A tale of 2 programs: How to implement ECPs
Are you wondering how to implement emergency contraceptive pills (ECPs) in your practice? Take a look at how a pilot project at a Southern California health maintenance organization (HMO) and an established program at a New Mexico university student health center are working to get ECPs in the hands of patients.
If you’re concerned about setting protocol or developing educational material, then the information from a nationally distributed provider kit will give you the necessary tools to build an effective program. Each kit includes a copy of the U.S. Food and Drug Administration’s Feb. 25, 1997, Federal Register notice affirming the safety and efficacy of the ECP regimen, as well as the December 1996 ECP practice pattern released by the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC. The project is sponsored by the Henry J. Kaiser Family Foundation of Menlo Park, CA, and co-sponsored by ACOG.
The Emergency Contraception Pilot Project of Kaiser Permanente of San Diego is the model of a carefully executed program. It was conceived over a year ago from ideas shared by members of the Pacific Institute of Women’s Health in Los Angeles and Diana Petitti, MD, director of research and evaluation at Kaiser Permanente of Southern California in Pasadena. The Program for Appropriate Technology in Health (PATH) of Seattle developed the client and provider material for the Kaiser project. (For more information on PATH, see Sources, p. 58.)
Featuring a detailed provider manual and tasteful patient brochures, wallet cards, and posters, the program is designed to work with a wide cross-section of patients within the HMO, says Debbie Postlethwaite, MPH, RNP, project team leader.
The Kaiser kits, which contain the birth control pills, an anti-emetic, and instructions, have been placed with some 275 providers in Kaiser-San Diego’s OB-GYN, primary care, urgent care, and pediatric facilities, with almost 100 kits dispensed to patients since July 1996, Postlethwaite says.
Other program material includes a pre- and post-implementation provider survey to assess providers’ knowledge and attitudes regarding ECPs. A consumer survey is designed to gather pertinent patient information from project participants ages 18 and above. The program also tracks the number of ECP kits given to those below age 18 and monitors trends in unintended pregnancies, including therapeutic abortions, low birth weight infants, and pre-term deliveries.
Kaiser has been dispensing ECPs for some time but has not tracked information to the degree found in the pilot project, says Postlethwaite. Based on the results of the post-implementation provider survey and the consumer survey, the program will be modified for use in other Kaiser facilities.
Brochures, wallet cards, and telephone education tapes are offered in English and Spanish. Posters proclaiming "Once A Secret, Now An Option" give the telephone numbers for both the appointment center and the education tape line.
Patients are not required to have a pregnancy test or a pelvic examination to obtain the pills, says Postlethwaite. (The ECP project member access chart, p. 57, shows how patients move through the system.) It is the responsibility of the provider who prescribes the ECP kit to ensure that the patient knows how the ECP pills work to prevent from her from becoming pregnant and how they should be taken, she notes.
Response has been positive
Although the consumer survey has just begun, members who have participated in the project seem to be delighted with it, says Postlethwaite. "The staff, I think for the most part, has been a little bit more varied in their opinions," she says. "From our evaluation, though, the majority of providers felt that if a woman wants information on ECPs or wants ECPs, she should be able to get it."
While the FDA notice in the Federal Register declaring the safety and efficacy of the ECP regimen may be a wake-up call for many clinicians to provide ECPs, it only serves to reinforce a long-standing policy of ECP dispensing at the University of New Mexico Student Health Center in Albuquerque.
ECPs, in one form or another, have been in force at the center for more than 20 years, says Bennette Meyer, CNP, certified OB/GYN nurse practitioner. The center’s pharmacy now dispenses Wyeth-Ayerst’s Ovral as a ECP kit, placing four tablets in a bottle for a cost of about $12 to the patient, notes Connie Rossignol, CNP, a fellow certified OB/GYN nurse practitioner at the center. More than 40 kits have been dispensed in the first three months of 1997.
Clinicians are proactive about what they term "the morning-after pill" at the university, getting the word out through a variety of methods: patient handouts, educational information via a telephone access line, bulletin boards, and bookmarks distributed through student orientations and other gatherings.
Members of the university’s peer education program, trained by health education coordinator Joyce Lisbin, MA, counsel students about ECPs, as well as birth control options. Another source of information comes from center nurse Karin Retskin, LPN, who takes the role of old-fashioned office nurse to a new plateau as she questions patients before the clinician enters the room.
"Whenever I have a student who’s on condoms, then I talk to them about the morning-after pill," she notes. "I talk with almost anybody who would ask me, but primarily patients who aren’t using protection or just using condoms, especially if they tell me that they’re happy with condoms and they don’t want to discuss other birth control methods."
This intensive quizzing helps Meyer and Rossignol follow through in discussing ECPs. The clinicians have the patients read the information on ECPs, check the date of their last menstrual period, look at basic vital signs as recorded by Retskin, and evaluate the need for ECPs. If students express a desire for ECPs, center clinicians invariably comply, says Meyer.
Providing ECPs also provides peace of mind, Rossignol says. She shares the tale of a recent patient: "She had intercourse, missed one pill, made it up. They used a condom. He didn’t ejaculate, but she was just frantic," she relates. "She wanted [ECPs], and I gave them to her."
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