Using Nurses to Support Rapid ART Scale up in Zambia

Mary MorrisNursing and QA/QC Coordinator

Centre for Infectious Disease Research in Zambia (CIDRZ)

The University of Alabama atBirmingham

#1 Challenge: limited resources, unlimited patients

Lusaka

• 2,000,000 inhabitants

• Adult (15-49) HIV prevalence = 22%

• Prevalence among children ~ =6%

• Estimated number HIV-infected = 267,900

ART requirement, Lusaka (assuming immediate universal coverage of 100% effective vaccine)

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The “ARVs in Vending Machines” Problem

• Zambian MOH reported clinical staffing levels in 2006: “slightly over 25%”

• (Partial) Solution: task shifting

Workforce Duties: Historical• Initial consultation/clinical evaluation

• Ordering lab tests / radiology

• Assessment of ART eligibility

• Initial ART prescription

• Toxicity management

• Treatment failure management

• Referral to tertiary care

• Triage of returning patients

• Consultation for stable patients

• ART prescription refills

• Registration

• Phlebotomy

• Pharmacy dispensation

• Education and counseling

• adherence counseling

• Vitals, height, weight

Doctors(MOs)

Nurses

Clinical Officers(COs)

• Initial consultation/clinical evaluation

• Ordering lab tests / radiology

• Assessment of ART eligibility

• Initial ART prescription

• Toxicity management

• Treatment failure management

• Referral to tertiary care

• Triage of returning patients

• Consultation for stable patients

• ART prescription refills

• Registration

• Phlebotomy

• Pharmacy dispensation

• Education and counseling

• adherence counseling

• Vitals, height, weight

Doctors(MOs)

Nurses

Clinical Officers(COs)

Clinical Officers(COs)

Nurses

Peer Educators

Workforce Duties: Revised

Advanced HIV nurse “triage training”

Objectives: • To train nurses to assist CO’s and MO’s in patient management• To train nurses to care for stable patients on ART

Evaluating new patients:• Record the presenting complaint and take a patient history• PMHx, Meds, ROS• Draw screening labs

Managing stable patients• Review the chart to determine what routine labs, care, and counseling is required at

each visit • Interval histories• Basic physical exam• Order routine monitoring labs • Maintain the ARV prescription• Assess response to ART• Assess for toxicities and clinical treatment failure• Recognize and refer patients with abnormal findings

Triage training process

• 5 days of classroom-style didactics– Modification of IMAI training materials used

with a combination of power point presentations, group work, and case studies.

• Pre and post tests– Those who score > 85% on post test progress

to the clinical mentoring module

Monday Tuesday Wednesday Thursday Friday

Chronic HIV careEligibility for ARTWHO Staging

IMAI Acute Care Emergency careCough/Difficulty breathing

ReviewHeadache/neurological problem

ReviewSpecial considerations in childrenDisclosure

Physical examination

Vital signs and review of symptoms

Anaemia/Undernutrition

Psychiatric problems Pediatric eligibility and prophylaxis

Physical examination

History taking, TB, Pregnancy, Family status

Mouth examination Treatment of common conditions

Pediatric dosing Physical examination

Prophylaxis STD and PID Significance of laboratory results

Pediatric growth charts

Post exposure prophylaxis

ARV therapy Fever Adherence PCR testing Prevention

Toxicities Diarrhea Treatment failure Pregnant women Confidentiality

Skin problems Treatment failure Pregnant women Post test and evaluation

Pre and Post test scoresDifference in Knowledge before and after HIV Nurse Training

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average scores

District clinic nurses

Clinical Mentoring

• 1:1 Clinical mentoring with nurse trainers– Trained by Project HEART staff

• Minimum 100 hours – Most require 300 hours

• Must demonstrate competency– Clinical competency checklist

Checklist for Clinical Review Pre Post Comments

Information to Review from the Chart

Greet patient

Check VS to ensure patient is stable. If not, refer to CO immediately

Are latest labs recorded on summary sheet? If not, record.

Are there any protocol labs that need to be ordered this visit? E.g. Has CD4 count been done in the past 6/12? Has HB been done in past 3/12 if on AZT? If anemia, is it treated?

Are labs normal? If not, refer to CO and re-check

Review CD4 counts and percentages. Does patient meet immunological or clinical failure criteria?

Review problem list: Diabetes? Depression? Kidney Problems? Hepatitis?

Review Patient Locator Form. Have children been tested?

Review Current Medications and ARVs, including dosage and timing

Review last three weights. Are they increasing or decreasing? If decreased by 2 kg and patient has other symptoms, refer to CO

Review last clinical note to see if there is need for follow-up this visit

Review Family Situation. Have children been tested for HIV?

Summary

• Nurses are a key component of the healthcare workforce

• General nursing training in Zambia does not teach patient management (or even physical examination)

• Most nurses need 3 months of intensive mentoring to become competent in caring for stable patients on ART

• Nurses can learn these skills, and once they do they do it well

End

Clinical Officer HIV Training

• Training in adult HIV AIDS care (8 days) • Training in pediatric HIV AIDS care (5 days)• Clinical mentoring at dedicated training facility

(3-4 weeks)• Continuous mentoring conducted by MO’s

– Rotating supervised clinical days– Weekly case conferences– Telephone and email consultation

Basic Nurse Training

• Adult and pediatric HIV and ART management– IMAI and patient management skills

• Counseling skills, psychosocial, referral, and adherence

• QA/QC

• Some go on to “triage training”

Peer Educators

• HIV-infected (mostly) members of the clinic community who work for the project

• Duties include– Group education– Counseling– Following up late patients– New: registering patients, vital signs

Task shifting in Lusaka

• Almost all ART care is provided by non-MD clinicians

• Clinical officers, nurses, and peer educators• Optimal staffing for clinic with 3000 patients on

ART– 2 clinical officers, 5 nurses, 3 peer educators in AM– 1 clinical officer, 3 nurses, and 2 peer educators in

PM

Monitoring and Evaluation

• In order to monitor nurse managed care nurses record the PTID of all patients that they see. Mentors routinely review those files to assess the quality of care given.

• At present all nurses trained and their mentors are being assessed by a nurse practitioner from the US.

Staff trained

• 670 Nurses and Clinical Officers trained in adult HIV care and ART

• 340 Nurses and Clinical Officers trained in pediatric HIV care and ART

• 74 nurses trained in clinical “triage” – 34 have completed mentoring program to

manage stable patients on ART

• 28 peer educators have been trained in patient check-in / vital signs

Total performance scores

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clinic name

J an-Mar 2007

Mar-J une 2007

Monitoring and Evaluation

• Quarterly performance reports generated for each site allow us to monitor trends in performance in each clinic.

• This can be attributed to improved knowledge and skills of nurses and improved data entry.