NONOCCUPATIONAL HIV PEP: ACCESS THROUGH HOSPITAL EMERGENCY DEPARTMENTS

1
NONOCCUPATIONAL HIV PEPACCESS THROUGH HOSPITAL
EMERGENCY DEPARTMENTS

• John McAllister
• Clinical Nurse Consultant
• St. Vincents Hospital, Sydney

2
Hospital emergency departments are key PEP
providers

• Key component of PEP efficacy is time
• Key message in the PEP promotion campaign is act
  fast
• Callers to the 1800 PEP NOW service are advised
  to access PEP immediately
• Emergency departments provide a 24-hour service

3
Hospital emergency departments are key PEP
providers

• 41.6 (283 of 680) of those enrolled in the
  National Centre PEP study had their initial PEP
  assessment through an emergency department
• 58 of actual or potential HIV exposures occur on
  a weekend (St. Vincents Hospital Data)

4
Barriers to PEP through an emergency department

• Poor PEP assessment skills
• failure to recognise a high risk exposure
• indiscriminate us of PEP for low/no risk
  exposures
• Poor PEP exposure management
• safety issues
• inadequate dosing
• High staff turnover
• nursing staff
• junior medical staff

• Complete ignorance of PEP
• there is no such thing
• Prejudice
• Privacy
• Low priority
• triage 4 or gt
• go see your GP on Monday
• PEP is an infrequent or rare event in most Eds
• low presentation rates impede staff
  familiarisation with the process

5
Enabling emergency departments to provide quality
PEP care

• Raise awareness
• Provide education
• Provide resources and support
• Establish a system of data collection quality
  monitoring

6
Raising awareness

• Identify key personnel
• unit manager
• medical director
• nurse educator
• person responsible for medical intern orientation
  and education
• Words speak louder than circulars

7
Education

• risk assessment
• if in doubt start
• baseline bloods
• pre-test counselling
• the regimen
• standardised
• tailored
• location of the starter packs
• likely side-effects
• adjunctive medications
• 1st dose in ED
• patient education
• dosing, side-effects, safety
• protected sex
• adherence
• where to get expert advice/support
• follow-up written information

• General
• unit in-service education program
• Targeted
• triage nurses
• the medical staff most likely to be assessing and
  managing the patient
• interns
• Continuous
• Key components
• patient privacy confidentiality
• sense of urgency
• triage category 3

8
Resources support

• Provide a simple risk assessment tool
• Provide an algorithm of care
• Supplement with a more detailed resource
• Make it easy
• pre-printed laboratory forms
• pre-printed referral slips

9
CONSIDER PEP IF
1 Unprotected anal or vaginal intercourse Unprotec
ted receptive fellatio with ejaculation Needle
sharing
2 Source is known to be HIV infected or belongs
to a high risk group
3 The exposure is an isolated event
4 The patient desires and consents to treatment
5 The patient presents within 72 hours
12345 PEP
10
THE PEP PROCESS - INITIAL CONSULTATION
Triage 3

• PEP YES
• 1st dose of regimen
• Supply starter pack
• Baseline bloods
• Patient education
• Provide written material
• Supportive counselling

PEP NO
First Aid
Risk assessment
Medical History
Discuss with HIV consultant on call
REFER FOR APPROPRIATE FOLLOW-UP
11
Establish a system of data collection quality
monitoring

• Create a data base
• Identify monitor key markers of quality care
• triage scores
• length of time between
• triage assessment
• assessment and 1st dose of regimen
• Talk to patients, nurses and medical staff
• Proactively address issues as they arise
• Provide positive feedback

12
Who is responsible?

• HIV Clinical Nurse Consultants
• HIV Area Coordinators
• own it and implement it

13
Is it possible?Time in hours from triage to 1st
dose PEP - St. Vincents Hospital Emergency
Department
14
Development of a state-wide resource for
emergency departments and GPs

• A Joint project between The Albion Street Centre
  and St. Vincent's Hospital
• An HIV/AIDS Health promotion Demonstration
  Project

15
Project description

• Strategies
• evaluate current level of knowledge
• pre-intervention knowledge surveys
• design an education resource
• simple laminated flow chart/algorithm of care
• education resource
• pilot resource
• promote distribute resource
• evaluate level of knowledge
• post-intervention knowledge survey

• Goals
• to facilitate appropriate access to PEP for all
  people at risk
• to ensure appropriate management of community
  needlestick injuries
• to reduce the inappropriate use of PEP
• Objectives
• ? ED and GP PEP awareness
• ? ED and GP PEP knowledge base
• ? PEP quality of care
• Target group
• NSW GPs EDs

16
Contents draft resource

• Contents
• explanation of package
• flow charts for management
• reference document with epidemiology and
  discussion
• key journal articles
• NSW Health circulars
• self assessment tool case studies and questions

• Areas to be covered
• responsibility
• risk assessment
• management
• referrals
•  For 
• community NSI
• sexual exposure
• skin exposure
• occupational exposure (less detail)