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Anaya HD (HSR&D COE Sepulveda; VA Greater Los Angeles Healthcare System, QUERI - HIV/Hepatitis ), Feld JE
(HSR&D COE Sepulveda; VA Greater Los Angeles Healthcare System, QUERI - HIV/Hepatitis), Golden JF
(HSR&D COE Sepulveda; VA Greater Los Angeles Healthcare System, QUERI - HIV/Hepatitis), Bokhour BG
(Center for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MA; Boston University), Knapp H
(HSR&D COE Sepulveda; VA Greater Los Angeles Healthcare System, QUERI - HIV/Hepatitis)
Objectives:
Translating health services research findings into sustainable practice poses widely recognized implementation challenges. Through a randomized controlled trial (RCT) we found that nurse-based HIV rapid testing (NRT) is more acceptable to patients than current venipuncture and increases receipt of test results. On the basis of these findings we implemented NRT at two VAMCs within the VA Greater Los Angeles Healthcare System (GLA). To ascertain the effectiveness of the implementation, we conducted both formative and process evaluations.
Methods:
Staff at 2 VAMCs were trained to administer RT. Prior to implementation at site 1, we conducted a formative evaluation. At site 2 we conducted a process evaluation of ongoing implementation activities. For both evaluations we conducted semi-structured qualitative interviews of pre-identified key informants. In addition, we employed modified snowball sampling, resulting in 9 manager and 24 front-line practitioner interviews. Field notes were analyzed for qualitative themes.
Results:
Distinct themes emerged regarding barriers/facilitators to NRT.
Barriers included:
clinical workload/staffing as insufficient for uptake of routine versus risk-based testing;
lack of congruence with perceived responsibilities and roles in administrating NRT;
bureaucratic delay for inclusion of NRT in nursing scope of practice;
and MD preference for blood draws.
Facilitators included:
tailored staff trainings, specific to departmental mission/logistics;
patient education activities/publicity;
identification of local champions dedicated to NRT;
and potential expansion of RT training to include LVNs/LVPs.
Implications:
Formative findings indicate staff concern regarding adequacy of training and incorporating NRT into workflow. Process findings indicate 1) concerns over training could be alleviated, but that workload/staffing concerns remained a barrier, 2) expanding training to include LVNs/LVPs may mitigate this constraint, and 3) post-implementation administration of NRT was highly variable by provider motivation and service area. Community care, substance abuse, and walk-in were identified as preferred clinics for NRT.
Impacts:
These qualitative findings regarding NRT can be used as a guide to implementing future routine HIV testing activities in accordance with CDC recommendations. Formative and process evaluations in health services research can reveal unforeseen barriers/facilitators and aid in dissemination of research findings.
