Non-Patient Specific Standing Orders as a Tool for Addressing Overlapping Epidemics
In the United States, the Department of Health and Human Services reports that approximately 3.2 million persons are living with chronic Hepatitis C viral infection (HCV), which is about three times the overall number of HIV cases in the country. Each year, an average 17,000 new infections of HCV occur, many of which go unreported. Not only do many cases of HCV go unreported, many go untreated, for a variety of reasons, including: a long incubation time for the virus, lack of access to care, co-occurrence with other challenging conditions (especially HIV and substance use disorders), and the side effects and low success rates of existing treatments. But the tide is turning for those infected by HCV.
There is a high co-occurrence of HCV with HIV and substance use, leading to a need to create mechanisms that would help identify comorbidities and begin treatment as early as possible. Currently, between 50% and 90% of persons living with HIV or AIDS (PLWHA) who use injection drugs are also infected with HCV. Overall, about 25% of all PLWHA are also infected with HCV. In New York City, the co-occurrence of HCV and HIV maps out on to the areas of high incidence for HIV in the South Bronx, Harlem, Central Brooklyn, and Chelsea. According to the CDC, HIV and HCV coinfection "more than triples the risk for liver disease, liver failure, and liver-related death from HCV," which includes both the incidence of cirrhosis and liver cancers.
The New York State Department of Health has taken measures to make diagnosis of HCV, HIV, and other disorders more accessible, as summarized in a new memorandum from the Department of Health's AIDS Institute on the "Use of Non-Patient Specific Standing Orders for HIV and Hepatitis C Testing." This memorandum highlights the important role that non-MD health professionals can play at the community-level to address ongoing epidemics and emergent public health issues. This standing order enables registered nurses (RNs) to provide HIV testing, hepatitis C testing, other specific immunizations for both adults and children, anaphylactic treatment medications, Tuberculin PPD tests, and emergency treatment of opioid overdose.
In New York, the regulations for non-patient specific standing orders are overseen by New York State's Department of Education Office of Professions. As their Website explains:
"A non-patient specific order authorizes named RNs or RNs who are not individually named but employed or under contract with a legally authorized entity, to administer specified immunization agents or anaphylaxis treatment agents for a specified period of time to an entire group of persons such as school children, employees, patients of a nursing home, etc. Some health care agencies think non-patient specific orders refers only to giving immunizations to employees. Such orders can actually be much broader than this."
The NYSED.gov Website's "Practice Alerts and Guidelines" are available online here, and at this site you can find information on how non-patient specific orders work and to what they apply, including the different adult and child immunizations that nurses are authorized to perform. In addition, pharmacists are also authorized to perform certain immunizations, and the NYS Department of Health provides guidance on pharmacists as immunizers as well.
Through the issuance of these standing orders, health care providers are able to provide community members with greater access to preventive services that will reduce the overall cost of care by keeping people healthy and out of the doctor's office or hospital. The standing order establishes the mechanism for providers to obtain reimbursement for these services directly, thereby easing the administrative cost of preventive care in the community. By enabling greater ease of access to testing, we increase the likelihood of identifying new comorbid cases and bringing them into the continuum of care.