Impact of Fast-Track Asymptomatic Screening Clinics on 48 Hour Access to Genitourinary Medicine (GUM) Services.

Background

As elsewhere in the UK, there have been sustained increases in the workload of the genitourinary medicine (GUM) clinic at the Royal Hallamshire Hospital, Sheffield during the past ten years, with large percentage increases in the annual numbers of bacterial STIs and HIV patients. Moreover, as people become more aware of the importance of assuring their sexual health status, there has been a huge increase in the numbers of asymptomatic individuals attending for STI and HIV screening each year.

Since 2000, the imbalance between service capacity and patient demand has widened. In 2001, the average time to a new patient appointment was five days, but this had increased to 26 days in April 2005 despite a 50% increase in patient throughput during this time. The Health Protection Agency (HPA) access survey data showed that 48 hour access was achieved by only 24% in May 2005 and 28% in August 2005, these results being in the lowest quartile for all GUM clinics in England ¹ .

Subsequently, the service reviewed its appointment system and developed new methods of optimising patient throughput to minimise delays. This included the introduction of the fast track screening service (FASS).

Similar increases in percentage workload and impacts on access were experienced in neighbouring Rotherham ¹ . The project was therefore extended to develop FASS in the GUM department there with equivalent success

Objectives of the FASS service

• To move towards 48 hour access targets for appointments to GUM services;
• To meet local demand for comprehensive STI and HIV screening in a GUM setting, facilitating patient choice;
• To provide a rapid patient-focused service with an efficient patient journey which minimised the time spent in the department;
• To free up mainstream appointment slots and staffing for managing more complex GUM conditions which require longer more detailed consultations;
• To increase availability of mainstream appointments for acutely symptomatic patients and thereby reduce morbidity and onward sexual transmission of infection;
• To reduce undetected STIs and HIV in the community, thereby reducing patients’ risk of long term complications and the spread of STIs and HIV sexually (to partners) and vertically (mother to child); and
• To reduce the spread of HIV by reducing the incidence of STIs which facilitate HIV transmission.

What is the problem you are trying to solve?

STIs are an increasing public health threat in the UK ^{2 3 4} . The costs to individuals and to the NHS from the rising incidence of STIs and HIV infection show a corresponding rise. Since 2000, despite large increases in the numbers of patients being seen in GUM clinics, there has been an increasing imbalance between patient demand and service capacity ⁵ . The existence of a pool of prevalent, undiagnosed asymptomatic infections and delay in providing services to many symptomatic patients seeking care favours onward transmission ^{6 7} . The Government White Paper, Choosing Health ⁸ established 48 hour access to GUM services as a national target. The need for improved access to GUM clinics has been identified as a NHS priority in 2006-7 ^{8 9} .

The application of new technology, especially the availability of highly sensitive and specific nucleic acid amplification tests (NAAT) for gonorrhoea and genital Chlamydia infection, facilitates innovative changes in STI screening ¹⁰ . Whilst NAAT testing offers non-invasive screening methods (using urine and vaginal specimens) appropriate for a wide range of healthcare settings, many patients choose to seek their sexual healthcare from GUM rather than primary care. Reasons given include added levels of confidentiality, anonymity and expertise ^{11 12} . We have developed a new service model using NAAT testing to provide an easily accessible, rapid STI/HIV screening service for asymptomatic patients attending GUM.

What local organisations are involved?

Departments of Genitourinary Medicine at the Royal Hallamshire Hospital, Sheffield Teaching Hospitals Foundation Trust and Rotherham Foundation Trust

How many people are running this project and who are they?

The original concept of the FASS service was discussed and agreed by the Clinical Director and the two lead Consultant Physicians in Sheffield who then provided clinical leadership for the project. A small working group comprising the two consultants plus four nurse practitioners designed the clinic protocol and developed a screening pathway.

The concept was then taken by one of the two lead consultants to Rotherham and adapted locally with help from one nurse practitioner and a staff grade physician.

What local population are you targeting?

People who are non-pregnant, over 16 years old, and with no signs or symptoms of STIs who wish to be screened for STIs and HIV

How many people are you targeting?

The Department of Genitourinary Medicine and the Royal Hallamshire Hospital in Sheffield sees around 30 000 patients each year of which 50% are asymptomatic new cases requiring screening tests for STIs and HIV.

The FASS service was started in a new clinic time slot which can accommodate 20 male and 20 female patients per week in Sheffield.

Similarly an extra clinic time slot was opened in Rotherham to see an extra 10 male and 10 female patients per week.

Interventions

What interventions are you using to address the problem?

GUM reviewed its appointment system and developed new methods of optimising patient throughput to minimise delays. This included the introduction of FASS.

Patients without signs or symptoms of STIs or HIV can then access a rapid through-put service which focuses on delivering accurate screening tests for STIs and HIV which are frequently asymptomatic but still a significant health risk to the patient, their sexual partners and children (in pregnant women). This then frees up slots in mainstream GUM clinics to provide a fully comprehensive diagnostic and therapeutic service to more complex cases. Access is improved for all GUM attenders as a consequence.

Is the project design based on evidence? If so, please state reference.

The Department of Health’s High Impact Change 4 in 10 High Impact Changes For Genitourinary Medicine 48-hour Access – “Develop a separate pathway to manage screening of patients at low risk for STIs” ¹³ . This includes Dr Christine Bowman’s Case study for high impact factor 4: fast-track asymptomatic screening for STIs and HIV.

Outcome

What outcomes or planned outcomes are you measuring?

We conducted a service evaluation of the new FASS service after the pilot period. The aims were to assess its impact on appointment waiting times and acceptability to patients. We also examined the demographics of it attendees.

Routinely collected data on waiting times, demographics, attendance rates, diagnoses were analysed using Excel spreadsheets and Access databases as appropriate. Patient evaluation forms were reviewed, collated and analysed using an Access database. Implementation of the service was described after interviews with staff.

In October 2005, real time monitoring improved our ability to track the impact of this service and other clinic innovations on patient access. Enhancements were made to the clinic computer system so that real time monitoring of access to services could be measured. When any patient contacts the clinic, either by telephone, walk-in presentation, or by referral letter, they are registered on the computer system and the first available appointment offered to the patient is recorded. If this is unsuitable for their requirements, then a convenient appointment time is negotiated and this is also recorded. From this data, we can derive at daily, weekly or monthly intervals the numbers of patients offered appointments within 48 hours and at longer intervals from their first contact with the clinic. Moreover, we can also derive an assessment of the current total patient demand.

Do you have any outcomes or results yet? If so, what are they?

Yes. FASS was introduced mid-June 2005, initially as a pilot service development project in Sheffield GUM. Evaluation of the pilot was completed in December 2005.

Results:

• Significant increase in 48 hour access (from 24% in May 2005 to 40% in November 2005). Increased numbers of new patients attending GUM (from 1525 in May 2005 to 1682 in November 2005). The numbers of those defaulting from their booked appointments decreased significantly from 375 (24.6%) to 289 (17.2%). Sustained improvements in patient access over subsequent six months (48 hour access rose to 58% in May 2006). Real time monitoring now demonstrates even higher levels offered 48 hour access to GUM, reaching over 95% in December 2006 for both Sheffield and Rotherham;
• FASS has helped meet local demand for GUM services and freed up general appointment slots for more complex cases;
• Increased patient choice and satisfaction around STI/HIV screening. Over 99% of patients surveyed who responded were satisfied with the service and would use it again. Factors sited included the attitude and professionalism of the staff as well as the speed and efficiency of the clinic;
• Positive infection results were most common in the under 25 age group and those with a larger number of partners in the past 12 months. Chlamydia trachomatis infection was found in 10.7% of the total population and Neisseria gonorrhoea in 1.5%. Single cases of syphilis and HIV, (both in women) were also diagnosed. Effective treatment and contact tracing was provided for all diagnosed infections.

Is your project relevant to a government target or guideline?

The Government’s 48 hour access to GUM services target ^{8 9} .

Feedback

What obstacles did you have to overcome to set up this project?

Initially, we planned to work towards a screening clinic which could run without clinically trained staff by using first catch urine samples from men and self taken vaginal swabs from women for Chlamydia and gonorrhoea testing plus a blood test for syphilis and HIV. As the patients were without symptoms no examination should be necessary in this clinic.

Problems with the nucleic acid amplification test (NAAT) using self taken vaginal swabs (high rates of inhibition of the strand displacement amplification assay, BD Probe Tec, test used for Chlamydia and gonorrhoea) required us to revert to clinician obtained cervical swabs. Unfortunately, urine samples in women are significantly less sensitive in detecting these infections than in men.

Collecting only urine samples for NAAT from men was inadequate to screen patients having predominantly or exclusively receptive anal or oral sex. This potentially excluded a significant proportion of homosexual men from the service. Homosexual men, however, did attend the clinic so the original exclusion criteria were removed in order to offer asymptomatic screening to this important group.

Although physical examination is not part of the FASS protocol (to maintain the ethos of asymptomatic screening for four specific infections and to ensure rapid patient flow through clinic) case review found that the majority of patients were examined in the early days of the clinic. Following team discussions, the percentage of patients examined fell by 38.6% between July and November 2005 due to increased compliance with the screening protocol.

Exclusion criteria for the patients were not always complied with, for example three 15 year olds were seen in the pilot period.

Maintaining this as a service for asymptomatic patients only has been a major challenge, either because of failure of staff to comply with protocol, or failure of patients to recognise symptoms or select a more appropriate clinic choice. This has had a major impact on patient flow through the service.

Since November 2005, FASS staff have been more consistent in recommending that symptomatic patients return for a more appropriate appointment where a comprehensive GUM assessment and clinical management can be provided. This reduced the amount of inappropriate appointments, from 27.5% to 23.7% in males and 21.4% to 8.3% in females within the pilot period. Inappropriate attendance of symptomatic male patients subsequently also fell.

What have you learned about the project so far?

Since introduction of FASS, waiting times department-wide have reduced, making the 48 hour targets increasingly achievable. Solutions to problems initially found were implemented in order for the clinic to remain productive. FASS is acceptable to the patients and it offers additional choice in sexual healthcare.

FASS was effective in identifying previously undetected STIs and HIV. The concept of this clinic has spread to other sessions throughout the working week and we are now able to offer more fast access appointments due to changing the way the nurse practitioners work.

FASS is a patient focused service adopting innovative clinical practise, delivered by a multidisciplinary team. It has a major impact on healthcare and disease prevention and has achieved a national access target.

We plan to develop FASS into an autonomous nurse led service. This is achievable through constant service review, modernisation and through the development of the nursing role.

What would you do differently?

• Spend even more time informing and educating staff about the nature of the FASS service to avoid inappropriate bookings at the beginning.
• Explore different ways of explaining the difference between asymptomatic screening and diagnostic clinical management to service users to aid appropriate patient choice.

References:

1. Health Protection Agency. GUM Clinic Waiting Times August 2005. National and Regional, residence and Clinic-based results. Health Protection Agency. 2005.
2. Health Protection Agency. Mapping the issues. HIV and other sexually transmitted infections in the UK. Health Protection Agency. 2005.
3. Health Protection Agency. Epidemiological Data-STIs July 2006. Health Protection Agency. 2006.
4. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect.1999; 75:3-17
5. Department of Health. Better prevention, better services, better sexual health - The national strategy for sexual health and HIV. 2001. http://www.dh.gov.uk/assetRoot/04/05/89/45/04058945.pdf (accessed 25 April 2007).
6. Ovaskainen OT, Grenfell BT. Mathematical tools for planning effective intervention scenarios for sexually transmitted diseases. Sex Transm Dis. 2003; 30(5):388-94.
7. Kretzschmar M, van-Duynhoven YT, Severijnen AJ .Modeling prevention strategies for gonorrhea and Chlamydia using stochastic network simulations. Am J of Epidemiol. 1996; 144(3):306-17.
8. Department of Health. Choosing Health: Making Healthy Choices Easier. 2004. www.dh.gov.uk (search for 4135, accessed 25 April 2007).
9. Department of Health. Our health, our case, our say: a new direction of community services. 2006. www.dh.gov.uk (search for 6737, accessed 25 April 2007).
10. Van Der Pol B, Ferrero DV, Buck-Barrington L, et al. Multicenter evaluation of the BD Probe-Tec ET System for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urine specimens, female endocervical swabs, and male urethral swabs. J Clin Microbiol. 2001; 39(3):1008-16.
11. Dixon-Woods M, Stokes T, Young B, Phelps K, Windridge K, Shukla R .Choosing and using services for sexual health: a qualitative study of women’s views. Sex Transm Dis. 2001; 77(5):335-9
12. Burack R. Young teenagers’ attitudes towards general practitioners and their provision of sexual health care. Br J Gen Pract. 2000; 50(456):550-4
13. Department of Health. 10 High Impact Changes For Genitourinary Medicine 48-hour access. December 2006. www.dh.gov.uk. (search for 7493, accessed 25 April 2007).