Universal Chlamydia and Gonorrhea Screening in a Primary Care Setting: A Quality Improvement Project

Chlamydia and gonorrhea (GC/CT) are two of the most frequently reported sexually transmitted infections (STIs) in the U.S. Often asymptomatic, they can have serious health consequences for women and most new infections occur among females 24 years old and younger. The purpose of this QI project was to evaluate the effectiveness and sustainability of a universal STI screening protocol in a primary care clinic setting. The primary goal was to align their clinical practice with CDC recommendations for universal screening and enhance chlamydia and gonorrhea screening and detection rates in females ages 24 years and younger. Local Problem: STI data in Utah indicate that rates of CT have increased by 44% since 2010, and GC by 818% since 2011. Clinic 2 providers performed risk-based screening only. Clinic staff reported significant discomfort in collecting sexual health histories as a barrier and therefore missed opportunities to screen asymptomatic patients. Methods: Participants from a similar project were surveyed and interviewed to determine the success and sustainability of a universal CT screening protocol that had been implemented in 2021. Feedback was used to inform revisions to the protocol, including the addition of GC screening. A pre-survey was given to the participating Clinic 2 staff to establish baseline measures of knowledge and comfort. A post-survey was distributed at the end of the project to determine participants' feedback regarding usability, feasibility, and satisfaction with the protocol. Chart audits were conducted to determine screening rates and individual provider adherence to the protocol. Interventions: Education on STI screening and taking sexual health histories was provided to clinic staff before protocol implementation. The use of repeated PDSA cycles addressed barriers and reinforced staff participation. Results: A total of 170 eligible patients were seen by 5 providers during 14 weeks of implementation and 117 (69%) patients were offered GC/CT screening. Only 65 (56%) patients had STI testing completed, and 2 (3%) patients had positive chlamydia results. Clinic staff found the protocol to be feasible within their daily workflow. Staff indicated that having a sexual health history questionnaire reduced their discomfort and bias in discussion of STI testing with patients. Conclusion: The asymptomatic nature of GC/CT infections will continue to allow infections to spread unknowingly and for this reason, the CDC guidelines for universal STI testing should be integrated into any clinic setting wherein patients at highest risk are seen by healthcare providers. Clinical behaviors were changed, and more women were screened for STIs due to the intervention. More research is needed to determine cost versus benefit, not only in financial costs but also in human costs associated with the adverse health consequences of undiagnosed STIs in asymptomatic patients.

1 Universal Chlamydia and Gonorrhea Screening in a Primary Care Setting: A Quality Improvement Project Morgan Judd & Pamela Phares University of Utah College of Nursing NURS 7703: DNP Scholarly Project III April 23, 2024 2 Abstract Background: Chlamydia and gonorrhea (GC/CT) are two of the most frequently reported sexually transmitted infections (STIs) in the U.S. Often asymptomatic, they can have serious health consequences for women and most new infections occur among females 24 years old and younger. The purpose of this QI project was to evaluate the effectiveness and sustainability of a universal STI screening protocol in a primary care clinic setting. The primary goal was to align their clinical practice with CDC recommendations for universal screening and enhance chlamydia and gonorrhea screening and detection rates in females ages 24 years and younger. Local Problem: STI data in Utah indicate that rates of CT have increased by 44% since 2010, and GC by 818% since 2011. Clinic 2 providers performed risk-based screening only. Clinic staff reported significant discomfort in collecting sexual health histories as a barrier and therefore missed opportunities to screen asymptomatic patients. Methods: Participants from a similar project were surveyed and interviewed to determine the success and sustainability of a universal CT screening protocol that had been implemented in 2021. Feedback was used to inform revisions to the protocol, including the addition of GC screening. A pre-survey was given to the participating Clinic 2 staff to establish baseline measures of knowledge and comfort. A post-survey was distributed at the end of the project to determine participants’ feedback regarding usability, feasibility, and satisfaction with the protocol. Chart audits were conducted to determine screening rates and individual provider adherence to the protocol. Interventions: Education on STI screening and taking sexual health histories was provided to clinic staff before protocol implementation. The use of repeated PDSA cycles addressed barriers and reinforced staff participation. 3 Results: A total of 170 eligible patients were seen by 5 providers during 14 weeks of implementation and 117 (69%) patients were offered GC/CT screening. Only 65 (56%) patients had STI testing completed, and 2 (3%) patients had positive chlamydia results. Clinic staff found the protocol to be feasible within their daily workflow. Staff indicated that having a sexual health history questionnaire reduced their discomfort and bias in discussion of STI testing with patients. Conclusion: The asymptomatic nature of GC/CT infections will continue to allow infections to spread unknowingly and for this reason, the CDC guidelines for universal STI testing should be integrated into any clinic setting wherein patients at highest risk are seen by healthcare providers. Clinical behaviors were changed, and more women were screened for STIs due to the intervention. More research is needed to determine cost versus benefit, not only in financial costs but also in human costs associated with the adverse health consequences of undiagnosed STIs in asymptomatic patients. Keywords: chlamydia, gonorrhea, universal screening, sexually transmitted infections 4 Universal Chlamydia and Gonorrhea Screening in a Primary Care Setting Problem Description Chlamydia and gonorrhea are two of the most frequently reported sexually transmitted infections (STIs) in the U.S. (CDC, 2021). More importantly, recent research has determined chlamydia to be the most common bacterial cause of STIs worldwide (Grygiel-Górniak & Folga, 2023). Utah data indicates that rates of chlamydia have increased by 44% since 2010, and gonorrhea by 818% since 2011 (Utah Department of Health, 2020). The most concerning issue with both STIs is that they frequently lack symptoms that would prompt individuals to seek medical care. It is estimated that 75% of female and 50% of male patients affected by chlamydia and gonorrhea are asymptomatic. Under these circumstances, it is reasonable to assume that actual disease prevalence is higher than currently reported (Grygiel-Górniak & Folga, 2023). The asymptomatic nature of chlamydia and gonorrhea results in delayed or missed diagnosis and treatment, unknown transmission to subsequent sexual partners, and rapid community spread of infection (Utah Department of Health, 2020). Untreated infection can result in adverse sequelae for women, the most severe of which include pelvic inflammatory disease, ectopic pregnancy, and infertility (CDC, 2021). Other complications include cervicitis, urethritis causing dysuria-pyuria (which can be mistaken as cystitis), chronic pain, complications with pregnancy, and vertical transmission to neonates (Hsu, 2022). Those at the highest risk of acquiring STIs are sexually active adolescents and young adults, specifically, those 24 years old and younger. At those ages, patients may be unaware of published screening recommendations (CDC, 2021). Grygiel-Górniak & Folga (2023) conducted a systematic review of the literature and found that two-thirds of new infections occurred among females in this age group. Though it is well known that this population is at the highest risk for 5 these infections, discomfort among both the medical staff and patients creates barriers to sexual health discussions at routine medical visits, leading to missed opportunities for screening (Allison et al., 2022). Available Knowledge Several studies have been conducted to ascertain the most effective approach for chlamydia and gonorrhea screening (Ahmad et al., 2022; Allison et al., 2022; Elattma et al., 2020; Goyal et al., 2016; Lane et al., 2020; Lunny et al., 2015; McDonagh et al., 2020; Pillay et al., 2021; Reed et al., 2020; Wong et al., 2019). Providers who see patients in the target age group must familiarize themselves with evidence-based STI screening and treatment recommendations as well as remain up to date on emerging research. The U.S. Department of Health and Human Services (2020) created a national strategic plan to slow the increasing incidence of chlamydia and gonorrhea. Experts cite current challenges to chlamydia and gonorrhea control are due to asymptomatic infections and lack of provider and community awareness of screening recommendations (U.S. Department of Health and Human Services, 2020). Current recommendations from the Centers for Disease Control and Prevention (CDC) include annual universal screening of sexually active females less than 25 years old (2020). Studies that have examined the effectiveness of universal screening have identified multiple benefits. Universally offering STI screening to adolescents at the time of check-in for their medical appointments increased screening and detection rates but did not adversely affect clinic workflow (Reed et al., 2020). It is projected to be more cost-effective to perform universal STI screening when considering the high potential for reducing disease incidence, as both infections are easily treated (Owusu-Edusei et al., 2016). Findings from a study by Lane et al. (2020) 6 demonstrated that both parents and their adolescents are amenable to sexual health education and STI testing, and often adolescents and young adults would prefer the provider initiate sexual health discussions. Lastly, the utilization of universal screening has the potential to reduce stigma and bias by offering an opt-out approach, rather than a targeted opt-in approach, which may reduce social inequities and discrimination in healthcare (Territo & Burstein, 2021). To aid in the uptake of this evidence-based practice change, researchers recommend the involvement of all healthcare clinic staff when providing education about universal screening. The use of incentives for providers who use the new protocol has the potential to increase compliance (Elattma et al., 2020). It is recommended that providers be given further training in how to obtain a sexual health history in a way that promotes a safe and comfortable environment for the patient to divulge sensitive information. When done correctly, sexual health conversations are normalized, and patients are empowered to advocate for themselves in the future. Researchers have found that patients are most amenable to sexual health conversations when initiated by the provider rather than having to broach the discussion themselves (Gearhart et al., 2020). Primary care clinics present an ideal setting for the implementation of universal STI screening (Allison et al., 2022). Its integration is feasible in a primary care clinic with the support and commitment of both the providers and their clinical support staff. Rationale Universal GC/CT screening is an important but underused clinical practice and presents a visible care gap in women’s health. The Institute for Healthcare Improvement’s (IHI) model for improving healthcare practices provides a logical framework for the implementation of a quality 7 improvement (QI) project focusing on universal screening. It has been widely used by many healthcare institutions to align the delivery of care with evidence-based recommendations. The IHI model consists of two parts. The first part poses fundamental questions of what the project is trying to accomplish, how will it be determined that the change is an improvement, and what change can be made that will result in an improvement (IHI, 2023). The primary aim of the project addresses the first question, which is to develop a feasible method to improve STI screening, specifically gonorrhea and chlamydia, in an outpatient clinical setting. Consistent use of universal screening over time and visible improvement in screening and detection rates addresses the second question. Finally, evaluating the experience of one clinic’s implementation of a universal chlamydia screening QI project two years ago will guide the implementation of an updated clinical practice guideline (CPG) for universal GC/CT screening at a new clinic. The revised CPG will be tailored to the needs of the target clinic for this project. The second part of the model is the Plan-Do-Study-Act (PDSA) cycle to test the changes in real time. As the name suggests, after planning and implementing the new protocol, the appropriate team members can study its effects and act on those results. This cycle was repeated multiple times throughout the implementation period to adjust the CPG to best fit the clinic’s unique needs and workflow. The principal investigator (PI) continued to make changes to the protocol throughout implementation until it was deemed usable and feasible within the clinic’s workflow. Specific Aims The purpose of this Doctor of Nursing Practice (DNP) QI project was to evaluate the adherence to and sustainability of a universal STI screening protocol at Clinic 1and identify necessary changes to the protocol before implementing an opt-out universal STI screening 8 intervention at Clinic 2 to increase rates of screening for chlamydia and gonorrhea in women ages 24 years and younger. The primary goal was to use this evidence-based practice change to encourage Clinic 2 clinicians and medical assistants (MAs) to align their clinical practices with CDC recommendations (CDC, 2021) for enhanced detection of STIs, and to improve patient outcomes. Methods Context Clinic 2 is a family practice and urgent care clinic located in Cottonwood Heights, a suburban city on the east bench of Salt Lake County. The population attending this clinic is primarily white, of middle and upper-middle-class socioeconomic backgrounds, and are mostly privately insured. The clinic is staffed by 21 providers, including medical doctors (MDs) and physician assistants (PAs). Two MDs, three PAs, and three MAs participated in this project. The patients targeted for the intervention were female patients ages 24 years and younger. To provide a reasonable cut-off for the staff, the minimum age for eligible female patients was set at 12 years of age. The final criteria for eligibility were the type of visit scheduled: annual visits and problem-focused gynecology visits. Prior to this project, universal STI screening was not in use at Clinic 2. Providers’ screening practices were centered on a patient’s risk factors, symptoms, and requests for testing. Selective screening such as this may have led to many missed opportunities to detect asymptomatic infections due to implicit biases. Intervention(s) The initial step of the intervention was to complete an evaluation of the feasibility, usability, satisfaction, and sustainability of the universal screening protocol that a previous DNP 9 student had implemented at Clinic 1 in 2021 (Dowdle & Phares, 2021). Survey data and user feedback were obtained from the staff of Clinic 1 (Appendix A). Following this evaluation, the CPG protocol from Dowdle and Phares’ QI project was adapted and revised specifically for Clinic 2. The MAs and providers at Clinic 2 were trained to obtain a sexual health history and received information regarding the fundamental concepts of universal chlamydia and gonorrhea screening before starting the intervention. A PowerPoint presentation was used to disseminate the information (Appendix B). Treatment guidelines were included. Pre-intervention preparation was intended to enhance uptake of the CPG by increasing participants’ knowledge on the topic and increasing buy-in through a better understanding of the importance of universal STI screening and the health consequences of not screening. Staff were asked to complete a survey before the training to assess their comfort level and practices regarding sexual health care (Appendix C). Staff also completed a follow-up survey at the end of the QI project for comparison (Appendix D). Both surveys included closed-ended questions and free-form text responses, which provided a trove of information. Unlike fixed-response survey questions with preconceived options, free-form text responses may uncover unexpected narratives and issues that may have otherwise been missed. Once the intervention was initiated at Clinic 2, the MAs were asked to add a notation in each eligible female’s chart each day to remind themselves, and the providers, to use the CPG for GC/CT screening. During patient visits, the MAs would gather a sexual health history, educate eligible females about the CDC recommendations, and offer GC/CT screening. Patients were expected to leave a urine sample either before or after the visit. A urine sample for screening is a non-invasive STI testing approach versus a specimen obtained by a cervical swab. This approach 10 enhances the uptake of testing by patients versus obtaining a specimen during a pelvic examination, which is not indicated for most patients at risk. Providers were notified if the patient refused screening with the expectation that he or she would reinforce the importance of STI screening and encourage them to be tested during the visit. The provision of multiple opportunities for STI screening has the potential to enhance patient’s uptake of screening. The PI also created “smart phrases” to promote ease of documentation in the electronic medical record (EMR). The first smart phrase was the sexual health history questionnaire (Appendix E). This questionnaire was adapted from the CDC’s guidebook (Reno et al., 2022). The second phrase was documentation stating the patient had been educated about and offered GC/CT screening and the patient’s decision on whether to complete screening. When the smart phrases were added to the note, it served as an additional reminder for the MA and provider to utilize the CPG. Study of the Intervention(s) Clinic 1 medical assistants completed a survey (Appendix A) to evaluate the sustainability, feasibility, usability, and satisfaction with the universal screening protocol implemented by a previous student in 2021 (Dowdle & Phares, 2022). Qualitative and quantitative data from the survey allowed for the identification of areas for improvement in the protocol. The results informed the PI about specific problems encountered among Clinic 1 staff regarding the use of the 2021 universal STI screening CPG and created an opportunity to revise those areas to augment the success of this QI project. At the educational meeting for Clinic 2 providers and staff, prior to deployment of the CPG, both groups completed a survey to determine baseline attitude, knowledge, and comfort with STI screening and obtaining sexual health histories from patients (Appendix C). They completed a post-implementation survey at the end of the project (Appendix D). The post-survey 11 also queried respondents about the feasibility, usability, and satisfaction with the CPG as well as its sustainability moving forward. During implementation, GC/CT screening and detection rates at Clinic 2 were determined using data extracted from chart audits. The PI frequently monitored patient data to ensure the CPG was being followed and that all eligible patients, females ages 24 years and younger scheduled for either annual exams or gynecologic visits, were being offered GC/CT screening. Testing completion was also being monitored. Frequent monitoring provided an opportunity to re-educate and reinforce the new protocol with staff, and to use the PDSA cycle to make necessary adjustments throughout the process. The PI conducted weekly site visits for the first month of implementation to troubleshoot obstacles, and then as needed during subsequent months. At the conclusion of the intervention, the PI compiled a formal report of findings and shared these with the project participants. Measures The surveys created for the intervention were reviewed and approved by the faculty project chair. In the pre-survey for Clinic 2 (Appendix C), seven of the survey questions used a five-point Likert format, wherein lower scores indicated less agreement with a statement or low frequency of a behavior and higher scores indicated stronger agreement with a statement or higher frequency of a behavior. Four multiple-choice questions were asked about demographic information. To assess barriers to STI screening in their clinic, one question allowed users to select as many options as desired, which included an option to write a free-text response if needed. Lastly, one question was open-ended for free-text responses so users could give specific recommendations regarding the implementation of QI projects at their clinic. 12 In the post-survey for Clinic 2 (Appendix D), ten of the survey questions used a fivepoint Likert format. Barriers to screening were again assessed utilizing a format of selecting all that applied, including an option to write a free-text response if needed. The final question was open-ended for free-text responses regarding final recommendations for improving the CPG. To determine the efficacy of the new CPG, the PI conducted chart audits to determine the number of completed screenings among eligible females and the number of STIs detected during the implementation period. In addition, completed screenings by individual providers were tallied to determine adherence. Analysis REDCap, a secure university web application for building and managing online surveys and databases, was used to collect survey data. Quantitative data were analyzed using descriptive statistics and were primarily reported as frequencies and measures of central tendency. These data included demographic information pertinent to project participants as well as responses to survey questions. Open-ended questions were treated as qualitative data. Responses were read, summarized, and categorized by common themes. Chart data were collected by EMR audit to determine the rates at which screening was being offered and completed. Descriptive statistics were used to analyze chart data and results were reported primarily as frequencies and measures of central tendency. Ethical Considerations This project was deemed quality improvement in nature and not subject to the University of Utah Institutional Review Board approval or oversight. All data collected from patients and staff were de-identified and reported in aggregate. Survey data were coded to protect participant anonymity. Data were stored on an encrypted, password-protected device to which only the PI 13 had access. There were no conflicts of interest to report, and clinic staff were not paid for their participation in the project. Results The results of the survey given to the medical assistants at Clinic 1 who participated in the original QI project in 2021 (n=7) are listed in Table 1. The majority reported that they never or rarely questioned patients about their sexual health history, but usually or almost always offered eligible patients STI screening. They identified three chief barriers to universal screening. These included not being asked by the provider to address sexual health, experiencing uneasiness in broaching the subject due to parents being in the room with adolescents, and having discomfort discussing sexual health histories with patients. Most MAs agreed that the CPG did not add significant time to clinic visits and that the protocol was easy to follow. A wide variation in responses was seen when asked whether the CPG increased STI screening rates in the clinic. Most of the MAs were neutral when asked if the education provided made them feel more comfortable discussing sexual health histories. Qualitative feedback was also elicited from the Clinic 1 MAs using open-ended, free-text responses. Results indicated a sexual health history questionnaire may have improved their comfort with STI screening, had they been provided one. Medical assistants also indicated that having a framework for this discussion may also have improved the knowledge base for both staff and patients since the focus would be gathering objective information and providing directed education to patients instead of navigating an uncomfortable social environment without guidance. The survey results and recommendations by MA staff at Clinic 1 were used to adapt the CPG before implementation at Clinic 2. For example, the providers were included in the QI project instead of focusing only on the medical assistants as was the case at Clinic 1. More 14 thorough education was provided to the staff at Clinic 2 before implementing universal GC/CT screening. This included the provision of a sexual health history questionnaire in both electronic and print form. Lastly, the previous student project at Clinic 1 focused on chlamydia screening only, however, gonorrhea is frequently comorbid with chlamydia. For this reason, gonorrhea screening was included for this CPG. This QI project was implemented at Clinic 2 from November 6, 2023, through February 9, 2024. Though initial plans were to collect, analyze, and report data throughout the implementation period, the PI was unable to do so because Clinic 2 had recently transitioned to a new EMR system, and the clinic did not permit timely access for the PI during that transition. Because of this, all chart data were collected retrospectively. The PI was able to continue the use of PDSA cycles throughout the intervention using verbal feedback elicited from participants at frequent site visits and email communications. Feedback facilitated timely adjustments to the protocol and helped to reinforce staff engagement. One example highlighting the use of the PDSA cycle was revising the protocol to allow individual MAs to decide when to collect the urine sample so that it could be more easily and quickly adapted to their normal workflow. Another revision to the CPG was to use it more frequently, specifically during gynecologicfocused visits such as patients presenting with UTIs, or for contraceptive counseling visits. Originally the staff had not recognized the opportunity to implement the CPG at these problemfocused visits. An unexpected benefit was found through conversation in which staff expressed their satisfaction with having the sexual health history questionnaire in print to give to patients, as well as included as a “smart phrase” for documentation in the EMR. Both providers and MAs reported that the questionnaire increased their comfort in discussing sexual health care with their 15 patients, reduced bias by eliminating individual judgments for determining who needed screening, and aided them in providing more comprehensive care. During the fourteen weeks of implementation, there were 170 eligible patients seen by the five participating providers (Table 2). Of those, 117 (69%) patients were offered GC/CT screening. Of those offered screening, 65 (56%) patients agreed to and completed a GC/CT test. There were only 2 (3%) patients who tested positive for chlamydia, and none tested positive for gonorrhea. Compliance with the CPG among individual providers was also analyzed (Table 3). The following rates by provider were calculated: provider #1 offered screening to 39 (80%) patients; provider #2 offered to 4 (31%) patients; provider #3 offered to 17 (52%) patients; provider #4 offered to 34 (83%) patients; and provider #5 offered to 23 (68%) patients. It is important to note that provider #2 saw only 13 eligible patients during the 14-week implementation period, making that individual an outlier which skewed the combined percentage of patients screened by all providers. The pre-survey for Clinic 2 was analyzed using only descriptive statistics, due to a few limitations discovered after the completion of the intervention. The first reason is because of the small sample size. Only eight people, five providers and three medical assistants, participated in the QI project. Of those eight people, only five of them completed the post-survey. Due to an error by the PI, a unique identifier was not given to each participant and therefore pre- and postsurveys could not be paired as initially intended. There was also no differentiation between providers and MAs when surveys were deployed. This was problematic in that the level of knowledge between providers and MAs cannot be assumed to be equivalent due to significant educational and role differences in these two groups. The errors posed significant barriers to 16 meaningful comparison of data to determine changes in each participant’s knowledge and behavioral changes. Therefore, no analysis was conducted comparing post-intervention survey results to pre-intervention surveys. Five Clinic 2 providers and three MAs completed the pre-implementation survey (Table 4). Most participants (n=5) were confident in their knowledge of STI risk factors, complications, and screening recommendations, which most likely represented responses from the five providers. The majority were also comfortable discussing sexual health histories with patients. Participants identified four chief barriers to screening all eligible patients. These included not being asked by the provider to address sexual health, experiencing uneasiness in broaching the subject due to parents being in the room with adolescents, having discomfort discussing sexual health histories with patients, and time constraints. Discussion Summary The purpose of this QI project was to improve upon a universal STI screening protocol previously used at Clinic 1 and then implement it in a different primary care outpatient clinic setting. The primary goal was to use an evidence-based CPG to encourage the clinicians and staff at Clinic 2 to align their clinical practices with CDC recommendations for enhanced detection of STIs which, by extension, improves patient health outcomes. Excluding provider #2, the other four providers offered screening to most of their patients. Ideally, all eligible patients would have been offered screening during the project’s implementation. Those who responded to the post-implementation survey did not find the CPG burdensome to use and expressed their satisfaction with the protocol. One clinical staff member commented, “This turned out to be much easier than expected and insightful.” Improvements that had been made to the previous CPG implemented at Clinic 1 were found to be beneficial to 17 staff and providers at Clinic 2, specifically, the teamwork involved between the MAs and providers and the use of a sexual health history questionnaire. Overall, the CPG was well received by participants and more patients were screened for STIs because of this project that may not otherwise have been offered STI screening. To conclude the project and provide recommendations for Clinic 2, an Executive Summary was created and disseminated (Appendix F). Interpretation It would have been meaningful to have had long-term, pre-implementation chart data of risk-based STI screening and detection rates to compare to post-implementation rates using the universal screening protocol. It is reasonable to assume that there would be an increase in both screening and detection rates with universal screening, but that is not always the case. Changing clinical practices and behaviors takes a significant amount of time and certainly more time than that of the implementation period for this project. Researchers have reported that universal screening is more cost-effective than risk-based screening when considering the high potential for reducing disease incidence and the serious health sequelae from undetected STI infections in females (Owusu-Edusei et al., 2016). During this QI project, only two cases of chlamydia were reported. The question remains whether those two cases were enough to justify the costs associated with the continued testing of urine samples for all eligible patients in the clinic. That question is beyond the scope of this project and additional research is recommended to address the cost versus benefit of universal STI screening. Monthly rates of GC/CT screening increased slightly over the course of the QI project. During the first month of implementation, 61% of eligible patients were screened. After fourteen weeks of CPG implementation, the cumulative rate was 69%. However, it is important to note 18 that provider #2 saw only 13 eligible patients during the fourteen-week implementation period. As an outlier, this provider skewed the combined percentage of patients screened by all clinic providers. If data from provider #2 were excluded, the cumulative screening rate among providers in the clinic would have risen to 72%. During the previous QI project at Clinic 1 in 2021 there were 85 patients eligible for universal screening. Per the report by Dowdle and Phares (2022), 54.1% (n=46) of those patients were offered chlamydia screening during the 12 weeks of CPG implementation. The implementation period during this QI project was lengthened to fourteen weeks at Clinic 2. Overall, Clinic 2’s total number of eligible patients (n=170) was much higher than Clinic 1's (n=85). Clinic 2 also had a higher cumulative screening rate (69%) than Clinic 1 (54.1%). Implementing the protocol for a longer period may have resulted in a higher percentage of patients being screened. In the pre-survey responses from Clinic 2, reported barriers to universal screening were very similar to those identified by Clinic 1 staff. The reported barriers were time constraints, providers not asking for sexual health to be addressed with patients, discomfort with a parent being in the room with their adolescent, and discomfort discussing sexual health histories. Throughout the implementation period, Clinic 2 staff reported that they became more comfortable when discussing sexual health histories with patients and even found parents to be open to these conversations, which aligns with findings from previous studies (Lane et al., 2020). At Clinic 2, MAs and providers were able to communicate effectively with one another, allowing them to complete the sexual health history questionnaire and adhere to the CPG more consistently. This is a notable improvement when this finding was compared to that of the MAs at Clinic 1, who had recommended in the survey for this project that their clinic providers should 19 have been more involved and that the provision of a sexual health history form would have been helpful. On the Clinic 2 post-survey, one participant identified two additional barriers to universal screening within the free-text response question. One of these barriers was the largely religious population attending the clinic, and the second barrier was patient resistance to screening. These would be important factors to study regarding the sustainability of using this CPG at Clinic 2. Patient education may have to be altered to address these barriers, particularly because sex education in Utah is highly regulated by the state which places several key limitations on the content of sex education programs (SIECUS, 2021). Developing an understanding of the issue at the community and state level and developing a strategy to address these related factors may improve the feasibility and usability of the CPG in practice, which would enhance the sustainability of the clinical practice change. Limitations There were several limitations identified in the project. Implementation time was limited to a few months and the number of participants was small (n=8). Implementing this project in a larger practice over a longer period of time may have resulted in very different findings. Another limitation was the lack of diversity in the clinic population. Most patients seen by providers in this practice were White, of middle to upper middle-class socioeconomic status, and belonged to a distinct religion that prohibits pre-marital sex as one of its tenets. This significantly limits the generalizability of findings from this project. Another limitation was the inconsistency of MA staffing among providers in the clinic. It was difficult to ensure that new MAs were properly trained on the CPG which likely resulted in failure to offer STI testing to all eligible females. 20 Design errors in the deployment of surveys prohibited meaningful comparison of pre- and post-implementation results. Surveys were not matched and were not categorized by type of provider, nor did all participants complete the post-survey. Educational background and therefore knowledge of medical guidelines, recommendations for screening and treatment, and population statistics cannot be assumed to be equivalent among providers and MA staff. Analysis of post-survey findings was essentially limited to feedback regarding the CPG and its implementation. Conclusions Chlamydia and gonorrhea rates will continue to rise as asymptomatic infections continue to spread before detection and treatment. Untreated STI infections in women place them at risk for a myriad of adverse gynecologic and fertility outcomes. It is incumbent upon healthcare providers to be familiar with and adhere to evidence-based clinical practices that align with universal STI screening as recommended by the CDC. The deployment of a CPG for universal STI screening in this project was found to be easy to implement in a primary care clinic’s workflow and was not found to be burdensome or time-consuming for both MAs and providers. Clinical behaviors were changed, and more women were screened for STIs due to the intervention. More research is needed to determine cost versus benefit, not only in financial costs but also in human costs associated with the adverse health consequences of undiagnosed, untreated STIs in asymptomatic patients. 21 Acknowledgments This project was made possible by the contributions of many. Acknowledgments are given to the project chair, Pamela Phares PhD, APRN, CNM, for comprehensive project mentoring and extensive editing. The content expert consulted with is Katie Ward DNP, WHNP. Eli Iacob PhD was consulted for guidance on data collection, analysis, and statistics. The project sponsor and clinic manager at Clinic 2 were critically important in the successful implementation of this quality improvement project, and their enthusiasm and support are much appreciated. Acknowledgments are also given to the DNP specialty track directors at the University of Utah College of Nursing, Jessica Ellis PhD, CNM, FACNM, and Erin Johnson Cole DNP, CNM, WHNP, FACNM, as well as the assistant dean Gillian Tufts DNP, FNP-BC. Lastly, a large thank you is deserved to the staff at Clinic 2, for being willing and eager to participate in a scholarly project and welcoming a graduate student into their work. This project could not have been successful without a team as strong as this one. 22 References Ahmad, F. A., Fischer, K., Gu, H., Bailey, T. C., Jeffe, D. B., Carpenter, C. R., & Payne, P. R. O. (2022). Impact of risk‐based sexually transmitted infection screening in the emergency department. Academic Emergency Medicine, 29(7), 879-889. https://doi.org/10.1111/acem.14465. Allison, B. A., Park, R. V., Walters, E. M., & Perry, M. F. (2022). Increased detection of gonorrhea and chlamydia after implementation of a universal screening protocol in a pediatric primary care clinic. Sexually Transmitted Diseases, 49(2): 117-122. https://doi.org/10.1097/OLQ.0000000000001534. Centers for Disease Control and Prevention. (2021). Sexually transmitted infections treatment guidelines, 2021. Retrieved May 27, 2023, from https://www.cdc.gov/std/treatmentguidelines/default.htm. Dowdle, M., & Phares, P. (2022). A quality improvement project to increase screening for chlamydia in a primary care setting. University of Utah College of Nursing. Elattma, A., Laves, E., Taber, B., Karvonen, K., Herrera, M. C., & Bakken, E. H. (2020). Using provider incentives and an opt-out strategy in a successful quality initiative to increase chlamydia screening. The Joint Commission Journal on Quality and Patient Safety, 46(6), 326-334. https://doi.org/10.1016/j.jcjq.2020.03.003. Gearhart, A. S., Badolato, G. M., & Goyal, M. K. (2020). Adolescent attitudes toward sexually transmitted infection screening in the emergency department. Pediatric Emergency Care, 36(10), 573-575. https://doi.org/10.1097/PEC.0000000000001387. Goyal, M. K., Teach, S. J., Badolato, G. M., Trent, M., & Chamberlain, J. M. (2016). Universal screening for sexually transmitted infections among asymptomatic adolescents in an urban 23 emergency department: High acceptance but low prevalence of infection. The Journal of Pediatrics, 171, 128-132. https://doi.org/10.1016/j.jpeds.2016.01.019. Grygiel-Górniak, B., & Folga, B. A. (2023). Chlamydia trachomatis – An emerging old entity? Microorganisms, 11(5), 1283. https://doi.org/10.3390/microorganisms11051283 Lane, K., Miller, E., Kisloff, L., & Wiesenfeld, H. C. (2020). Many parents would accept STI screening for their adolescent at a pediatric office visit. Journal of Adolescent Health, 66(5), 626-628. https://doi.org/10.1016/j.jadohealth.2019.12.019. Lunny, C., Taylor D., Hoang, L., Wong, T., Gilbert, M., Lester, R., Krajden, M., & Ogilvie, G. (2015). Self-collected versus clinician-collected sampling for chlamydia and gonorrhea screening: A systematic review and meta-analysis. PloS ONE, 10(7). https://doi.org/10.1371/journal.pone.0132776. McDonagh, Harwood, H., Saunders, J. M., Cassell, J. A., & Rait, G. (2020). How to increase chlamydia testing in primary care: a qualitative exploration with young people and application of a meta-theoretical model. Sexually Transmitted Infections, 96(8), 571–581. https://doi.org/10.1136/sextrans-2019-054309. Owusu-Edusei, K. Hoover, K. W., & Gift, T. L. (2016). Cost-effectiveness of opt-out chlamydia testing for high-risk young women in the U.S. American Journal of Preventive Medicine, 51(2): 216-224. https://doi.org/10.1016/j.amepre.2016.01.007. Pillay, J., Wingert, A., MacGregor, T., Gates, M., Vandermeer, B., & Hartling, L. (2021). Screening for chlamydia and/or gonorrhea in primary health care: Systematic reviews on effectiveness and patient preferences. Systematic Reviews, 10(1): 118. https://doi.org/10.1186/s13643-021-01658-w. 24 Reed, J. L., Alessandrini, E. A., Dexheimer, J., Kachelmeyer, A., Macaluso, M., Zhang, N., & Kahn, J. A. (2020). Effectiveness of a universally offered chlamydia and gonorrhea screening intervention in the pediatric emergency department. Journal of Adolescent Health, 68(1), 57-64. https://doi.org/10.1016/j.jadohealth.2020.09.040\. Reno, H., Park, I., Machefsky, A., & Bachmann, L. (2022). A guide to taking a sexual health history. Centers for Disease Control and Prevention. Retrieved October 23, 2023, from https://www.cdc.gov/std/treatment/sexualhistory.htm. SIECUS (2021). Utah state profile: Utah’s sex education snapshot. https://siecus.org/state_profile/utah-fy21-stateprofile/#:~:text=Utah%20schools%20are%20required%20to,sexual%20orientation%20or% 20gender%20identity. Territo, H., & Burstein, G. (2021). Opt-out chlamydia screening should be a part of routine adolescent health care services. Contemporary Pediatrics. Retrieved June 27, 2023, from https://www.contemporarypediatrics.com/view/opt-out-chlamydia-screening-should-bepart-of-routine-adolescent-health-care-services. U.S. Department of Health and Human Services. (2020). Sexually transmitted infections national strategic plan for the United States: 2021-2025. Retrieved June 27, 2023, from https://www.hhs.gov/sites/default/files/STI-National-Strategic-Plan-2021-2025.pdf. Utah Department of Health. (2020). Sexually transmitted disease surveillance, 2010-2019. Retrieved May 27, 2023, from https://ptc.health.utah.gov/wpcontent/uploads/2021/10/2010-2019-Utah-STD-Surveillance-Report-1.pdf. 25 Wong, W. C. W., Lau, S. T. H., Choi, D. P. H., Tucker, J. D., Fairley, C. K., & Saunders, J. M. (2019). A systematic literature review of reviews on the effectiveness of chlamydia testing. Epidemiologic Reviews, 41(1), 168-175. https://doi.org/10.1093/epirev/mxz007. 26 Tables and Figures Table 1 Survey Responses from Clinic 1 Medical Assistants Variable n 1. Age 26-30yo 31-35yo 36-40yo 41yo or older 2. Length of employment at Clinic 1 0-2yr 5yr or more 3. Sexual health history use Never/Rarely Usually/Almost Always 4. Offer screening to patients Never/Rarely Usually/Almost Always 5. Barriers to offering screening Provider doesn’t ask Discomfort with parents Discomfort with discussing 6. Time efficiency Neutral Agree 7. Easy to do Neutral Agree 8. Increased rates of screening I don’t remember Strongly Disagree Neutral Agree Strongly Agree 1 3 1 2 1 6 5 2 2 5 5 3 2 2 5 4 3 1 1 3 1 1 27 Variable 9. Education provided to you Neutral Agree Strongly Agree 10. Provider involvement I don’t remember Neutral Agree Strongly Agree n 5 1 1 1 3 2 1 28 Table 2 GC/CT Screening & Detection Rates at Clinic 2 Eligible Offered Screening Accepting Screen Neg. Results Pos. Results n n % n % n % n % Month 1 56 34 61 24 71 23 96 1 4 Month 2 47 33 70 17 52 17 100 0 0 Month 3 46 32 70 21 66 20 95 1 5 Final 2wks 21 18 86 3 17 3 100 0 0 Total 170 117 69 65 56 63 97 2 3 29 Table 3 GC/CT Screening & Detection Rates Per Provider Eligible Offered Screening Accepting Screen Neg. Results Pos. Results Provider n n % n % n % n % 1 49 39 80 29 74 29 100 0 0 2 13 4 31 4 100 4 100 0 0 3 33 17 52 12 71 11 92 1 8 4 41 34 83 14 41 13 93 1 7 5 34 23 68 6 26 6 100 0 0 30 Table 4 Pre-Survey Responses from Clinic 2 Variable n 19-25yo 26-30yo 31-35yo 41yo or older 2. Gender Female Male 3. Role at Clinic 2 Medical Assistant Physician Assistant Medical Doctor 4. Time in career field 0-1yr 2-3yr 4-5yr 10yr or more 5. Knowledge Strongly Disagree Neutral Agree 6. Comfort Disagree Neutral Agree Strongly Agree 7. Screening Compliance Disagree Neutral Agree 8. Risk Factors Agree 4 1 1 2 1. Age 7 1 3 3 2 3 2 1 2 1 2 5 1 2 4 1 2 4 2 8 31 Variable 9. Complications Strongly Disagree Neutral Agree Strongly Agree 10. Sexual Health History Never/Rarely Usually/Almost Always 11. Offer Screening Never/Rarely Usually/Almost Always 12. Barriers to Screening Provider doesn’t ask Discomfort with parents Discomfort discussing Time Constraints n 1 1 5 1 2 6 2 6 3 4 4 4 32 Appendix A Clinic 1 Survey – Feedback Regarding 2021 QI Project 1. What is your age? a. 16-18yo b. 19-25yo c. 26-30yo d. 31-35yo e. 36-40yo f. 41yo or older 2. For how long have you worked at Clinic 1? a. 0-2years b. 3-4years c. 5+ years For questions 3 and 4, please choose the response that best applies to you in regard to patients who are female and ages 24 years old or younger. Responses: 1) Never, 2) Rarely, 3) Usually/Sometimes, 4) Almost Always, 5) Always 3. How frequently do you ask about their sexual health history, including if they have had any new sexual partners in the past 6-12mos? 4. How frequently do you screen or offer screening for sexually transmitted infections? 5. What is/are the largest barriers for you to screen all female patients ages 24 years and younger for sexually transmitted infections (STIs)? (choose all that apply) a. Time constraints b. Discomfort discussing sexual health histories c. Discomfort with a parent being in the room with adolescents d. Being unfamiliar with the importance of STI screening e. Being unfamiliar with CDC recommendations for STI screening f. Being unfamiliar with specimen collection methods used to screen for STIs g. Being unfamiliar with the treatment of STIs, including recommendations for their sexual partners h. Difficulty with the EMR (ordering, documenting/charting, resulting, etc.) i. The provider doesn’t ask me to address sexual health with patients 33 For questions 6-10, please choose the response that best describes your level of agreement with the following questions, in regards to the Universal Chlamydia Screening Protocol that was implemented by a University of Utah graduate student in October 2021 - January 2022. (Universal = screening all female patients ages 24 years old or younger) Responses: 0) I do not remember/not applicable to me, 1) Strongly disagree, 2) Disagree, 3) Neutral, 4) Agree, 5) Strongly Agree 6. The new protocol did not add much time to a clinic visit. 7. The new protocol was easy to do. 8. The new protocol increased the rates of chlamydia screening. 9. The education provided throughout those months made me feel more comfortable in asking patients questions about their sexual health history. 10. The student involved the providers (doctors, PAs, NPs) enough to make this a successful protocol change. 11. Do you have any suggestions on how to improve the project that was implemented by the University of Utah graduate student regarding universal screening for chlamydia for female patients ages 24 years old or younger? 12. When any quality improvement project is implemented in your clinic, is there anything in particular that makes it inconvenient or frustrating for you to make the practice change? 34 Appendix B 35 36 37 38 Appendix C Clinic 2 Pre-Survey 1. What is your age? a. 16-18yo b. 19-25yo c. 26-30yo d. 31-35yo e. 36-40yo f. 41yo or older 2. What gender do you identify as? a. Female b. Male c. Transgender d. Gender Queer / Gender Fluid e. Nonbinary f. Prefer to self-describe: _____ g. Prefer not to say 3. What is your role at Clinic 2? a. Front Desk / Scheduling / Administrative b. Medical Assistant c. Registered Nurse d. Physician Assistant e. Nurse Practitioner f. Doctor g. Other: _____ 4. How long have you worked in your career field (as chosen above) in total, not just at Clinic 2? a. 0 - 1yr b. 2 - 3yr c. 4 - 5yr d. 6 - 9yr e. 10yr or more 39 For questions 5-9, please rate the amount to which you agree with the following statements. Responses: Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5 5. I know the CDC screening recommendations for chlamydia and gonorrhea. 6. I am comfortable discussing sexual histories with patients. 7. I screen all eligible individuals for chlamydia and gonorrhea. 8. I know the risk factors for chlamydia and gonorrhea. 9. I know the complications of untreated chlamydia and gonorrhea. For questions 10-11, please choose the response that best applies to you in regard to patients who are female and ages 24 years old or younger. Responses: 1) Never, 2) Rarely, 3) Usually/Sometimes, 4) Almost Always, 5) Always 10. How frequently do you ask about their sexual health history, including if they have had any new sexual partners in the past 6-12mos? 11. How frequently do you screen or offer screening for sexually transmitted infections? 12. What is/are the largest barriers for you to screen all female patients ages 24 years and younger for sexually transmitted infections (STIs)? (choose all that apply) a. Time constraints b. Discomfort discussing sexual health histories c. Discomfort with a parent being in the room with adolescents d. Being unfamiliar with the importance of STI screening e. Being unfamiliar with CDC recommendations for STI screening f. Being unfamiliar with specimen collection methods used to screen for STIs g. Being unfamiliar with the treatment of STIs, including recommendations for their sexual partners h. Difficulty with the EMR (ordering, documenting/charting, resulting, etc.) i. The provider doesn’t ask me to address sexual health with patients j. Other: _____ k. There are no barriers 13. When any quality improvement project is implemented in your clinic, is there anything in particular that makes it inconvenient or frustrating for you to make the practice change? 40 Appendix D Clinic 2 Post-Survey For questions 1-8, please rate the amount to which you agree with the following statements. Responses: Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5 1. I know the CDC screening recommendations for chlamydia and gonorrhea. 2. I am comfortable discussing sexual histories with patients. 3. I screen all eligible individuals for chlamydia and gonorrhea. 4. I know the risk factors for chlamydia and gonorrhea. 5. I know the complications of untreated chlamydia and gonorrhea. 6. Implementing universal STI screening was easy to do. 7. I will continue to perform universal STI screening in my future practice. 8. I would recommend this universal STI screening protocol to other family practice clinics. For questions 9-10, please choose the response that best applies to you in regard to patients who are female and ages 24 years old or younger. Responses: 1) Never, 2) Rarely, 3) Usually/Sometimes, 4) Almost Always, 5) Always 9. How frequently do you ask about their sexual health history, including if they have had any new sexual partners in the past 6-12mos? 10. How frequently do you screen or offer screening for sexually transmitted infections? 11. What is/are the largest barriers for you to screen all female patients ages 24 years and younger for sexually transmitted infections (STIs)? (choose all that apply) a. Time constraints b. Discomfort discussing sexual health histories c. Discomfort with a parent being in the room with adolescents d. Being unfamiliar with the importance of STI screening e. Being unfamiliar with CDC recommendations for STI screening f. Being unfamiliar with specimen collection methods used to screen for STIs g. Being unfamiliar with the treatment of STIs, including recommendations for their sexual partners h. Difficulty with the EMR (ordering, documenting/charting, resulting, etc.) i. The provider doesn’t ask me to address sexual health with patients j. Other: _____ k. There are no barriers 41 12. Do you have any suggestions on how to improve the project that was implemented by the University of Utah graduate student regarding universal screening for chlamydia for female patients ages 24 years old or younger? 42 Appendix E Patient Name: _________________________________ Date of Birth: __________________________________ Sexual Health History – Sexually Transmitted Infection (STI) Questions • Have you been sexually active in the last 12 months? YES / NO • Have you had any new sexual partners the last 12 months? If so, how many? YES / NO___ • Are you having sex with men, women, or both? • Did you use a condom to prevent STIs with each act of sexual intercourse? • Have you ever been tested for STIs? If so, when was your last test? • Have you ever tested positive for an STI? If so, write the type of infection and date. YES / ________________ YES / NO YES / NO _________ NO ______________________________________________________________________ • Thank you for being open to answering those questions! Do you have any questions or concerns about your sexual health? YES / NO _________________________________________________________________________ The CDC recommends chlamydia and gonorrhea screening annually and after every new exposure or sexual partner for patients 24 years old and younger, so we will collect a urine sample for testing today. Is that okay? YES / NO 43 Appendix F Executive Summary: Universal Chlamydia and Gonorrhea Screening Situation & Background Chlamydia and gonorrhea (GC/CT) are two of the most frequently reported sexually transmitted infections (STIs) in the U.S. STI data in Utah indicate that rates of CT have increased by 44% since 2010, and GC by 818% since 2011. Often asymptomatic, they can have serious health consequences for women. Current CDC recommendations include annual universal screening of sexually active females less than 25 years old (2020). Studies that have examined the effectiveness of universal screening have identified multiple benefits, including increased screening and detection rates, reduction in bias, and improved costefficiency for a clinic, all while not increasing the time required for a visit. Training in obtaining a sexual health history improves staff comfort with these discussions. The purpose of this QI project was to evaluate the effectiveness of a universal GC/CT screening protocol in a primary care clinic. The primary goal was to align Clinic 2’s practice with CDC recommendations to enhance GC/CT screening and detection rates in females ages 24 years and younger. Originally, Clinic 2 performed risk-based screening only. Clinic staff reported significant discomfort in collecting sexual health histories and therefore missed opportunities to screen asymptomatic patients. Assessment & Recommendations A total of 170 eligible patients were seen by 5 providers during 14 weeks of implementation and 117 (69%) patients were offered GC/CT screening (Table 1). Only 65 (56%) patients had STI testing completed, and 2 (3%) patients had positive chlamydia results, and none tested positive for gonorrhea. Compliance with the CPG among individual providers was also analyzed (Table 2). The following rates by provider were calculated: provider #1 offered screening to 39 (80%) patients; provider #2 offered to 4 (31%) patients; provider #3 offered to 17 (52%) patients; provider #4 offered to 34 (83%) patients; and provider #5 offered to 23 (68%) patients. It is important to note that provider #2 saw only 13 eligible patients during the 14-week implementation period, making that individual an outlier which skewed the combined percentage of patients screened by all providers. Table 1 GC/CT Screening & Detection Rates at FFC Eligible Neg. Results Pos. Results n Offered Screening n % Accepting Screen n % n % n % Month 1 56 34 61 24 71 23 96 1 4 Month 2 47 33 70 17 52 17 100 0 0 Month 3 46 32 70 21 66 20 95 1 5 Final 2wks 21 18 86 3 17 3 100 0 0 Total 170 117 69 65 56 63 97 2 3 Clinic staff found the protocol to be feasible, usable, and satisfactory within their daily workflow. They reported that having a sexual health history questionnaire reduced their discomfort and bias in the discussion of STI testing with patients and endorsed plans to continue using it. It is recommended that this questionnaire become a standard inclusion in annual or gynecologic patient visits at Clinic 2. The asymptomatic nature of GC/CT infections will continue to allow infections to spread unknowingly and for this reason, the CDC guidelines for universal STI testing should be integrated into your practice. Due to this QI project, clinical behaviors were changed, and more women were screened for STIs. More research is needed to determine cost versus benefit, not only in financial costs but also in human costs associated with the adverse health consequences of undiagnosed STIs in asymptomatic patients.