Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections are highly prevalent in sexually active girls and women younger than 25 years. In the United States, the incidence of CT and GC infections has increased by 5% and 19%, respectively, from 2016 to 2017.1 Efforts have been made to incorporate sexually transmitted infection (STI) screening into health care settings other than primary care such as emergency departments and national job training programs.2,3 Adolescents and young adults (AYAs) frequently do not access preventive health care services, therefore hospitalizations provide another important opportunity to screen for STIs.4,5 Although testing is important, reviewing laboratory test results after a patient encounter can be challenging for physicians in all practice settings, but especially the inpatient setting after patient discharge. The World Alliance for Patient Safety established by the World Health Organization designated test follow-up as a major process contributing to unsafe patient care.6,7 A systematic review of studies of missed test results for hospitalized patients, including a pediatric study of missed positive CT tests and subsequent development of pelvic inflammatory disease, found that follow-up failure rate ranged between 1% and 23% for hospitalized patients.6,8 For this study, we aimed to understand whether quality improvement (QI) interventions improve tracking of screening CT and GC laboratory test results pending at the time of hospital discharge of AYA patients admitted for non–STI-related conditions.
MATERIALS AND METHODS
We conducted this study on the inpatient service at an urban, academic children's hospital where we see a high prevalence of CT and GC infections in AYAs in our clinics and emergency department settings.9 As per our inpatient protocol, all AYAs who disclose sexual activity during their hospitalization are offered CT and GC screening using urine nucleic acid amplification tests. For 21 of the 29 months that we implemented the QI interventions, our hospital used a hybrid paper and electronic health record (EHR), with laboratory tests being ordered and results posted electronically, whereas patient care notes were documented manually in paper charts. A binder with handwritten documentation was expected to be used to track CT and GC tests pending at discharge. During the last 8 months of the study, the hospital transitioned to a comprehensive EHR that included all patient care activities, and test results pending at discharge were incorporated into this system.
A multidisciplinary team created a protocol in August 2014 which outlined residents' responsibilities to document pending CT and GC tests, review results, and provide patient treatment when indicated. It included scripts on how to contact patients, disclose positive screening STI test results, and provide treatment or referral for treatment. Baseline data were collected for 3 months, from June to August 2014, prior to any intervention. Between September 2014 and January 2017, 5 Plan-Do-Study Act (PDSA) cycles were completed. Provider-reliant interventions were used in the first 4 PDSA cycles, and the intervention was fully automated via a new hospital-wide comprehensive EHR in PDSA cycle 5. Initial interventions included (1) weekly text-page reminders for senior residents, (2) the addition of text-page reminders for attending physicians, and (3) the addition of reminder stickers on each computer in the residents' workroom area. For PDSA cycle 4, a hospital-wide protocol for tracking all pending laboratory tests after hospital discharge, not just CT and GC, was created. The final PDSA cycle coincided with a hospital-wide transition to a new comprehensive EHR. An electronic in-basket was created for each inpatient unit, where results of all laboratory tests pending at the time of patient discharge were automatically collated. Additionally, the results were also sent to the in-basket of the attending physician of record at the time of the patient's discharge. The study was approved by the Children's Hospital at Montefiore/Albert Einstein College of Medicine Institutional Review Board.
Measures and Analysis
Our primary quality measure was the percent of pending CT and GC tests captured by the medical team as pending at the time of discharge from the hospital. An interactive software application, Clinical Looking Glass10 was used to obtain the medical record numbers of all the patients who had CT and GC tests performed at the children's hospital. These medical records were reviewed by the research team to identify the number of CT and GC tests which were screening tests, and were still pending at discharge. This number was used as the denominator. The number of documented pending CT and GC tests by the residents in the laboratory binder was used as the numerator in the first 21 months of the study. After the hospital transitioned to a comprehensive EHR, the number of tests released into the inpatient unit in-basket was used as the numerator. For all positive tests, if there was no documentation of patient notification and treatment in the medical record, the research team contacted the patient, disclosed the test results, and prescribed or referred for treatment. We also tracked the percent of AYAs with positive STI tests who received treatment or referral for treatment. A run chart and Nelson Rules were used to assess the impact of interventions to improve the capture of pending STI tests.11 Nelson Rules assess if variation in data points comparing preintervention versus postintervention periods represent a statistically significant change. STI tracking and notification rates were compared using χ2 analysis.
Of the 559 screening CT and GC laboratory tests that were pending at the time of AYAs patient discharge, 26 (4.7%) had a positive CT test and 1 (0.2%) had both a positive CT and GC test. Using Nelson Rules we found a significant shift toward documentation improvement during the first 13 months of the study period, although this waned in the latter months (Fig. 1). After automated capture of CT and GC tests pending at discharge during PDSA cycle 5, the proportion of pending CT and GC tests documented in the unit in-basket increased to 100% with significant improvement based on Nelson Rules. The documentation improvement from baseline through cycles 1 to 4, to cycle 5 (30% vs 62% vs 100%; P < 0.001). During the baseline data collection, 4 patients had positive CT test results posted after discharge, and none of them had documentation of notification or treatment for the infection (0%). During provider-reliant PDSA cycles 1 through 4, 22 patients had positive screening CT and/or GC test results posted after discharge. Twelve (55%) patients were notified and treated or referred for treatment by the inpatient team. During PDSA cycle 5, all 5 AYAs with positive CT tests (100%) were notified and treated by the inpatient team. The percent of CT and/or GC-positive patients treated or referred for treatment by the inpatient team significantly increased from 0% at baseline, to 55% during provider-reliant PDSA cycles to 100% during the automated EHR PDSA cycle (P < 0.05).
Our intervention successfully improved tracking of screening STI test results that were pending at the time of hospital discharge of AYA patients, an important component of care necessary to ensure treatment of asymptomatically infected youth. Our baseline data indicated that positive screening CT and GC tests resulting after patient discharge were often missed by inpatient teams that performed these tests because STI tests that were pending at discharge were not being adequately tracked. This finding is consistent with other studies of inpatient laboratory testing when the results are reported after the patient had been discharged.12 In this study, we show that rates of missed STI test results can be improved with protocols. The Agency for Healthcare Research and Quality has developed similar protocols for improvement of the follow up of outpatient laboratory testing.13 When examining our run chart, gains obtained in the beginning of our QI project appear to have diminished over time. This suggests the importance of “hard-wired” system changes that force clinicians to perform appropriate behaviors. Our study took advantage of a natural experiment when our hospital converted from a hybrid paper and EHR system to a comprehensive EHR system prior to our final PDSA cycle. We were able to show the utility of automation in creating a sustainable intervention that enhanced follow-up of pending STI testing. A limitation of this study is that it was performed at a single institution. Another limitation is that our baseline data were only collected for 3 months, therefore, the initial improvement in capture should be interpreted with caution. The improvement in laboratory review and patient treatment was likely driven by decreasing the burden of handwritten documentation of pending STI results, elimination of human dependent steps in review and the automatic delivery of laboratory results to both the resident and attending in-baskets. By optimizing the notification of all team members and simplifying the tracking process, clinicians can ensure appropriate tracking of pending laboratory results and patient treatment.
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