Multifactor Intervention to Reduce TNP Results of HIV Lab Orders Within a Community Health Center

Background: An estimated 190,000 patients living with, or at risk of contracting HIV, receive primary care at community health centers (CHC). HIV labs are an essential part of routine care and are utilized to determine the viral load, which is necessary to develop a care plan. A result of “test not performed” (TNP) occurs when there is an error processing the lab work. TNP results create an additional burden for both the patient and their providers and potentially delay proper care planning.

Method: In response to the prevalence of TNP results, the nursing team at a New York City CHC implemented a multifactor intervention in April 2023 to reduce TNP results. The intervention included email and instant message reminders, a time-out system where two medical office assistants confirm patient information to label the lab orders, verbal and written warnings for employees with multiple associated TNPs, a countdown board of days since the last TNP result, and a lab requirement cheat sheet. To evaluate outcomes, we examined electronic health record data on orders placed before intervention (January 1st, 2023, through April 16, 2023) and after intervention (April 17, 2023, through October 31st, 2023) to calculate the average monthly rate of TNPs and number of days between TNPs. Senior nursing leadership solicited informal feedback and documented successes and barriers.

Results: Over the period of observation, the site performed over 1,200 HIV labs, with 2.5% of labs resulting in TNP. Before the implementation, there were 22 TNP results, with an average of 4.9% results being TNP. After implementation, there were 7 TNP results, with an average of 1.1% results being TNP. The average number of days between TNPs increased after intervention from an average of 4.2 days between TNPs pre-intervention and 20.4 days post-intervention.

Discussion: The intervention experienced some limitations. Staffing challenges did not allow for the time-out system during busy clinical hours because it would delay patient care. The disciplinary system of warnings also had a perceived negative impact on staff morale. Additionally, TNPs can result from errors within laboratories independent of clinical staff; manual audits would determine the exact cause of TNP error. Despite these challenges, the multifactor intervention was shown to be successful in lowering the rate of TNPs at the center. Future research is needed to examine the causes of continuing TNPs to improve intervention, the sustainability of the intervention, and its application to other types of lab orders.