Chlamydia infection affects more than 1.7 million people each year, making it the most common bacterial sexually transmitted infection (STI). It costs $691 million in lifetime medical costs, and if left untreated, the infection can put women’s sexual and reproductive health at risk, leading to ectopic pregnancy, infertility, and pelvic inflammatory disease.1
Using a screening tool and checklist, a family planning clinic found success in improving the chlamydia screening rate, identifying more cases of the STI, and making patient visits more efficient by reducing time spent on visits.1
Reproductive health leaders are concerned because rates of chlamydia are rising, particularly among people aged 24 years and younger, says Vanessa Shields-Haas, DNP, FNP-C, lead study author and a family nurse practitioner and director of the Maine Family Planning clinic in Thomaston, ME.
“These rates are high among young women and women of color,” Shields-Haas says. “This study focused on improving chlamydia screening for women assigned female at birth in the age range that the Centers for Disease Control and Prevention [CDC] and other best practice guidelines identify as being most at risk.”
Screening for chlamydia is a quality indicator for family planning clinics that receive Title X funding. “Our screening levels as an organization were not where they should be for chlamydia, so our clinic was a pilot for improving screening rates,” Shields-Haas notes. “It’s something we need to collect data on and show improvements and improve testing rates. Our goal is to screen 80% of people assigned female at birth who meet the screening criteria.”
The project used a right care checklist and a screening tool completed by patients. It also gave patients information about chlamydia and answered questions about their risk level. “Patients were educated about chlamydia in a way they never had been before they walked through the exam room door,” Shields-Haas explains. “They became aware they had risk factors. When we were advocating for them to get tested, they came into the exam room requesting it.”
The clinic achieved its screening goal, increasing the number of patients tested by 32% compared with pre-implementation. Patients received the risk assessment at check-in. The form noted the importance of chlamydia screening and asked the patient to check “true” or “false” on six evidence-based risk-assessment questions, including age, testing, history, partners, and symptoms. Answers of “true” indicated a positive risk factor and led to the implementation of the second core intervention, the right care checklist.
The evidence-based checklist prompted providers to complete information about the patient’s sexual education, condom distribution, chlamydia test order, vaginal swab, set electronic medical record notifications, and how patients would receive test results.
“We utilized a right care checklist, so staff had their own checklist that standardized best practices for patients who screened positive for chlamydia,” Shields-Haas says.
The checklist laid out steps of what clinicians should do at these patient visits. “What’s different about this is normally patient education is done by the clinician or nurse in the exam room,” Shields-Haas explains. “But this was a screening tool used by patients in the waiting room.”
Quality improvement projects often result in a cost increase in terms of time because they add a task to an already busy staff’s workload. “If you’re doing something special and unique and different, your visit times may increase,” Shields-Haas says.
But when Shields-Haas and her co-investigator measured the time spent on visits during the chlamydia screening project, they found that clinicians spent less time discussing behavioral risks than they did before implementation.
“We decreased our patient visit time by 39%,” Shields-Haas says. The patient visit time decreased from 38 minutes to 23 minutes. The number of positive chlamydia test results doubled from three to six.
There was little inconvenience for patients as well. They filled out the screening tool in the 10 or 15 minutes they spent in the waiting area before their appointments. Some patients did not want to be screened. Shields-Haas and her co-investigator surveyed them about their reasons for opting out.
“Some didn’t want to be screened because they weren’t identified as having a risk level or, more commonly, they didn’t think they were at risk,” Shields-Haas explains. “Some were screened in the last 12 months. They met the guidelines for being screened but were not screened that day.” If patients had been screened within the previous 12 months, they would have been opted out, she adds.
Before implementing the patient screening tool, investigators conducted surveys on patient education around chlamydia, asking patients about their knowledge of the STI. They asked these questions:
- “Can you name two negative consequences of infection?”
- “Do you know how long after intercourse you should wait to be tested?”
No patients could name two negative consequences of infection. “There was very low understanding of why they should be tested and even what chlamydia is,” she says.
The quality improvement project was based on the Institute for Healthcare Improvement’s Plan-Do-Study-Act process. The results were assessed daily and weekly, and the team made incremental changes throughout the process.
“Some of the limitations of this process were that the family planning clinic is only open three days a week, so there were some timing constraints,” Shields-Haas says.
The Thomaston, ME, community is rural and does not serve a large population as do Title X programs in urban areas. “Chlamydia rates are disproportionately higher amongst key demographics due to health disparities, and our demographic group is predominantly white,” Shields-Haas notes. “We do serve a large community of people who are on hormonal treatment for transgender care.”
Ten percent of the clinic’s patients identify as transgender or nonbinary. About six in 10 patients are on Maine Care, a Medicaid equivalent. Patients range in age from adolescents to 60-year-olds.
The project succeeded at its goal by increasing effective care from 42% to 81%. Using the evidence-based guidelines on chlamydia risk assessment and creating a checklist on the right care resulted in patients receiving an intervention only when they needed one.
“More people who should have been screened were screened, and among that group, there were more positive tests identified because we were screening more people,” Shields-Haas says. “They were treated with antibiotics for their infection.”
Shields-Haas created the screening checklist used by the staff, as well as the patient screening based on best practice guidelines from the CDC, the U.S. Preventive Services Task Force, and the American Academy of Family Physicians.
“There are 18 clinics that are part of Maine Family Planning, and this was presented to them after the study was completed,” Shields-Haas says. “There’s interest and adoption by other Maine Family Clinics.” After the team presented the preliminary results at the organization’s quarterly quality improvement meeting, all the clinics requested the chlamydia risk assessment in English and Spanish.
Medical care and STI screening and treatment checklists can help clinicians apply best practices consistently. Similar screening tools and right care checklists could be adapted for use in assessing the risk of other STIs, including gonorrhea and syphilis. “This tool has not been utilized for other sexually transmitted infections, but I don’t see why it couldn’t be adapted,” Shields-Haas says.
One of the challenges was that the project occurred during the pandemic years when clinics were operating in a telehealth environment. “When we didn’t do our interventions, it was because these were telehealth patients,” Shields-Haas adds.
Eventually, the checklist became ingrained in the clinic’s practice, and a physical checklist was no longer needed. “It is ingrained in our process, both in the electronic medical record and in how we discuss chlamydia with patients,” she says. “It was a paper form that we don’t use anymore.”
Since implementing the QI project, the clinic’s chlamydia screening rates have maintained the level they were after the project, Shields-Haas adds.
Family planning centers, OB/GYN offices, and other primary care settings should adopt strategies to increase STI testing. “We know STI testing is overlooked in a primary care setting, and that is a contributing factor to the increase we’re seeing in the rates of sexually transmitted infections,” Shields-Haas explains. “Interventions like this that are targeted on increasing patient education around sexually transmitted infection and following up to make sure there’s a checklist, and they’re making best practice standards, can create new processes where you have patient flow and reduced visit times and increased screening rates.”
REFERENCE
- Shields-Haas V, Bray C. Improving effective chlamydia screening for women at risk at a rural family planning clinic. J Dr Nurs Pract 2023;16:205-212.
Chlamydia infection affects more than 1.7 million people each year, making it the most common bacterial STI. Using a screening tool and checklist, a family planning clinic found success in improving the chlamydia screening rate, identifying more cases of the STI, and making patient visits more efficient by reducing time spent on visits.
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