Improving screening rates for sexually transmitted and blood-borne infections among patients initiating care in a low-barrier addiction medicine clinic: a quality improvement project

Abstract

Despite a high prevalence of sexually transmitted and blood-borne infections (STBBIs) among patients with substance use disorders, screening rates in addiction medicine settings are often low. At baseline in our addiction clinic, only 65% of patients were offered screening and only 6% completed screening blood work. This quality improvement project aimed to improve the rate of STBBI screening among new intakes in our clinic by 50%.

Interventions included the creation of clinic screening guidelines to include annual screening for all patients for HIV, hepatitis B and C, syphilis, gonorrhoea and chlamydia. Additionally, an on-site phlebotomist was hired. These interventions increased screening rates to an average of 33% with the greatest improvement seen after the addition of the phlebotomist. We found that implementing a bundle of interventions improved rates of screening and detection of STBBIs in a low-barrier addiction medicine clinic. Comprehensive infection prevention, screening and linkage-to-treatment protocols are needed to close gaps in care for this vulnerable patient population.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• People with substance use disorders are at increased risk for sexually transmitted and blood-borne infections (STBBIs); however, this population is medically underserved, often with low rates of screening.

WHAT THIS STUDY ADDS

• We developed a bundle of interventions in our low-barrier addiction medicine clinic, which increased rates of screening and diagnosis of STBBIs in our clinic.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Addiction medicine clinics can implement the bundle of interventions to improve rates of screening for STBBIs.

Introduction

Problem

Patients with substance use disorders (SUDs) have a high prevalence of sexually transmitted and blood-borne infections (STBBIs) due to a variety of factors; however, screening rates are often low in addiction medicine settings.¹,⁴ For many patients, their addictions clinic is their only point of contact with the healthcare system and thus represents a key opportunity to complete STBBI screening.^{3 5 6} Unfortunately, this is often a missed opportunity resulting in underdiagnosis, increased community transmission and increased associated morbidity and mortality among this patient population.⁷,⁹

Available knowledge

Over the past 10 years in North America, increased rates of STBBIs in conjunction with an increase in substance use-associated morbidity and mortality have resulted in a dual public health crisis.¹⁰,¹⁵ The link between substance use as a risk factor for HIV and hepatitis C (HCV) infections has been well described.¹¹⁶,²⁰ In 2020, it was estimated that 19.8% of new HIV infections in Canada were in persons who inject drugs (PWID).²¹ The 2019 Canadian surveillance report on HCV estimated that PWID made up between 60% and 85% of new HCV infections.¹³ As a result, integrative models of care have been described for people with SUD and concurrent HIV and/or HCV.^{3 8 22 23} However, bacterial sexually transmitted infections (STIs) among people with SUDs have received less attention.

Recently, Harvey et al published a retrospective chart review study describing the rates of diagnosis of HIV, HCV, hepatitis B (HBV), syphilis, gonorrhoea (GC) and chlamydia (CT) in the 9 months after implementation of a screening programme for patients initiating care at a low barrier SUD clinic.⁵ Their study showed high rates of diagnoses and reinforces the need for ‘comprehensive infection prevention, screening and linkage-to-treatment protocols in low barrier addiction medicine clinics’. In Canada, STI rates are increasing: CT incidence increased by 40% and GC increased by 190% from 2009 to 2018.^{11 24} Canadian syphilis rates increased by 729% in women and 96% in men from 2017 to 2021.¹¹ In British Columbia, marginalised populations are over-represented, as 71% of new syphilis cases were among people marginally housed and 68% reported substance use.²⁵

Local addiction medicine guidelines and national STBBI screening guidelines do recommend testing for STBBIs in people with SUD^{12 26}; however, these guidelines vary and are often non-specific with respect to which pathogens to test for, and at what frequency. Consequently, there is significant variability in physician screening patterns.

Rationale

Implementation of a comprehensive infection prevention, screening and linkage-to-treatment protocol in people with SUD is needed to adequately diagnose and treat STBBIs.⁷ At baseline, in our clinic, only 65% of new patients (a sample of 11/17 new intakes eligible for screening) were offered screening at intake, and only 6% (1/17) completed screening blood work within the first 30 days of care, and 12% (2/17) in the first 60 days of care. Located within St. Paul’s Hospital in Vancouver, British Columbia, the Rapid Access Addiction Clinic (RAAC) is a low-barrier clinic offering treatment of SUD to a highly marginalised patient population. The clinic’s mandate is to provide short-term substance use stabilisation and referral to ongoing care in the community.²⁷ See the Context section for further details. Prior to this project, the decision to screen for STBBIs was left to the discretion of the individual physician, and the process of creating a lab requisition was cumbersome. Patients often lost the requisition, or faced prohibitively long wait times at the local laboratory.

Specific aim

This project aimed to improve the rate of STBBI screening of new intakes within the first 30 days of care at the RAAC by 50% over the 6-month project period (November 2020—April 2021). STBBI screening included HIV, HCV, HBV, GC/CT and syphilis. Given a median length of stay of 60 days in our clinic, we aimed to complete screening within the first 30 days after intake.

Methods

Context

The RAAC, a high-volume clinic, primarily addresses alcohol, opioid and stimulant use disorders. The clinic serves a complex patient population, many of whom face housing insecurity and psychiatric comorbidities. With an average of 4–5 new intakes and 40–60 patients seen daily, the clinic is open 7 days per week. The nursing staff conducts triage, which precedes the physician assessment. Subsequently, support is provided by peers and social workers. Patients receive ongoing care until stable for transfer to a community provider.

Interventions

The initial intervention (figure 1) involved developing comprehensive screening guidelines for the clinic, incorporating recommendations from local and regional opioid agonist therapy (OAT), HIV, HCV and STI guidelines.^{12 27} These guidelines recommend annual screening (GC/CT by urine nucleic acid amplification testing (NAAT), syphilis, HCV, HBV and HIV), or more frequently according to individual risk. Additionally, baseline serum chemistries, liver and renal function tests, and complete blood counts were recommended. These guidelines were communicated and adopted by nursing and physician staff, with physicians assessing and ordering more frequent screening for patients at higher risk.

Figure 1. Interventions implemented over time. GC/CT, gonorrhoea/chlamydia; PDSA, plan-do-study-act; UDS, urine drug screening.

The second intervention involved having the triage nurse to perform screening, including phlebotomy and urine collection for urine drug screening (UDS) on all new intakes. The third intervention introduced a phlebotomy supply cart to the clinic. The fourth intervention entailed creating a preprinted order (PPO) sheet with routine and STBBI screening labs, requiring only a patient demographic sticker and physician signature. The fifth intervention placed urine GC and CT NAAT containers in the nurse triage area alongside existing containers for UDS in new intakes.

The sixth and final intervention involved hiring a phlebotomist in clinic for 2.5 days weekly to conduct phlebotomy on consenting new intakes, and other patients requiring STBBI screening or blood work. Routine, opt-out screening with onsite phlebotomy was universally implemented for all RAAC patients (both new intakes and follow-up) on the designated days when the phlebotomist was present in the clinic.

Study of the interventions

Our project spanned 12 months from August 2020 to August 2021. We assessed the percentage of eligible new intakes completing baseline screening for STBBIs in the initial 30 days of care. Eligibility was determined based on patients not having undergone screening in the 12 months preceding their presentation, confirmed through a provincial clinical database by clinic staff. We surveyed staff to obtain feedback on the project.

At the project’s outset, the QI team created a fishbone diagram to outline screening completion barriers. Clinician-related obstacles, primarily time constraints and insufficient skill sets were identified by clinical staff. Most barriers identified were patient-related, with perceptions that patients did not prioritise screening, faced challenges reaching the lab and prioritised substance use or treatment. Additional factors included clinic and environmental issues, such as the lack of appropriate phlebotomy or STI urine collection supplies in the clinic.

A QI team member attended the morning nursing huddle to discuss the project, provide education around STBBI prevalence and diagnosis and stress the significance of integrating routine screening into addiction care. Clinicians received updates during monthly clinic meetings. Various clinical workflows were developed to guide the test result notification and treatment processes.

Measures

Outcome measure

Our primary outcome measure was the percentage of eligible new intakes who completed baseline screening for STBBIs in the first 30 days of care, using HCV testing as a proxy. Our team built an electronic query using the quality improvement interface of our electronic medical record (EMR). Since building the query was a cumbersome process, the team limited the initial outcome to one screening test (HCV) to use as a proxy. Acknowledging its limitations, this served as a readily accessible proxy measure for real-time detection of changes in screening rates in our clinic. We chose a blood-based screening test rather than a urine specimen, due to historical challenges with phlebotomy as patients regularly provided urine samples for UDS. On detecting a change through this proxy, the more detailed chart review assessed disease-specific screening rates in a 3-month period before and after the intervention bundle. Additionally, a sample of medical records was reviewed to determine the average baseline percentage of intakes eligible for screening, defined as patients with no screening within the last year and no known diagnosis of HCV.

Process measure

Following the implementation of nurse-led phlebotomy, we asked nurses to track new intakes each day, and if phlebotomy was offered, attempted or completed. The phlebotomist was tasked to track the same data on joining the clinic. Patient surveys revealed a positive response with 90% (27/30) expressing that completing blood work was beneficial and a willingness to complete.

Balancing measures

We examined STBBI diagnosis and treatment rates before and after interventions, as a balancing measure. We also surveyed clinic staff to determine satisfaction with the changes.

Analysis

We plotted HCV screening rates on a run chart, calculated the median rate, then applied the run chart shift rule: a significant change is indicated by six or more consecutive data points above or below the median. Using this rule, there is less than 5% likelihood that the conditions of the rule will be met simply by chance. We inferred that increased screening would lead to an increase in diagnosis and treatment of STBBIs, thereby improving the quality of patient care.

Ethical considerations

This initiative was exempt from ethical review by the Providence Health Care Research Institute as it was considered a quality improvement project and it only included the implementation of standard-of-care.²⁸ The completed Project Ethics Community Consensus Initiative tool yielded a score of 5, indicating minimal risk and obviating the need for a second opinion review or organisation’s recognised review process.²⁹ Consent to STBBI screening was obtained by the triage nurse, and positive STBBI results were reported to the public health authority.

Results

Plan-do-study-act cycle

The first plan-do-study-act (PDSA) cycle tested the impact of the clinic adopting standardised screening guidelines (figure 1) recommending annual screening (or more frequently based on risk) along with basic serum biochemistries. Despite expectations of increased screening, the run chart revealed no significant change with this intervention (figure 2). We initiated additional PDSA cycles to test in-clinic screening, eliminating the need for patients to visit an external laboratory.

Figure 2. Run chart August 2020–July 2021 showing the percentage of eligible new intakes seen in each week in clinic, who completed HCV screening within the first 30 days of care. Red line: every week the percentage of patients screened for HCV (in the first 30 days of care) out of the estimated eligible number of patients was calculated. The estimated number of eligible patients was calculated using the total number of new intakes multiplied by the average fraction of new patients who were eligible for HCV screening based on historical data. Black line: the median weekly screening rate. After there were eight consecutive data points on one side of the baseline median line, a shift was detected. At that inflection point, a new median rate was calculated. PDSA 5 was not included in figure as not expected to change the proxy outcome of HCV screening which relied on phlebotomy. HCV, hepatitis C; PDSA, plan-do-study-act.

The second PDSA cycle tasked the triage nurse to perform screening on all new intakes (including phlebotomy and urine collection), however, this did not increase screening rates. The triage nurses reported a variable level of comfort with phlebotomy, and the process interfered with patient flow, resulting in excessive wait times. In addition, phlebotomy supplies were not readily available, therefore a third PDSA cycle included the addition of a phlebotomy supply cart in the clinic. Nurses were asked to track their phlebotomy completion on new intakes; however, this was inconsistently completed. Screening rates showed no significant change, as shown in figure 2.

During this time, clinic staff identified time constraints as a consistent barrier to completion of screening, particularly with the time-consuming task of creating a laboratory requisition on the Electronic Medical Record. On 20 January 2021, the fourth PDSA cycle introduced a standardised PPO sheet which obviated the need for physicians to create requisitions, but screening rates were not impacted, as seen in figure 2. A fifth PDSA cycle addressed difficulties finding GC/CT NAAT containers by making them available in the nurse triage area along with routine urine drug screen containers. Staff were also trained on collection methods. These changes resulted in an increase in the percentage of new intakes completing urine NAAT tests from 2.4% (1/44) in September 2020 to 54.5% (24/44) in February 2022.

Our final PDSA tested the impact of a phlebotomist present in the clinic 2.5 days per week, utilising previously implemented but underutilised interventions including screening guidelines, PPO sheet and phlebotomy supplies.

Findings

At baseline, an average of 89% of new patients were eligible for HCV testing (monthly average baseline range 85%–92%, measured over a 3-month period). The percentage of eligible new intakes that completed screening within the first 30 days of care (the main outcome variable) was calculated by dividing the total number of new intakes screened for HCV (within the first 30 days of care) divided by the total number of new eligible intakes.

Increased STBBI screening rates

Our team observed a significant increase in STBBI screening rates in our clinic following the addition of the phlebotomist. This change increased screening rates among patients initiating care from 7% to 33% (weekly median screening rate of all new intakes in clinic, see figure 2) using our proxy measure. The phlebotomist effectively used the previously underutilised interventions including screening guidelines, PPO sheet, phlebotomy supplies, acting as a crucial ‘linchpin’ to create a successful bundle of interventions.

To assess the change, a chart review compared STBBI screening rates before and after the interventions: a 3-month preintervention (May—August 2020) period was compared with a 3-month postintervention (May—August 2021) period. In the preintervention period, only 25/200 (13%) of new intakes had any STBBI screening within the first 30 days of care, compared with 170/349 (49%) in the postintervention period (figure 3).

Figure 3. Percentage of new intakes who completed any STBBI screening in 3-month period preintervention versus 3-month postintervention, within first 30 days of care. Preintervention (May–August 1, 2020), there were 200 new intakes (n=200), of which only 25 (13%) had any screening, and 175 (87%) had no screening. Postintervention (May–August 1, 2021), there were 349 new intakes (n= 349) of which 170 (49%) had any screening, and 179 (51%) had no screening. STBBI, sexually transmitted and blood-borne infection.

Increased STBBI detection rates

Prior to the intervention bundle, only 3/200 (1.5%) new intakes were diagnosed with an STBBI. This included two HCV and one CT diagnosis, despite only 13% (25/200) undergoing screening for at least one STBBI. Postintervention, 8% (27/349) of the 349 new intakes tested positive for an STBBI, revealing 18 HCV, 4 CT, 4 untreated syphilis and 1 hepatitis B diagnosis within the 3-month period. This occurred with only 49% (170/349) of new intakes being screened for at least one STBBI.

Type of screening performed—full screening, blood testing only or urine testing only

In the preintervention period, only 2% (4/200) of new intakes had full blood (HIV, syphilis, HCV and HBV) and urine (CT/GC) screening, compared with 16% (56/100) postintervention (figure 4). Preintervention, only 12% (24/200) of new intakes completed full blood work contrasting with 32% (111/349) postintervention. Additionally, preintervention, only 3% (5/200) of new intakes had their urine tested for GC/CT, while postintervention, this increased to 33% (115/349).

Figure 4. STBBI screening of new intakes, within 30 days of care, pre- versus postintervention divided into full screening, blood testing and urine testing. Full STBBI testing (both blood and urine testing completed) versus blood testing HIV, HCV, syphilis and HBV testing completed) versus urine testing (both gonorrhoea and chlamydia urine NAAT completed) in the preintervention and postintervention periods. HBV, hepatitis B; HCV, hepatitis C; NAAT, GC/CT by urine nucleic acid amplification testing; STBBI, sexually transmitted and blood-borne infection.

Impact of phlebotomist on STBBI screening rates

Due to funding constraints, the phlebotomist was available only 2.5 days per week. We evaluated the impact of their presence during the initial intake visit on STBBI screening, considering the brief duration of care for many patients. Beyond the intake, patients had potential access to the phlebotomist during follow-up visits if they coincided with the phlebotomist’s workday. In the postintervention period, 61% (94/154) of new intakes completed screening (within the first 30 days of care) when their initial visit fell on the phlebotomist’s workday in contrast to only 39% (76/195) of new intakes seen for an initial visit on the other 4.5 days (figure 5). Although screening increased overall postintervention, complete STBBI screening and blood testing were more prevalent when intake occurred on a phlebotomist workday (38% (36/94) and 81% (77/94), respectively), compared with days without the phlebotomist (26% (20/76) and 45% (34/76), respectively).

Figure 5. Comparison of screening rates (%) between patients who had their intake day on a day the phlebotomist worked versus new intakes seen on days the phlebotomist did not work. Full screening: includes both blood and urine testing, ie, all new intakes that were tested for HIV, HCV, hepatitis B, syphilis and urine for gonorrhoea and chlamydia on their intake day. Blood: blood testing for all new intakes, ie, all new intakes who were tested for HIV, HCV, hepatitis B, syphilis. Urine: urine testing for all new intakes, ie, all new intakes who were screened for urine gonorrhoea and chlamydia on their intake day. Since the phlebotomist only worked 2.5 days per week and there was no phlebotomist available for 4.5 days per week, more patients (195 vs 154) were seen on a day when no phlebotomy was available. HCV, hepatitis C.

Unintended consequences

After implementation of the intervention bundle by 15 March 2021, the clinic faced challenges with the increased volume of lab work results requiring review and follow-up. Physicians expressed difficulty finding time to manage the results, especially given the sharp rise in new diagnoses of STBBIs necessitating patient counselling and treatment of these infections, in addition to existing patient care responsibilities. As a response, a set of balancing measures related to staff satisfaction were introduced, including a staff survey. Overall, 63% (10/16) of staff reported being dissatisfied with the screening programme before the QI project, but, 88% (14/16) of staff were ‘somewhat’ or ‘very’ satisfied with the screening programme after the interventions. However, 44% (7/16) reported negative impacts, citing time constraints and an increased workload as contributing factors.

Discussion

Summary

Implementing a bundle of interventions in the RAAC enabled the clinic to offer low-barrier screening for STBBIs onsite to patients presenting for care for SUD. Consequently, we exceeded our aim to improve screening rates by 50% and achieved a 470% increase (from 7% to 33%). Recognising that screening was the major hurdle to delivering STBBI care, we created a bundle of interventions to lower the barriers, increase the screening rate and consequently increase diagnosis and treatment of STBBIs. As depicted in the run chart, the initial interventions alone did not meaningfully impact screening rates. A significant improvement from 7% to 33% occurred when the phlebotomist was introduced to perform onsite phlebotomy. This success was the result of building on prior interventions, enabling the phlebotomist to work independently after patients consented to screening with the triage nurse (shown in online supplemental figure).

The major strength of this project lies in achieving a substantial increase in STBBI screening through implementing relatively straightforward interventions. This model can be adapted and reproduced in other settings such as OAT clinics and detoxification centres. In our clinic, having a phlebotomist available on the intake day is an important factor in screening completion, and having a full-time phlebotomy may increase screening rates further.

We were able to create a meaningful change despite multiple challenges including high patient volumes, time constraints, nursing and physician staffing shortages and significant staff burnout all transpiring during years of dual public health emergencies—the overdose crisis and the COVID-19 pandemic.

As an alternative, if implementing the full bundle of interventions is not feasible, our project offers a simple, low-cost, feasible and effective intervention that many SUD clinics can adopt—providing urine collection containers for GC/CT testing alongside testing for UDS. At our clinic, this was the main driver that increased GC/CT testing from a baseline rate of 3%–33%.

Another important impact of our project is the cultural shift that occurred in our clinic, transitioning from focused SUD care to a more comprehensive model. Given the significant unmet need to address infections among patients with SUD, interventions like those described in our project are crucial. This shift not only facilitates access to diagnosis, counselling and treatment of STBBIs for individual patients but also contributes to decreased transmission risks at the community level.

Interpretation

The increase in screening rates immediately following the addition of the phlebotomist, along with other bundled changes, suggests a causal link to the increase in screening completion. Although the influence of unknown factors cannot be entirely ruled out, no other likely factors were identified. Like the study by Harvey et al,⁵ our project highlights the need to optimise screening and treatment protocols for STBBIs in SUD clinics. Our findings are consistent with those of Chadwick et al, who reported an increase in STI screening rates from 5.5% to 45% after introducing routine, opt-out screening in a high-risk population. Despite the project’s success, still only 49% of new intakes underwent any STBBI screening postintervention, indicating a persistent care gap in care for people with an SUD. Additional efforts are required to further enhance screening rates.

A phlebotomist brings a specialised skill set, which may be particularly important given the difficult venous access commonly encountered in this patient population. Our data emphasise the significance of having early access to a phlebotomist, in settings such as ours where care periods might be brief. Patients who had phlebotomy available on the first day of care were 56% more likely to complete screening within the first 30 days. This insight can guide future workflow analyses and interventions, such as having a phlebotomist consistently available or scheduling follow-ups on phlebotomist work days.

In our high-volume clinic, overstretched staff lacked capacity to incorporate screening into existing workflows until a phlebotomist was hired. However, clinics with different staffing models or workflows may be able to implement parts of this bundle of changes without additional resources. For example, if onsite phlebotomy and supplies are already available, implementing screening guidelines and PPO sets may be sufficient to create a sustainable change.

Limitations

Our project has several limitations. Despite improvement in median screening rates for new intakes, overall screening rates remain low, and there was significant week-to-week variability. Limited funding allows for phlebotomy on site for 2.5 of the 7 clinic days per week, resulting in an ongoing gap in care. In addition, not all patients consent to screening, which may be partially overcome with increased patient education. With respect to the weekly variability of screening rates, this may be due to the weekly physician staff changes. However, further analysis could be considered to investigate the root causes. The generalisability of our findings to other clinics may be limited given the funding required for a dedicated phlebotomist, suggesting potential adaptation by training existing healthcare staff to perform phlebotomy. Where this is not feasible, implementing a modified bundle to include only GC/CT screening with urine UDS, or utilizing other screening methods such as dried blood spot or point-of-care testing could be considered. Our protocol relied on urine NAAT for GC/CT screening potentially missing some diagnoses, and adaptation to include oral or rectal swabs is recommended where feasible. The project’s generalisability may also be limited by the challenge of managing the increased workload associated with a successful screening programme, particularly in a patient population with high STBBI rates. Clinics considering similar programmes will also need to scale up other services, including STBBI prevention, counselling and treatment.

Sustainability

The improvements achieved by this project have been sustainable in our clinic, as demonstrated by the run chart reflecting stable screening rates sustained for months after the bundle of interventions was implemented. Integrating low-cost, patient-centred interventions, like onsite phlebotomy and standardised protocols, into existing workflows has been a key to sustainability. Additionally, staff education created a sustained cultural shift in our clinic. Staff now view comprehensive STBBI care as a key component of addiction medicine care. Since 2020, the STBBI treatment clinic has expanded to a busy full-day weekly embedded clinic, providing onsite HCV and STI treatment and counselling, and provides STBBI-specific physician expertise to clinic staff.

Conclusions

Patients presenting for care for SUD are at high risk for STBBIs; however, multiple barriers exist to screening, diagnosis and treatment. This underserved population requires robust care at every contact point with healthcare. Broad implementation of routine, opt-out low-barrier STBBI screening at SUD clinics and other addiction medicine settings may reduce disease burden at the community level. Given the medical and social complexity of our patient population and competing priorities for both patients and healthcare providers, STBBI screening is often deferred or missed. This project represents a first step towards closing the gap in care for STBBIs in people with SUD at our clinic. Nevertheless, ongoing efforts are required. Exploring barriers to screening among patients who do not initially complete the process through research or additional quality improvement efforts may pave the way to tailored strategies to overcome these barriers. This approach holds potential to optimise STBBI screening for all patients seeking care for SUD.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.