Improving Sexually Transmitted Infection Screening in Inpatient Pediatric Patients Free

Sexually transmitted infections (STIs) are a group of diseases spread by sexual contact that can cause acute illness and lifelong health effects, including pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain.^1–3  According to the Centers for Disease Control and Prevention’s 2019 STI Surveillance Report, primary and secondary syphilis rates in the United States have increased by 74%, gonorrhea by 56%, and Chlamydia by 19% since 2015.⁴  In 2018 alone, there were 26 million new STIs reported, with almost half of those in youths ages 15 to 24, totaling nearly $16 billion in direct medical costs.⁵  When examining racial differences in STI prevention, African American students had a lower prevalence of condom use at last sexual intercourse than Caucasian and Hispanic students.⁶ 

Current Centers for Disease Control and Prevention and US Preventive Services Task Force guidelines include annual screening as follows: for HIV for all sexually active persons ages 13 to 64, for Chlamydia and gonorrhea in those <25 years old and sexually active, and for syphilis in areas of high prevalence, such as the southern United States.^7,8  The American Academy of Pediatrics also recommends that providers minimize barriers to STI screening, including addressing confidentiality, stigma, and access to care.⁹  However, less than half of adolescents report having private discussions with their primary care providers, or receiving a preventive checkup in the previous 12 months.¹⁰ 

We see hospital admission as an opportune time to engage in sexual health conversations with adolescent patients and provide appropriate screening. In 1 study, the majority of pediatric hospitalists across 5 academic pediatric hospitals felt that many reproductive services, such as STI testing, are appropriate in their clinical settings.¹¹  However, pediatric hospitalists report several barriers to care provision, and the majority report counseling adolescents ≤5 times in the past year on sexual risk-reduction, condom use, or contraception.¹¹  This indicates that hospitalization is a unique opportunity to discuss sexual health that may not otherwise be addressed.¹² 

According to our 2018 State Epidemiologic Profile, our county was the public health region with the highest rate of Chlamydia and gonorrhea in the state.¹³  Despite this, sexual history documentation and STI screening rates in adolescents admitted to our hospital are low. To address this, our team designed a quality improvement (QI) project to improve 2 related but separate outcomes. The purpose of this study is to use QI methodology to improve the percent of inpatient adolescent patients 14 to 18 years of age who had documentation of sexual histories from 49% to 69% and STI testing from 29% to 49% over the course of 6 months, thus balancing ambition with achievability.

Our study took place at a large, 255-bed tertiary care academic children’s hospital located in an urban area. The hospital serves a tristate area in the southern United States and serves ∼70% Medicaid patients. At this institution, the majority of admitted general pediatric patients are initially seen by resident physicians and then staffed by pediatric hospital medicine attending physicians. Although an attending-only team exists, the resident service covers patients representing a broader geographic basis, a higher proportion of Medicaid patients, and all patients without an identified primary care provider. General pediatric patients and those patients awaiting inpatient psychiatric care are admitted to this service. Patients with particular primary care providers are staffed by the attending-only service. Our hospital provides care to ∼9000 children per year with 15% of those being between the ages of 14 and 18. The electronic medical record (EMR) used at this institution is Cerner (PowerChart 2018.01, Cerner Corporation, Kansas City, MO).

Eligible patients included all adolescents ages 14 to 18 admitted to our academic general pediatric inpatient service. We focused on this population because of the involvement of residents as the initial and primary caregivers on this service. This age group was selected because 14 years of age is the age of assent in our state. Patients who were admitted to surgical subspecialties, the attending-only service, or pediatric ICU were not included in our project. We also excluded patients who had significant developmental delay, specifically nonverbal patients or patients unable to indicate comprehension of sexual history questions, as well as patients who had any STI screening obtained in the emergency department (ED) before admission. We did not exclude repeat admissions within the study period in our data set.

We formed a QI team at the onset of the project that included 4 physicians: an adolescent attending, an academic hospitalist attending, and 2 resident physicians. We conducted this QI project using the Plan-Do-Study-Act methodology.¹⁴ 

We then developed a key driver diagram to outline the primary drivers that would contribute to achieving our goal of increasing documented sexual history and STI screening in adolescent patients. We identified primary drivers for thorough adolescent sexual history documentation and STI screening (Fig 1). We then reviewed all eligible patients beginning 1 year before any interventions to calculate a baseline.

The first intervention was a large group educational session for pediatric and medicine/pediatric residents using a short PowerPoint presentation. This discussion during protected learning time outlined our local STI rates and difficulties residents face with obtaining and documenting a sexual history. This presentation emphasized the need for private conversations between the provider and the patient with caregivers outside of the room, as well as an opt-out method to screening. Additionally, the importance of standardized and thorough sexual history documentation was discussed, including obtaining a patient’s cell phone number to relay results if the patient was already discharged. Finally, residents were instructed to document sexual history in a nonportal note to ensure patient privacy.

For the second intervention, a sexual history documentation template was included in the paper history and physical (H&P) forms that residents frequently use for history documentation. Residents have a portable paper guide they take into the patient’s room to briefly document the H&P. This form serves as a prompt to ensure complete history documentation and documentation. The paper form is then used to produce an electronic H&P within the EMR.

The subsequent intervention involved our team creating a badge buddy, that included standardized sexual history scripted questions. This clinical tool (Fig 2) was introduced to improve resident comfort with obtaining a sexual history, as well as to aid in the standardization of sexual health discussions with adolescent patients. These badge buddies were distributed to all residents. They were designed to easily attach onto existing lanyards or badge reels worn by residents and faculty during clinical duties.

Our team provided small-group in-service resident education on the importance of obtaining and documenting a sexual history, as well as screening for STIs.

Our team met with the general pediatric inpatient faculty to discuss the goal of improving STI screening in our inpatient adolescents. Faculty could then remind residents to obtain sexual history and STI screening laboratories and could document this information in their addendums as well.

Our sixth and final intervention consisted of a template that could be easily integrated into our EMR. This was developed as another prompt to help remind residents and faculty to document any sexual health discussions they had with their patients.

All data were extracted from the patient's EMR for patients discharged between March 2018 and September 2020. Data collected included age, race, sex, admit date, and discharge date. We reviewed 1 year of baseline data before the first intervention for all academic general pediatric inpatient admissions of patients ages 14 to 18, excluding those in the pediatric ICU (PICU). For the interventional data, the team received monthly reports and reviewed all eligible patients. Within this data, we extracted the chief complaint, sexual history documentation, and STI screening with results and documented follow-up. This was done through personal chart review by 2 resident physicians. Although no formal data dictionary was created, multiple conversations occurred early on to ensure consensus with the overriding principle to include documentation of any conversation regarding patient engagement in sexual activity.

We assessed the percentage of patients in which sexual history was present or absent in the initial H&P. We considered a full sexual history documented if it included the answer to the question, “Are you sexually active?” This was to be as inclusive as possible. Following the American Academy of Pediatrics recommendation to screen all adolescents regardless of reported sexual history, we then assessed the percentage of patients who received opt-out testing and had results for any one of the following STIs: Chlamydia, gonorrhea, HIV, and syphilis.

We initially tracked the monthly progress of our project using run charts and monitoring for shifts, trends, or runs to indicate special cause variation. Data for sexual history documentation and STI screening was obtained monthly because the residents are on a designated inpatient team for 1 month at a time. Once enough data had been collected, the QI team transitioned to statistical process control (SPC) charts with upper and lower control limits to determine if our interventions revealed special cause variation. Our SPC charts were created by using the Microsoft Excel plug-in QI Macros (version 2021.07, KnowWare International Inc, Denver, CO). The SPC charts were used for monitoring the outcome measure. We used the baseline data to calculate a centerline. A new baseline was calculated once special cause variation was identified by using the Montgomery rules.¹⁴ 

After the completion of data collection, the association of demographics (race, sex, and age) with measures was evaluated. Pre- and postintervention testing was performed by using the shift in the SPC center line as the dividing mark in time to retain some power and because the subgroups did not contain enough patients to create meaningful SPCs. Hypothesis testing was performed by using χ² test for independence.

Our institutional review board approved this QI project.

The preintervention data included 373 patients and the postintervention data set included a total of 543 patients. In the preintervention data, 54 patients were excluded from the totals (30 initially admitted to the PICU, 12 with developmental delay, and 12 with testing done in the ED). In the postintervention data, 106 patients were excluded from the totals (70 initially admitted to the PICU, 22 with developmental delay, and 14 with testing done in the ED). A retrospective chart review of 1 year of data revealed that a sexual history was obtained in only 48.7% of inpatient patients ages 14 to 18. In these patients, inpatient screening for gonorrhea, Chlamydia, HIV, or syphilis was only performed 29.1% of the time. Only 5 patients declined STI screening using the opt-out method. These 5 patients were not excluded from the data set.

Using a total of 6 simple interventions, we increased our documentation of sexual history from 48.7% to 67.1% and baseline STI screening rate from 29.1% to 49.1%, which nearly achieved our goal of improving STI screening rates by 20% (Figs 3 and 4).

Interventions to improve our rates of documentation and STI screening interventions included resident and faculty education on the importance of STI screening, introducing prompts to obtain sexual history on paper H&P forms, developing and distributing a badge buddy to be used as a sexual history template, and an autotext template that could be integrated into our EMR.

Documentation of sexual history had a positive, sustained shift in midline from 48.7% to 67.1% starting in May 2019, with 17 consecutive months above the previous midline. This special cause variation occurred 2 months after the large-group resident conference occurred and 1 month after the H&P template was updated (Fig 3). Screening for STIs had a positive shift in midline from 29.1% to 49.1% starting in December 2019, with 10 consecutive months above the previous midline. This occurred in the fifth month of ongoing small-group in-service resident education and 1 month after faculty development occurred (Fig 4).

There were no differences in preintervention or postintervention rates of success by race for either sexual history documentation or STI screening. Females consistently had their sexual history documented more often both in the preintervention (51.7% vs 35.7%, P = .002) and postintervention periods (72.4% vs 59.6%, P = .004). Females had STI screening performed more often in the preintervention (33.3% vs 17.8%, P < .001), but there was no statistical difference in the postintervention (51.5% vs 44.7%, P = .249) periods. There were significant differences by age in sexual history documentation preimplementation (P < .001) and postimplementation (P = .008). There were also significant differences by age in STI screening preimplementation (P < .001) and postimplementation (P = .018) (Supplemental Fig. 5).

We successfully implemented a quality improvement project to increase STI history documentation and STI screening rates in inpatient adolescents. Utilizing a targeted approach toward resident and faculty education and visual and electronic prompts, we increased our baseline documented sexual history from 48.7% to 67.1% and baseline STI screening from 29.1% to 49.1%. Previous studies have revealed that inpatient admissions provide an opportunity to provide routine sexual health care to adolescents who often do not have primary care providers.¹²  This study adds to the literature in that it provides a QI methodology to leverage inpatient adolescent admissions for routine sexual health screening. Additionally, this study expands on the use of standardized scripts, which are recommended by the American Academy of Family Physicians, to improve sexual history documentation in the form of a badge buddy and EMR prompts.¹⁵ 

We chose the primary interventions in this study to involve resident physicians for 2 reasons. First, residents are a primary point of contact for medical care for many of the patients admitted to our hospital. Thus, interventions involving residents improve the overall quality of care our patients receive. Secondly, providing residents with practice norms such as sexual history documentation during training provides them with skills they can continue to use in their future practice after training. Using visual and electronic prompts, we found that residents more consistently and accurately integrated sexual history documentation into their standard of care. Having standardized scripts and multiple interactions with a patient during hospitalization addresses many physician barriers to obtaining a sexual history, including lack of time and physician discomfort with discussing sexual activity and safe sexual practices.¹⁶ 

In addition to the expected improvements in overall sexual history documentation and STI screening, we also saw an elimination of the sex gap that existed in our preintervention data. At the beginning of the study, we found that adolescent females were more likely to have a sexual history documented and to have STI screening. After our interventions, there was no significant difference in sexual history documentation or STI screening between males and females. We propose that the initial disparity may be related to provider comfort with sexual history documentation with female patients over male patients. It may also be related to the implicit bias assuming that female patients may be more likely to have STIs. Despite these barriers, we found that a focus on improving overall STI history documentation and STI screening has revealed improvement such that this gap was closed.

Overall, we postulate that the cumulative effects of our multiple interventions led to a marked improvement in sexual history documentation and STI screening. When assessing these outcomes, we found that sexual history documentation improved more rapidly than STI screening. We hypothesize that providing multiple interventions as well as screening tools such as the badge buddy enabled a cultural shift toward normalization of sexual history documentation and STI screening. A strength of this study included providing standardized questions and reminders about including sexual history as a part of routine care. As more residents and faculty were exposed to these needs and interventions, sexual history documentation improved and was followed by an improvement in STI screening. Thus, we believe the greatest strength of our study is the use of multiple QI interventions to shift a cultural norm toward best practices in adolescent health.

One of the major limitations of this study was the relatively small sample size. Because of the coronavirus disease 2019 pandemic, hospitalization rates were low. In addition, data were limited to the general pediatric service and did not include the nonteaching service, pediatric subspecialties, or surgical services. We are in a large urban center with a high prevalence of STIs; similar studies may have a lower yield in areas with low STI prevalence.

Inpatient hospitalization plays a vital role in the current STI epidemic because many STIs begin in adolescence and a concerning number of this age group do not follow up regularly with primary care providers. This QI project revealed that, through interventions aimed at education of residents and faculty, use of badge buddies for scripting, and EMR prompts, the inpatient setting can be successfully used for sexual history documentation and STI screening. Our results were notable for a 20% increase in both sexual history documentation and screening. Future studies should focus on expansion to all inpatient services and observed treatment of STIs in the inpatient setting, which would allow for more comprehensive care of patients. Additional studies should also seek to understand how similar QI methodology could lessen the sex gap or other disparities in sexual history documentation and STI screening in various settings.

We thank Britney Byars, MBA, RRT, at Le Bonheur Children’s Hospital for her role in data extraction.