Abnormal Pap Smear Tracking in General Internal Medicine Clinic J A C O B K U R L A N D E R & T A R A O B R I E N C A R Q I P R O J E C T J A N U A R Y 2 0, 2 0 1 0
PDSA cycle Plan Act Do Study
Our Charge Creating a treatment algorithm based on pap results Design an abnormal tracking sheet Creating a patient correspondence template for reporting normal results Boiler plate email for abnormal Pap Smears Create training material for MD and RN at the completion of this meeting
The current process MD RN Orders pap Sets up Pap Performs Pap Completes lab form, puts specimen in bin, records pt info in PAP smear notebook Receives result in Webcis +/- message from Theresa. Should contact pt, arrange follow up if abnormal, update healthcare mtn tab LAB Receives specimen Pathologist reads slide Theresa Follows up result and records in notebook. Sends phone msg to MD if abnormal. Sends letter to patient if normal.
Pap tracking log
Current tracking system
Previous findings Kiran Venkatesh and Amanda Allen found: Pap smears are often deferred, for many reasons No clear algorithm for reporting and triaging normal and abnormal results to patient Redundancy, lost to follow up There are relatively few abnormal Pap smears 24/579 from 12/08 to 12/09. 18/24 were ASCUS. The remainder were LSIL/HSIL. Other observations: No standardized way of tracking BV, trich, candida
Previous triage of abnormal Paps No follow up Referred to GYN, but no GYN note Referred to GYN, + note in Webcis Repeat pap in 6 months Reflex HPV testing negative ASCUS (18) 3 3 2 7 2 LSIL 1 2-1 - HSIL - 1 1 - - For ASCUS, 1/3 were triaged improperly or without follow up. For LSIL, ½ were improperly triaged or without follow up. Allen and Venkatesh, 2009
Other barriers to follow-up Patient factors: demographics, social support, lack of understanding, fear Healthcare factors: Inconvenient clinic hours, male providers, insensitive staff Patient followup Abercrombie, 2006
Treatment Algorithm: American Society for Colposcopy and Cervical Pathology
Treatment Algorithm: American Society for Colposcopy and Cervical Pathology
Treatment Algorithm: American Society for Colposcopy and Cervical Pathology All patients with >ASCUS (AGC, ASCUS-H, LSIL, HSIL) are recommended for colposcopy
Use of ThinPrep Must use ThinPrep to perform reflex HPV test HPV status currently used in UNC Gyn-Onc Dysplasia Clinic triage guidelines Cost-effective for evaluating ASC-US* *ACOG 2009
Our simplified treatment alogrithm ASCUS Repeat Pap at 6 months, with ThinPrep Abnormal pap smear >ASC (ASCUS-H, AGC, LSIL, HSIL) Normal cytology and no high risk HPV >ASCUS or high risk HPV Repeat Pap at 12 months with conventional >ASCUS Refer to Gyn-Onc Normal Done
Caveats Assumes no pregnant patients Assumes use of conventional Pap for screening Paps and ThinPrep for 6 month follow up of ASCUS Treats adolescents the same as adults Very small number of adolescents
Insights from algorithm ASCUS management has many branching points ASC-H, AGC, LSIL and HSIL management is linear
Four sections Pap Tracking Notebook 1. All pap smears performed in clinic 2. ASCUS patients actively being treated Pulled from section 1 3. ASCUS patients who have completed treatment Pushed from section 2 4. All patients with ASCUS Pulled from section 1
Section 1: All Paps and results
Section 2: ASCUS tracking sheets
Section 4: Non-ASCUS abnormal tracking sheet
Pap Smears found to have infection present Phone message sent to MD by RN MD also receives notification through activity list in WebCis MD contacts patient and treats accordingly with expectation of documentation
Summary of process by pap result Patient correspondence MD notification by RN RN schedule follow up Referral to dysplasia clinic Normal ASCUS ASCUS Infection RN RN RN MD No Yes Yes Yes No Yes No No - RN if indicated RN -
Three clicks! ASCUS initial We have reviewed the results of your recent Pap smear. As you may know, Pap smears are used to screen for changes in the cervix that could lead to cervical cancer. Your Pap smear showed a finding called ASCUS, which means that some of the cells seen do not appear completely normal. In the vast majority of cases, ASCUS does not lead to cancer. However, to be on the safe side, we recommend that you have a repeat Pap smear in 6 months and again in 12 months. You will be contacted about scheduling a 6-month appointment if you don't already have one. If you have access to the Internet, you can read more about Pap smears and your result at a website sponsored by the National Cancer Institute: http://www.cancer.gov/cancertopics/understandingcervicalchanges/page1 If you want to discuss your Pap smear result with your care provider before your next appointment, please call the clinic at (919) 966-1459. We are here to help.
Example of boiler plate message to MD #1. ASCUS pap smear Your patient had a finding of ASCUS on their most recent Pap. Per general medicine clinic protocol, they have been scheduled for continuity visit in 6 months, at which time the patient should have another Pap smear using the ThinPrep, in order to test for high-risk HPV types. Please finalize. Robin, RN
Future Steps Repeat process evaluation Patient surveys RN surveys Ensure all Paps are entered into notebook to start Oversight Increase screening rates PDSA to look at proportion of patients who receive recommended Pap screening Should nurses do paps? Make online tracking database We have developed the logic Network space Nurse training Align attending and resident Pap practices Consider using ThinPrep for all Paps
References 1. Allen A and Venkatesh K. CAR QI Project: Cervical Cancer Screening in the ACC Internal Medicine Clinic. December 2009. 2. Abercrombie PD. Improving adherence to abnormal Pap Smear follow up. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2006; 30:80-88. 3. Wright TC, Massad LS, et al, for the 2006 American Society for Colposcopy and Cervical Pathology-sponsored Consensus Conference. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. AJOG. 2007; 197: 346-55. 4. American Society for Colposcopy and Cervical Pathology. Alrogrithm for 2006 Consensus Guidelines for the Management of Women with Cervical Intraepithelial Neoplasia or Adenocarcinoma in situ http://www.asccp.org/pdfs/consensus/algorithms_hist_07.pdf Accessed January 15, 2010. 5. ACOG Committee on Practice Bulletins Gynecology. ACOG Practice Bulletin No. 109: Cervical Cytology Screening. Obstetrics and Gynecology. 2009.; 114:1409-20. 6. Kottke TE and Trapp MA. The quality of Pap test specimens collected by nruses in breast and cervical cancer screening clinic. American J of Preventive Medicine. 1998; 14:196-200.