19. Improving Adolescent Gynecologic Care and Contraceptive Counseling: A Resident QI Project

Abstract

Participation in a mandatory workshop early in the R2 year provided a basic understanding of quality and improvement. During the R2 and R3 years, ongoing project development and implementation greatly impacted adolescent primary care in a resident continuity clinic. The Concern: High rates of adolescent pregnancy and sexually transmitted infections (STI) which exceed national averages in our clinic population. Potential solution: Improve STI screening and contraceptive counseling. Problem: Does our clinic systematically provide “best practice” for adolescent girls? Using the PDSA cycle we learned how our practice differed from ideal practice and then implemented changes to eliminate the gap between current practice and ideal practice. PLAN: Evaluate care and counseling of a group of adolescent girls. We conducted a chart review of well-child visits for girls ages 15-19. DO: After development of a chart review tool, we assessed 100 charts: 1. Was a Sexual History (SH) documented? 2. Were sexually active (SA) adolescent girls screened for STIs, including gonorrhea, Chlamydia, and HIV? 3. Were SA adolescent girls offered contraception? 4. Were SA adolescent girls offered Emergency Contraception (EC)? STUDY: 93% had SH documented; 50% were SA and of those, 46% were screened for gonorrhea and Chlamydia; 30% were offered HIV testing; 74% were offered contraception; 6% were offered emergency contraception. SH documentation met standards; however we wanted to increase STI screening and EC discussion. ACT: Findings were presented to faculty, residents and nurse practitioners at pre-clinic conferences. The electronic medical record template was modified with prompts for STI screening and EC. A second chart review after provider education and implementation of the new template showed higher HIV screening rates (40%), and improved contraception (81%) and EC (24%) management. Given the large adolescent female population served by our clinic, improving our practice will hopefully impact STI and teen pregnancy rates. Offering better care to our patients with a relatively simple process helped us appreciate the value of QI.