HIV - 4911
• (888) 448 - 4911
• 24 hours/day
• 7 days/week

• For questions about occupational exposures to HIV
  and other blood-borne pathogens

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PEPline Call Scenario

• At 6 p.m., you are approached by a nurse who was
  stuck by a bloody 22-guage needle. When she
  removed her glove, there was a small puncture
  site with no blood present.
• The source patient is HIV-positive with a CD4
  count of 20 cells/?L and a viral load of 5000
  copies/mL. The patient is taking zidovudine,
  lamivudine, and efavirenz.
• You are uncertain whether this represents a true
  exposure requiring prophylaxis and if so, whether
  2 or 3-4 drugs would be appropriate post-exposure
  prophylaxis. You also wonder what tests to
  obtain.

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Goals in Post-Exposure Care

• Prevent transmission
• Avoid unnecessary PEP and PEP toxicity
• Provide counseling and follow-up

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Risk of Transmission
Overall risk, percutaneous ??????????
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Risk of Transmission

• Overall risk, percutaneous 0.3 (3 per 1000)
• Henderson, Tokars, Ippolito, Gerberding, Bell
• Risk Factors Odds ratio
• Visibly bloody device 6.2
• Device used in artery or vein 4.3
• Deep injury 15.0
• End-stage AIDS 5.6
• Decreased risk of transmission 80 w AZT PEP
• Cardo, et al. N Engl J Med 19973371485-90

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Steps in Managing BBP Exposures

• Assess injury/exposure risk
• Assess source patient (SP) risk
• Determine whether to offer PEP
• Select PEP regimen
• Obtain baseline laboratory tests
• Counsel the HCW and/or treating clinician
• Crisis management?
• Follow-up care

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PEPline Call by Call Type
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PEPline Treating Clinician Profession
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PEPline Exposure Type 9/3/04 7/30/05
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PEPline Gender of Exposed 9/3/04 7/30/05
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PEPline Caller Satisfaction Survey, 2005 Scale
Likert 1 - 5
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PEPline

• Issues
• Treating clinicians
• treating clinicians w/o knowledge, experience, or
  skills/interest in counseling
  
• Exposed HCP
• no face-to-face counseling or support
• might not seek actual care
• PHS Guidelines vs clinical experience
• Second opinions
• Special problems
• obsessive compulsive disorder
• non-HCPs claiming to be HCPs
• Part of hospital protocols

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National Perinatal HIV Consultation and
Referral Service (Perinatal Hotline)

• For questions about rapid and standard HIV
  testing and care of HIV-infected pregnant women
  and their children

888/448-8765 24 hours/day 7 days/week
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Perinatal Hotline Call Scenario

• A 27-year-old woman with no perinatal care
  comes to the hospital in labor. Her rapid HIV
  test is positive. She has no pre-existing
  diagnosis of HIV infection and appears healthy.
• What should you tell her? Do you need to treat
  her immediately? Should she receive ARV drugs in
  labor? Should the baby be treated? What tests
  need to be performed on the baby?

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Two Key Perinatal Services

• Perinatal Hotline
• 24-hour telephone consultation
• Perinatal HIV Clinicians Network
• Help clinicians connect their patients with
  HIV-experienced providers.
  

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Perinatal Hotline Caller Profession
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Perinatal Hotline Facility Type
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Calls 362 Topics per call 3.3Period 1/05
3/06
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Perinatal Hotline Patient Race
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Perinatal Hotline Consultant Group

• Quarterly conferences
• High-risk labor and delivery scenarios
• Treatment choices for newborns
• Resistance
• Based on National Guidelines

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Two Key Perinatal Services

• Perinatal Hotline
• 24-hour telephone consultation
• Perinatal HIV Clinicians Network
• Help clinicians connect their patients with
  HIV-experienced providers
  
• Coordinator - Shannon Weber, MSW

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Perinatal Hotline Caller Satisfaction Survey,
2005 Scale Likert 1 - 5
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NCCC Scholarly Activities

• PEP Resource Guide
• Kindrick
• Perinatal Hotline - CROI Fogler et al
• Assessment of the types of calls to the PH
• PUP III - Myers, Cocohoba, Goldschmidt
• Qualitative study of HCW experiences with PEP
• PUP IV - Sterkenburg
• Clinicians needs in managing PEP
• PUP V Dong, Goldschmidt
• Assessment of PEP guideline use
• Non-occupational PEP - CROI Amy Kindrick
• 840 calls RE consensual non-consensual sexual
  exposures
  
• Other in progress
• African American callers Rural Hospitals
• State laws on HIV testing - Kali Stanger, Alison
  Chang
  
• Compendium on line (AHA HRET, CDC, UCSF)

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NCCC Biggest Challenges

• Data collection and entry
• Standardization of terms, fields and coding
• Standardization inter- and intra-faculty
• Clinician faculty priorities call quality data
  precision
  
• Caller priorities time pressures research
• Guidelines vs clinical experience and expert
  opinion
  
• Research unrepresentative samples
• International consultation