Ryan White Part C and D grantee and Louisiana HIVQUAL-US Regional Group participant, Louisiana State University (LSU) Health Care Services Division (HCSD), has offered HIV-specific care since 1987, serving 5711 unique patients across seven hospitals in the greater New Orleans and southern Louisiana region. LSU HCSD opened its HIV Outpatient Program in New Orleans at what was then the Medical Center of Louisiana at New Orleans (now Interim LSU Public Hospital) with funding from a Robert Wood Johnson grant. It was initially staffed by family practitioners and has since expanded to include infectious disease specialists. HCSD’s HIV clinics range in patient population size from 100 to 2300 individuals, and staffing ranges from one physician and 2-3 nurses (all part-time for HIV) to 5-8 physicians and a cadre of nursing, social service, health educators and subspecialty services.
Each of the HCSD medical centers has established a Quality Management (QM) Committee, composed of its Quality Manager, a physician, members of the nursing and hospital administrations and representatives from other disciplines as appropriate. The purpose of the QM committee is to collect and aggregate data, analyze its significance, present the results to the appropriate hospital bodies, and ascertain the need for changes in policies and procedures. HCSD chose improving rates for annual sexually transmitted infection (STI) screening across all facilities as its focus area starting in April 2008.
Globally, the United States has one of the highest rates for bacterial STIs while Louisiana ranks among the top five states for rates of gonorrhea, Chlamydia, and syphilis (including primary, secondary and congential syphilis). Each of these bacterial infections have potentially serious complications if left untreated. For an HIV-positive individual, a STI can stimulate the immune response and increase HIV replication rate, thus straining an already challenged immune system. Also, because STIs causes an increase in the number of HIV-infected immune cells present in genital or other bodily secretions, there is an increased risk for HIV-transmission during high-risk sexual activities.
Baseline and subsequent interim performance measurements were calculated for each individual HCSD clinic, as shown below. To quantify performance and ensure comparability across all HCSD clinics, participating QM Committee teams agreed to a shared quality measure for STI screening based upon the HRSA/HAB Performance Measures, Group 2 (Click here for a list of all indicators
). All patients who had a medical visit with a provider with prescribing privileges at least once in the measurement year and were a) newly enrolled in care; b) sexually active; or c) were diagnosed with an STI within the last 12 months, were counted as part of the measure’s denominator. Numerator patients included those for whom an STI screening (including Chlamydia, gonorrhea and syphilis) was documented during the measurement year. The data source for all clinics’ measured rates was HCSD’s “home-made” electronic respository. Clinics’ baseline STI screening values in late 2008 ranged between 6 and 62%.
The wide diversity of the HIV clinics in physical size and location, number of patients and staff, and organization of on-site and other services precluded a one-size-fits-all approach to reaching HCSD’s goal for STI screening rates of 85%. Each HIV outpatient clinic then developed methods to improve their rate using standard quality improvement tools such as cause-and-effect analyses, process maps and Pareto charts.
Interventions employed to increase rates for STI screening generally fell into two major categories: staff education and delivery system changes. Trainings were given to all members of the clinical teams prior to starting the project to emphasize the importance for both the patient and the wider community in identifying and treating STIs. Quarterly HCSD disease management meetings then provided opportunities for re-education and reinforcement as needed.
System-wide adjustments such as changes to the laboratory order form, the availability of screening before or during clinic hours and the establishment of standing orders to allow nurses to order the screening tests were all used across the HCSD clinics in order to integrate STI screening into routine laboratory monitoring. These approaches helped to evenly distribute responsibility and effort among several different clinical team members, particularly for larger clinics with staff consisting primarily of part-time clinicians. Also implemented were providing specimen collection cups early in the clinic visit (after vital signs were taken) to patients identified as needing screening and placing collection kits in the clinic. Although “low-tech,” such highly reproducible methods were especially effective at smaller clinics with tight-knit staffs and fit well into the flow of a busy clinic when paired with additional reminders and prompts within the medical record.
All HCSD HIV clinics improved screening rates for Chlamydia and GC over the ensuing two and a half years. Less robust results were seen in screening for syphilis, yet a significant increase for those clinics in particular that had the lowest rates before the start of the STI project. Re-measurement was performed by each site on a sequential basis and was reported during quarterly QM Committee meetings.
As of April 2011, L. J. Chabert Medical Center recorded the highest achieved screening rates at 82% (Chlamydia and GC) and 88% (syphilis), as well as the largest average percent-increase (56%) across all three STIs. HCSD HIV clinics saw an average improvement of 42.9% for Chlamydia, 47.7% for GC and 6.3% for syphilis.
In order to sustain these improvements, each clinic developed plans to systematize successful interventions and expand upon existing strategies. Re-education and STI-focused trainings for staff continue to be held during quarterly HCSD disease management meetings. For some clinics that chose to develop standing orders to grant nurses the ability to order the STI screenings be performed, lab order sheets are placed within the chart with the patient’s needed tests indicated. One clinic also added STI screening to the nursing assessment sheet which is then reviewed by the clinicians at each visit.
These efforts illustrate the LSU Hospital - HCSD HIV clinics’ innovative and robust approaches to the improvement of screening rates for Chlamydia, GC and syphillis as well as the associated health outcomes for all HIV-positive patients. In terms of next steps in 2011, HCSD has begun to examine the performance of each clinic in monitoring and managing diabetic HIV patients. The team has also decided to initiate QI projects targeting Hepatitis B and other vaccination rates for patients. This ambitious agenda demonstrates LSU Hospital - HCSD’s commitment to improving all elements of HIV primary care and targeting significant public health priorities.