Form 1 National Survey of HIV Testing in Hospital

OMB Number: 0920-XXXX

National Survey of HIV Testing in Hospitals

Attachment 3

Data Collection Instrument

Public reporting burden of this collection of information is estimated to average 1 hour per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions regarding this burden estimate of any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer: 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-08BD).

National Survey OF HIV Testing in Hospitals

This is a survey to gather information on HIV testing services available in hospitals. We are asking that individuals who are most knowledgeable about HIV testing and services in the hospital complete this survey. We also encourage you to seek input from others in the hospital that may have information to help you complete the survey, including persons from the emergency, inpatient unit, and labor and delivery.

The Health Research and Education Trust (HRET) stresses the importance of this survey, and the vital role that your input plays. We will keep the answers you provide in the strictest of confidence. We will use the aggregated results of this survey to develop relevant operational guidance for hospitals and health systems to assist administrators, department heads, and chiefs in incorporating testing, where possible, to prevent HIV transmission.

This survey should take up to four hours to complete. You may 1) complete the survey online at http://response.survey-one.com/jsp/hiv.jsp using the login and password included in the letter that accompanied the questionnaire, or 2) return the completed questionnaire in the enclosed, prepaid envelope. In either case, we ask that you respond by June 1, 2009, so that your hospital may be represented in this nationwide survey. If you would like a copy of the report we develop, please include your contact information at the end of the survey form.

Again, we emphasize the value of your contribution to this survey, and thank you in advance for your time.

National Survey OF HIV Testing in Hospitals

In this survey, we are interested in learning more about HIV testing for patients in the hospital. We are not asking questions about HIV testing of source patients in cases of needle sticks.

I. GENERAL QUESTIONS

1. Are HIV tests ever performed for patients in this hospital?

 Yes (Continue)

 No (Go to Q48)

2. Are HIV tests ever ordered for patients in the following departments? (If a particular department or setting does not exist in the hospital, please select NA for not applicable. If you do not know whether HIV tests are ordered in a particular department, please inquire with that department before answering DK, don’t know.)

	Yes	No	NA	DK
Emergency department				
Inpatient unit				
Labor and delivery				
Primary care clinic(s)				
Urgent care				
Substance abuse treatment clinic(s)				
Psychiatry/mental health				

3. Are patients screened for HIV in this hospital? (By screened we mean that HIV testing is offered to all patients in some defined population)

 Yes, everywhere throughout the hospital (Go to Q5)

 Yes, in some departments (Continue)

 No (Go to Q5)

 Do not know (Go to Q5)

4. In what departments are patients screened for HIV? (If a particular department or setting does not exist in the hospital, please select NA for not applicable. If you do not know whether HIV screening takes place in a particular department, please inquire with that department before answering DK, don’t know.)

	Yes	No	NA	DK
Emergency department				
Inpatient unit				
Labor and delivery				
Primary care clinic(s)				
Urgent care				
Substance abuse treatment clinic(s)				
Psychiatry/mental health				

5. How are patients notified that an HIV test may be performed?

Select one

 Patients are offered an HIV test and must give consent to be tested (also called opt-in testing)

 Patients are told that an HIV test will be performed unless they refuse it (also called opt-out testing)

 Patients are not notified that an HIV test will be performed

 Other (specify_____________________________________________________)

6. How does a patient consent to an HIV test?

Select one

 Written consent specifically for HIV testing

 Written consent for medical care including HIV testing

 Oral consent

 Other (specify_____________________________________________________)

7. Are any of these types of information documented in the patient’s medical record?

	Yes	No	DK	NA
HIV test was offered to patient				
Patient declined/refused HIV test				
Positive test result				
Negative test result				
Health department notification of test result				

8. Are there written guidelines that inform procedures for HIV testing of patients in the hospital?

 Yes (Continue)

 No (Go to Q48)

 Do not know (Go to Q48)

9. Are the guidelines the same throughout the hospital or do they vary department by department?

Select the one that best describes this hospital

 Same guidelines throughout the hospital (Go to Q10)

 Guidelines vary department by department (Go to Q23)

II. HOSPITAL GUIDELINES

(COMPLETE THIS SECTION IF YES TO Q9; OTHERWISE GO TO Q23 - LABOR & DELIVERY)

10. How long have the hospital-wide HIV testing guidelines been in place?

Select one

 Less than 1 year

 1 year to <2 years

 2 years to <3 years

 3 years or more

 Do not know

11. Do the HIV testing guidelines specify that an HIV test should be performed for all patients ages 13 through 64 years with unknown HIV status?

 Yes (Go to Q13)

 No (Continue)

 Do not know (Continue)

12. Do the HIV testing guidelines specify that HIV tests should be performed for patients with any of the following conditions or characteristics?

	Yes	No	DK	NA
Clinical signs or symptoms of HIV or AIDS				
Pregnancy with unknown HIV status				
Sexual assault victim				
Sexually transmitted disease				
Tuberculosis				
High-risk sexual activity				
Injection-drug use				
Other (specify___________________________)				

13. Do the HIV testing guidelines require that patients receive any information about HIV prior to an HIV test? (Types of information include an explanation of HIV infection, how HIV is transmitted, the meaning of test results, and risk reduction strategies)

 Yes

 No

 Do not know

14. How is this information communicated to the patient?

Select all that apply

 One-on-one discussion

 Pamphlet / brochure

 Computer, video or kiosk

Other (specify____________________________________________________)

 Do not know

15. Who usually communicates this information to the patient?

Select one

 Physician

 Nurse

 Counselor

 Social worker

 No one

Other (specify____________________________________________________)

16. Are rapid HIV tests, conventional HIV tests, or both used in the hospital? (A rapid HIV test is a screening test for HIV in which the results are available within 30 minutes.)

Select one

 Only rapid HIV tests (Continue)

 Only conventional HIV tests (Go to Q19)

 Both rapid and conventional HIV tests (Continue)

17. Where are rapid HIV tests run?

Select all that apply

 At the point of care (i.e., at or near the site of patient care, including at a satellite or STAT laboratory)

 In the hospital’s central laboratory

 Other (specify_____________________________________________________)

18. If a rapid test is reactive, how is a specimen collected for confirmatory testing?

Select all that apply

 Specimen is collected during patients’ stay

 Patient is referred to another provider for confirmatory testing

 Other (specify_____________________________________________________)

 Do not know

19. How are patients are notified of a positive HIV test result?

Select all that apply

 Result is communicated in person by a provider in the hospital (e.g., physician, nurse, counselor or other skilled staff)

 Result is communicated in person by a referral provider after patient discharge

 Result is provided on discharge instructions

 Other (specify_____________________________________________________)

20. Which of the following occurs when a patient has a positive HIV test result?

Select all that apply

Patient is provided information by which they may seek subsequent services

 Patients are given an appointment time with an infectious disease provider

 An infectious disease provider or social worker meets with the patient in the hospital to facilitate entry to HIV care

 The health department is notified

 Other (specify_____________________________________________________)

21. When are patients who test negative but are known/suspected to be at high risk for HIV infection advised to be retested?

 3 months

 6 months 

 12 months

 Other (specify ____months)

 Patients are not advised of a specific time interval

 Do not know

The next question pertains to guidelines for testing pregnant women in labor and delivery.

22. Do the hospital guidelines for HIV testing specify any of the following?

	Yes	No	DK
Any woman with undocumented HIV status at the time of labor should be screened with a rapid HIV test unless she declines			
The HIV test result of the mother is to be documented in the medical record of the newborn			
HIV prophylaxis is to be initiated immediately on the basis of a preliminary positive rapid HIV test result of a pregnant woman			

Go to Q48 (Plans)

III. LABOR & DELIVERY GUIDELINES

23. Are there written guidelines for HIV testing in Labor and Delivery?

 Yes (Continue)

 No (Go to Q25)

 Do not know (Go to Q25)

24. Do the guidelines for HIV testing in Labor and Delivery specify any of the following?

	Yes	No	DK
Any woman with undocumented HIV status at the time of labor should be screened with a rapid HIV test unless she declines			
The HIV test result of the mother is to be documented in the medical record of the newborn			
HIV prophylaxis is to be initiated immediately on the basis of a preliminary positive rapid HIV test result of a pregnant woman			

Go to Q25 (Emergency Department Guidelines)

IV. EMERGENCY DEPartment GUIDELINES

25. Are there written guidelines for HIV testing in the emergency department?

 Yes

 No (Go to Q38)

 Do not know (Go to Q38)

26. How long have the emergency department HIV testing guidelines been in place?

Select one

 <1 year

 1 year to <2 years

 2 years to <3 years

 3 years or more

 Do not know

27. Do the HIV testing guidelines specify that an HIV test should be performed for all patients ages 13 through 64 years with unknown HIV status?

 Yes (Go to Q29)

 No (Continue)

 Do not know (Continue)

28. Do the HIV testing guidelines specify that HIV tests should be performed for patients with any of the following conditions or characteristics?

	Yes	No	DK	NA
Clinical signs or symptoms of HIV or AIDS				
Pregnancy with unknown HIV status				
Sexual assault victim				
Sexually transmitted disease				
Tuberculosis				
High risk sexual activity				
Injection-drug use				
Other (specify___________________________)				

29. Do the HIV testing guidelines require that patients receive any information about HIV prior to an HIV test? (Types of information include an explanation of HIV infection, how HIV is transmitted, the meaning of test results, and risk reduction strategies)

 Yes

 No

 Do not know

30. How is this information communicated to the patient?

Select all that apply

 One-on-one discussion

 Pamphlet / brochure

 Computer, video or kiosk

Other (specify____________________________________________________)

 Do not know

31. Who usually communicates this information to the patient?

Select one

 Physician

 Nurse

 Counselor

 Social worker

 No one

Other (specify____________________________________________________)

32. Are rapid HIV tests, conventional HIV tests, or both used in this emergency department? (A rapid HIV test is a screening test for HIV in which the results are available within 30 minutes.)

Select one

 Only rapid HIV tests (Continue)

 Only conventional HIV tests (Go to Q35)

 Both rapid and conventional HIV tests (Continue)

33. Where are rapid HIV tests run?

Select all that apply

 At the point of care (i.e., at or near the site of patient care, including at a satellite or STAT laboratory)

 In the hospital’s central laboratory

 Other (specify_____________________________________________________)

34. If a rapid test is reactive, how is a specimen collected for confirmatory testing?

Select all that apply

 Specimen is collected during patients’ stay

 Patient is referred to another provider

 Other (specify_____________________________________________________)

 Do not know

35. How are patients are notified of a positive HIV test result?

Select all that apply

 Result is communicated in person by a provider in the hospital (e.g., physician, nurse, counselor or other skilled staff)

 Result is communicated in person by a referral provider after patient discharge

 Result is provided on discharge instructions

 Other (specify_____________________________________________________)

36. Which of the following occurs when a patient has a positive HIV test result?

Select all that apply

Patient is provided information by which they may seek subsequent services

 Patients are given an appointment time with an infectious disease provider

 An infectious disease provider or social worker meets with the patient in the hospital facilitate entry to HIV care

 The health department is notified

 Other (specify_____________________________________________________)

37. When are patients who test negative but are known/suspected to be at high risk for HIV infection advised to be retested?

 3 months

 6 months 

 12 months

 Other (specify ____months)

 Patients are not advised of a specific time interval

 Do not know

Go to Q38 (Inpatient Unit Guidelines)

V. iNPATIENT UNIT GUIDELINES

38. Are there written guidelines for HIV testing in inpatient units?

 Yes (Continue)

 No (Go to Q48)

 Do not know (Go to Q48)

39. How long have the inpatient HIV testing guidelines been in place?

Select one

 <1 year

 1 year to <2 years

 2 years to <3 years

 3 years or more

 Do not know

40. Do the HIV testing guidelines specify that an HIV test should be performed for all patients ages 13 through 64 years with unknown HIV status?

 Yes (Go to Q42)

 No (Continue)

 Do not know (Continue)

41. Do the HIV testing guidelines specify that HIV tests should be performed for patients with any of the following conditions or characteristics?

	Yes	No	DK	NA
Clinical signs or symptoms of HIV or AIDS				
Pregnancy with unknown HIV status				
Sexual assault victim				
Sexually transmitted disease				
Tuberculosis				
High risk sexual activity				
Injection-drug use				
Other (specify___________________________)				

42. Do the HIV testing guidelines require that patients receive any information about HIV prior to an HIV test? (Types of information include an explanation of HIV infection, how HIV is transmitted, the meaning of test results, and risk reduction strategies)

 Yes

 No

 Do not know

43. How is this information communicated to the patient?

Select all that apply

 One-on-one discussion

 Pamphlet / brochure

 Computer, video or kiosk

Other (specify____________________________________________________)

 Do not know

44. Who usually communicates this information to the patient?

Select one

 Physician

 Nurse

 Counselor

 Social worker

 No one

Other (specify____________________________________________________)

45. How are patients are notified of a positive HIV test result?

Select all that apply

 Result is communicated in person by a provider in the hospital (e.g., physician, nurse, counselor or other skilled staff)

 Result is communicated in person by a referral provider after patient discharge

 Result is provided on discharge instructions

 Other (specify_____________________________________________________)

46. Which of the following occurs when a patient has a positive HIV test result?

Select all that apply

Patient is provided information by which they may seek subsequent services

 Patients are given an appointment time with an infectious disease provider

 An infectious disease provider or social worker meets with the patient in the hospital to facilitate entry to HIV care

 The health department is notified

 Other (specify_____________________________________________________)

47. When are patients who test negative but are known/suspected to be at high risk for HIV infection advised to be retested?

 3 months

 6 months 

 12 months

 Other (specify ____months)

 Patients are not advised of a specific time interval

 Do not know

Go to Q48 (Plans)

VI. PLANS

48. This question pertains to the whole hospital. For each of the following please indicate if this is current practice anywhere in the hospital, if the hospital plans to implement it in the next 12 months, or if it is not being considered by the hospital at this time.

	Current Practice	Plan to Implement	Not Being Considered	DK	NA
Offering HIV tests to all patients at high risk for HIV infection					
Offering HIV tests to all patients regardless of risk or symptoms					
Incorporating consent for HIV testing into the patient’s general consent for medical care (i.e., no separate written consent for HIV testing)					
Removing requirements to provide HIV prevention counseling before testing					
Offering HIV tests on an opt-out basis (i.e., patient is notified that an HIV test will be performed unless he/she declines)					

49. For each of the following areas is “offering HIV tests to all patients regardless of risk or symptoms” current practice or are there plans to implement this in the next 12 months?

	Current Practice	Plan to be implemented	No	NA	DK
Emergency department					
Inpatient unit					
Labor and delivery					
Primary care clinic(s)					
Urgent care					
Substance abuse treatment clinic(s)					
Psychiatry/mental health					

50. For each of the following areas, is “offering HIV tests to all patients on an opt-out basis” current practice or are there plans to implement this in the next 12 months?

	Current Practice	Plan to be implemented	No	NA	DK
Emergency department					
Inpatient unit					
Labor and delivery					
Primary care clinic(s)					
Urgent care					
Substance abuse treatment clinic(s)					
Psychiatry/mental health					

Go to Q51 (Reimbursement)

VII. REIMBURSEMENT

51. Does the hospital receive funding, resources, or in-kind support from external organizations (such as local or state health departments, federal departments, private foundations) to support facilitating HIV-infected patients’ entry to care?

 Yes (Continue)

 No (Go to Q54)

 Do not know (Go to Q54)

52. Does the hospital receive funding, resources, or in-kind support from external organizations (such as local or state health departments, federal departments, private foundations) to support HIV testing?

 Yes (Continue)

 No (Go to Q54)

 Do not know (Go to Q54)

53. Which of the following does the hospital receive to support HIV testing or linkage to care?

	Yes	No	DK	NA
Funding (other than reimbursement from 3rd party payers)				
Test kits				
Staff				
Training				
Laboratory Services				
Partner counseling and referral services				
Tracking patients testing positive who are lost to follow up				
Prevention counseling				
Other (specify__________________________________)				

54. Does the hospital receive reimbursement from 3^rd party payers, such as Medicaid, Medicare or private insurance plans, for HIV tests that are performed for screening purposes?

 Yes

 No

 Do not know

Go to Q55 (HIV Testing Volume)

VIII. HIV TESTING VOLUME

55. How many HIV tests were performed at this hospital in 2008?

____________Tests  Do not know

56. How many HIV tests performed at this hospital were positive in 2008?

____________Tests  Do not know

Conclusion

Thank you for your participation in this important survey. Your input is very important to monitor HIV testing in healthcare settings.

If you would like to receive a free copy of our report, please provide your contact information.

Name:________________________________________________Title:________________________________

Organization:_________________________________________________________________________

Address:____________________________________________________________________________

City:________________________________________ State:__________ Zip Code: _______________

Telephone:(______)______________________ Email:_______________________________________