Transcript Nurse Training - I-TECH

Using Nurses to Support Rapid
ART Scale up in Zambia
Mary Morris
Nursing and QA/QC Coordinator
Centre for Infectious Disease Research in
Zambia (CIDRZ)
Ministry of Health
The University
of Alabama
at
University
of Alabama
at Birmingham
Birmingham
#1 Challenge: limited resources, unlimited patients
Lusaka
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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)
350000
300000
250000
200000
150000
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100000
50000
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ART requirement, Lusaka
(assuming immediate universal coverage of 100% effective vaccine)
350000
300000
250000
200000
150000
100000
50000
20
07
20
08
20
09
20
10
20
11
20
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20
13
20
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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
Doctors
(MOs)
Clinical
Officers
(COs)
Nurses
•
Initial consultation/clinical evaluation
•
Ordering lab tests / radiology
•
Assessment of ART eligibility
•
Initial ART prescription
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Toxicity management
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Treatment failure management
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Referral to tertiary care
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Triage of returning patients
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Consultation for stable patients
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ART prescription refills
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Registration
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Phlebotomy
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Pharmacy dispensation
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Education and counseling
•
adherence counseling
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Vitals, height, weight
Workforce Duties: Revised
Doctors
(MOs)
Clinical
Officers
(COs)
Nurses
•
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
Clinical
Officers
(COs)
Nurses
Peer
Educators
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 care
Eligibility for ART
WHO Staging
IMAI Acute Care
Emergency care
Cough/Difficulty
breathing
Review
Headache/neurologica
l problem
Review
Special considerations
in children
Disclosure
Physical examination
Vital signs and review
of symptoms
Anaemia/Undernutriti
on
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 scores
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
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?
Pre
Post
Comments
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
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.