Improving notification of sexually transmitted infections: a quality improvement project and planned experiment

Abstract

Background and objective: Inadequate follow-up of positive sexually transmitted infection (STI) test results is a gap in health care quality that contributes to the epidemic of STIs in adolescent women. The goal of this study was to improve our ability to contact adolescent women with positive STI test results after an emergency department visit.

Methods: We conducted an interventional quality improvement project at a pediatric emergency department. Phase 1 included plan-do-study-act cycles to test interventions such as provider education and system changes. Phase 2 was a planned experiment studying 2 interventions (study cell phone and patient activation card), using a 2 × 2 factorial design with 1 background variable and 2 replications. Outcomes were: (1) the proportion of women aged 14 to 21 years with STI testing whose confidential telephone number was documented in the electronic medical record; (2) the proportion of STI positive women successfully contacted within 7 days.

Results: Phase 1 interventions increased the proportion of records with a confidential number from 24% to 58% and the proportion contacted from 45% to 65%, and decreased loss to follow-up from 40% to 24%. In phase 2, the proportion contacted decreased after the electronic medical record system changed and recording of the confidential number decreased. Study interventions (patient activation card and study cell phone) had a synergistic effect on successful contact, especially when confidential numbers were less reliably documented.

Conclusions: Feasible and sustainable interventions such as improved documentation of a confidential number worked synergistically to increase our ability to successfully contact adolescent women with their STI test results.

FIGURE 1

Key driver diagram: this QI tool starts by identifying our aim (left side of the diagram). We used qualitative interviews and clinical experience to identify the key drivers (center) that affect this aim. We then brainstormed design changes that might be implemented as interventions (right side).

FIGURE 2

Learning from PDSA cycles to increase our ability to make voice-to-voice contact with adolescent women who have a positive STI test result. I, intervention; L, learning.

FIGURE 3

Patient activation card. Intervention: cards distributed to all adolescent women with STI testing at their ED visit. During the planned experiment, the active version included all text, and the inactive version excluded the italicized text between the asterisks.

FIGURE 4

Shewhart P chart: percentage of charts with confidential number documented in the EMR for women with STI testing, over time. n, number of charts per interval. Solid line: mean percentage. Dotted lines: control limits. Initial intervention (box 1): E-mail ED staff reminders to collect confidential number whenever STI tests ordered. Arrows indicate subsequent interventions.

FIGURE 5

Shewhart P chart: percentage of women with an STI who were successfully contacted within 7 days of their ED visit, over time. n, number of infected women per interval. The vertical axis is the percentage of women contacted. Solid line is the mean, and dotted lines are control limits. Arrows indicate interventions.

FIGURE 6

Design matrix for a 2 × 2 factorial planned experiment denoting the order of runs and replications. The 2 modifiable factors (patient card and NP cell phone) each had 2 levels, resulting in 4 combinations or “runs.” The experiment was replicated, reversing the runs, after a change in the EMR system.

FIGURE 7

Response plots of the outcome (percentage of infected women contacted within 7 days) for the planned experiment according to replication and background variable (confidential telephone number). Each point is the mean result for the 4 conditions of the experiment. Patient card condition is noted on the horizontal axis, and lines represent NP cell condition.