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Ministry of Health Zambia. University of Alabama at Birmingham. 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). The University of Alabama at Birmingham.
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Ministry of Health Zambia University of Alabama at Birmingham 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) The University of Alabama at Birmingham
Lusaka • 2,000,000 inhabitants • Adult (15-49) HIV prevalence = 22% • Prevalence among children ~ =6% • Estimated number HIV-infected = 267,900
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) Clinical Officers (COs) Nurses
Workforce Duties: Revised • 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) Doctors (MOs) Clinical Officers (COs) Nurses 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
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
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
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.