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Summary HIV shared care is uncommon in the UK although shared care could be a beneficial model of care. We review the literature on HIV shared care to determine current practice and clinical, economic and patient satisfaction outcomes. We searched MEDLINE, EMBASE, NICE Evidence, Cochrane collaboration, Google and websites of the British HIV Association, Aidsmap, Public Health England, World Health Organization and Terrence Higgins Trust using relevant search terms in August 2014. Studies published after 2000, from healthcare settings comparable to the UK that described links between primary care and specialised HIV services were included and compared using principles of the Critical Appraisal Skills Programme and Authority, Accuracy, Coverage, Objectivity, Date, Significance frameworks. Three of the nine included models reported clinical or patient satisfaction outcomes but data collection and analyses were inadequate. None reported economic outcomes although some provided financial costings. Facilitators of shared care included robust clinical protocols, training and timely communication. Few published examples of HIV shared care exist and quality of evidence is poor. There is no consistent association with improved clinical outcomes, cost effectiveness or acceptability. Models are context specific, driven by local need, although some generalisable features could inform novel service delivery. Further evaluative research is needed to determine optimal components of shared HIV care.

BackgroundOn our paediatric intensive care unit (PICU), we have historically used heparin in 0.9% sodium chloride as a continuous flush to maintain patency of arterial and central venous pressure (CVP) central lines. Practice varies across the UK, some units use heparin in sodium chloride whilst others use sodium chloride alone to maintain line patency. Currently in paediatrics there is not enough evidence to change local practice by removing heparin from the flushes.1 A cost saving scheme was identified whereby using heparin in sodium chloride 0.45% was cheaper than using heparin in sodium chloride 0.9% (both products from Baxter). A proposal was put together and approved by the PICU quality improvement group, demonstrating that in theory, there should be no significant loss of sodium to patients due to the change in fluids. Although it may seem that flushes would not contribute a large proportion of a patient’s fluid requirement, in a typical 2.5 kg patient post cardiac surgery, 2 ml/hour would actually provide 40% of the patient’s total fluid allowance. This change in practice was implemented in June 2018.AimThe aim of this audit was to establish whether patients receiving heparin in sodium chloride 0.45% had lower sodium blood levels or a greater drop in sodium levels than patients on heparin in sodium chloride 0.9%. We also evaluated whether a higher incidence of line blockage was reported in either group.MethodsData was collected retrospectively using the Phillips ICCA electronic prescribing system, using 25 patients pre (April 2018) and 25 patients post (June and July 2018) implementation of the heparin in sodium chloride 0.45% flushes. Sodium blood gas levels were used as these were more consistently taken than plasma blood samples.ResultsThe data showed that heparin in sodium chloride 0.45% did not reduce sodium levels in patients. In each group 1 patient required additional sodium supplementation and 2 patients’ lines became blocked and therefore were removed. The average sodium on admission in the heparin in sodium chloride 0.9% group was 139.96 mmol/L (CI 95% ±1.17 mmol/L) compared to the heparin in sodium chloride 0.45% group which was 135.68 mmol/L (CI 95% ± 1.91mmol/L). The average sodium level on either line removal or discharge from PICU was 138 mmol/L (CI 95% ± 1.35mmol/L) in the heparin sodium chloride 0.9% group compared to 135.72 mmol/L (CI 95% ± 1.88 mmol/L) in the heparin sodium chloride 0.45% group. The results indicated that patients within the pre-change group lost, on average, 2 mmol/L sodium compared to their admission sodium levels compared to 0.04 mmol/L in the post-change group. The reason for this difference is unclear would warrant further investigation into alternative sources of sodium e.g. drug infusions and additional fluids which were outside of the scope of this audit.ConclusionThe change from using heparin in sodium chloride 0.9% to heparin in sodium chloride 0.45% was not found to lead to a reduction in plasma sodium levels in our patient population. Limitations to the audit include not considering alternative sources of sodium and a small patient population.ReferenceBeswick T, Skipp M. Should heparin based flushing solutions be used in preference to saline to maintain the patency of indwelling intravascular catheters and cannulae? – SPS - Specialist Pharmacy Service [Internet]. Available at www.sps.nhs.uk. 2016 [accessed 3 Aug 2018]. Available from: https://www.sps.nhs.uk/articles/should-heparin-based-flushing-solutions-be-used-in-preference-to- saline-to-maintain-the-patency-of-indwelling-intravascular-catheters-and-cannulae/

AimOur paediatric intensive care unit (PICU) has been using the Phillips ICCA electronic prescribing system since 2016. This system has an ‘order set’ function that allows a pre- populated list of medications to be created for use in certain situations. Potential benefits include reduced time to prescribe medications, reduced medication error rate and improved prescribing efficiency. The PICU quality improvement group and Pharmacy Informatics team created an order set for patients under 1 year of age admitted from theatre following cardiac surgery, which was implemented in June 2017. Our theatres do not use the ICCA system so as the patients are transferred with infusions running, there is a time gap where the patient has infusions running on PICU without a live prescription on ICCA. The aim of this project was to establish a reduction in the time taken for all 13 medications to be prescribed. In turn this would reduce the risk of running infusions without a live prescription.MethodsData was collected retrospectively from the ICCA system on 15 patients pre and 15 patients post the introduction of the order set. Time of admission was set when the patient was allocated a bed on ICCA. The times at which each medication was prescribed were taken directly from ICCA. A user satisfaction survey was also sent out to during the order set implementation phase.ResultsThe time taken to prescribe all 13 medications was reduced on average by 9.4 hours per patient. The average time saved per medication was 43 minutes. Pre implementation, the average time to prescribe the medications was 11.4 hours (95% CI [5.5, 17.3]). Post implementation, the time taken to prescribe the same medications was 2 hours (95% CI [0.5, 3.5]). Pre implementation, prescriptions were started at least 30 minutes (average) after the patient arrived on PICU. Post implementation, prescriptions were started 30 minutes before patient admission and completed within 30 minutes of arrival. 20 staff members completed the user satisfaction survey. The survey had a 13% return rate. 70% of users agreed or strongly agreed that using the order set function improved prescribing efficiency and 55% of users agreed or strongly agreed that the order set helped ensure appropriate doses.ConclusionImplementation of an order set for this patient group removed the risk of running infusions without a live prescription. This project is an example of how prescribing support functions within electronic prescribing packages can reduce time taken to write up medications within our unit, allowing prescribers to spend more time on other duties. Following the success of this intervention, further order sets will be created for use on our unit. A high level of clinical knowledge from the pharmacy support team and strong engagement with the clinical team was essential in creating a product that was fit for purpose. Limitations of this project are that we did not have the capability to assess a reduction in medication error. We now have increased support within the Pharmacy Informatics team to enable this for future projects.

UK sexual health services are shifting from hospital-based clinics into primary care, creating a need for high quality clinical sexual health training for non-specialists. Here we describe development, evaluation and costing of a new competency-based training programme, the Sexually Transmitted Infection (STI) Foundation Competency (STIF Competency) programme, based on the Department of Health's toolkit for delivering more specialized sexual health in primary care. We used an action research paradigm with two iterative cycles. Evaluation was to Kirkpatrick's third level with triangulation of results between trainers and trainees, and different methods, including portfolio evaluation, nominal group technique process, semi-structured interviews, Likert questionnaires and chlamydia testing rates. All 13 primary care clinicians completed the training successfully (median 20 hours) and rated STIF Competency highly. Trainers needed to reduce their clinical workload to accommodate the training. Average cost per trainee was £1125, reflecting the need for direct observation of competence across a wide range of clinical skills.

BackgroundHIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care but evidence on implementing testing is lacking.AimWe aimed to determine the effectiveness of post-trial implementation of a cluster randomised controlled trial (RHIVA2) promoting HIV testing in Hackney general practice.MethodThe RHIVA2 intervention (2010–12) comprised initial education and training, nomination of a practice lead nurse, external quality assurance, and referral of newly diagnosed patients to HIV services. Post-trial implementation (2012–2015) included additional intervention training, and audit of antiretroviral co-prescribing and missed HIV diagnoses. Monthly computerised HIV testing data, remotely extracted by the clinical effectiveness group, were analysed using interrupted time series analysis.ResultsFollowing RHIVA2 (20 intervention and 20 control practices), an additional 12 practices (11 former trial control, one former non-participating) received the intervention, and training was reinforced in six former trial intervention practices; a total of 31 practices (13 former trial intervention, 15 former trial control, and three former non-participating) completed the audit. HIV testing rates in intervention practices (trial or post-trial) increased immediately following the intervention by 85% (IRR = 1.85, 95% CI 1.72 to 1.99), and a similar effect (IRR 1.82, 95% CI 1.72 to 1.93) was observed when including comparator practices that didn’t receive the intervention at any point. The change in the effect of the intervention during the three years following the intervention decreased significantly (IRR = 0.99, 95% CI 0.99 to 0.99).ConclusionPost-trial implementation of a research intervention increased testing activity but may require regular support for sustainability.

The sexual health care of 175 HIV-positive patients attending the two HIV clinics at Barts and the London NHS Trust was audited for the first time. The audit standard was that 100% of patients should be in receipt of a sexual health screen within six months of their first HIV out-patient appointment. Overall, 44.5% of patients had a sexual health screen, of which 46 (60.5%) were diagnosed with a sexually transmitted infection. Those screened were younger than those who were not. Five factors were identified which were significantly associated with not having a genitourinary screen performed; site of HIV care, setting of HIV diagnosis, stage of HIV disease, specialty of HIV physician and whether a screen was recommended by the HIV physician. A number of recommendations have been implemented to improve the uptake of sexual health screening amongst HIV-positive patients.

IntroductionHIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets).Methods and analysisService evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses.Ethics and disseminationThe chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.

HIV care in the UK is led by hospital-based specialists with limited general practitioner (GP) involvement. As GPs have expertise in some non-microbial HIV-associated co-morbidities (e.g. cardiovascular disease), and more people are disclosing their HIV status to their GPs, there could be benefits in sharing HIV care. We describe contemporary models of shared HIV care in relevant developed world settings to inform future shared HIV care in the UK. An interview survey of key informants was used to explore experiences and models of shared care, and identify promoting and inhibiting factors. We interviewed ten key informants from six shared care models. There were three broad categories of shared care, with varying degrees of GP involvement. Strong clinical leadership in primary care, good professional relationships and communication, and tailored GP training were facilitators. Barriers included stigma, confidentiality concerns, and low prevalence of HIV outside major conurbations. Contemporary shared HIV care models have emerged organically and seem to work when grounded in good collaboration between a small number of dedicated GPs and specialist units. We propose two models for further study which may only be feasible in high HIV caseload practices. User acceptability, clinical and cost effectiveness must be considered.

STIF Advanced Competency was launched in October 2014 and is the second work-based training and assessment module in the STIF portfolio. It builds on the knowledge and skills acquired through completion of STIF Intermediate Competency by further developing the knowledge, skills, experience and competence of healthcare professionals to diagnose and manage sexually transmitted infections (STIs). It is designed for those who wish to lead and deliver a Level 21 standard sexual health service and hence is suitable for senior doctors from non-GUM settings such as sexual and reproductive health or primary care as well as specialist sexual health nurses in Level 3 GUM services training to become advanced nurse practitioners. Registrants for STIF Advanced must first complete STIF Intermediate as well as have a specified amount of prior clinical experience in sexual health. Each trainee must have a named clinical trainer who fulfils specifications for …