Background: Patients evaluated after sexual assault may require non-occupational post-exposure prophylaxis (nPEP) to prevent infection with human immunodeficiency virus (HIV), depending on the assessed risk of HIV transmission in each case1-4. Access to nPEP medications, patient counseling, and follow-up care should be offered in a systematic, comprehensive, and compassionate setting. Unfortunately, multiple barriers may impede this process. The University of New Mexico (UNM) IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice) project is a trainee-driven, multidisciplinary, interdepartmental quality improvement (QI) effort to improve HIV prevention in patients evaluated after sexual assault, while emphasizing the centrality of the patients’ experience in the resulting process of care.
Methods: The IN-STEP team identified and addressed several key areas for clinical QI and infrastructure development. An emergency department (ED) nPEP prescribing algorithm was developed. Funding was secured from the UNM Committee of Interns and Residents QI grant program to cover the full treatment cost of nPEP medications for patients evaluated after sexual assault. Patient and provider education materials were developed in collaboration with IN-STEP team members and the New Mexico AIDS Education and Training Center. An ED provider survey was conducted to inform project planning and provider education. A parallel-cycle Plan-Do-Study-Act (PDSA) analysis was used to track the complex, concurrent QI efforts undertaken in each area of the project; and an IN-STEP dashboard was developed to facilitate project communication.
Results: Four key areas for improvement were identified. These included: (1) access to HIV testing in the ED; (2) provision of nPEP medications, using a patient-centered approach; (3) continuity of care between the ED and 10 follow-up sites within the community; and (4) education and training of ED and community site providers. These key areas corresponded well with the barriers to nPEP delivery identified by surveyed ED providers (n=42). PDSA cycles were prepared for each key area, and a composite cycle was shared with other stakeholders at the institution. The IN-STEP dashboard was a useful tool for project communication. IN-STEP was instrumental in implementing ED point-of-care HIV testing, an ED clinical workflow with nPEP decision support, nPEP medications available at no cost for patients evaluated after sexual assault, numerous patient educational materials, and access to follow-up care coordinated through a 24/7 phone line.
Conclusions: The infrastructure developed for IN-STEP resulted in significant systems improvements in HIV screening, prevention, and continuity of care at our institution, influencing the care of patients affected by sexual assault as well as those evaluated for other indications. These results support the implementation of complex QI efforts using parallel-cycle PDSA analysis and highlight the importance of implementing such efforts with a multidisciplinary team. Lessons learned from this project may be useful for other large-scale, multidisciplinary efforts.