Quality Improvement Project to Develop a Telephone Protocol to Triage Vaginitis Complaints in Adult Non-pregnant Patients

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Quality Improvement Project to Develop a
Telephone Protocol to Triage Vaginitis Complaints
in Adult Non-pregnant Patients

• Ann Evensen, MD
• UW Health Monona
• November 6, 2008

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Question 1

• 22 y/o unmarried female in long term
  monogamous relationship calls with vulvar
  itching, swelling and dysuria for the past three
  days. Has tried nothing at home. Wants diflucan
  called in.

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Treatment options

• A) Treat with Diflucan over the phone
• B) Treat with metronidazole over the phone
• C) Treat with Monistat over the phone
• D) Treat with sulfa over the phone
• E) Schedule office visit for evaluation
• F) Other?

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Project Objective

• Develop a protocol for telephone triage of
  vaginitis complaints from non-pregnant, adult
  females

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Diagnosis of Yeast Vaginitis
Sign or symptom Sensitivity Specificity
Increased discharge 59 67
Itching 50-91 37-64
Vulvar swelling 24 92
Clinician curdy discharge and inflammation 77-81 95-100
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Triage Protocol Design

• Literature review
• Assessment of our clinical practice
• Stakeholder input

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Literature review

• Previously created protocols
• Sensitivity and specificity of signs and symptoms
• Correlation between telephone and in-person
  interviews

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Assessment of clinical practice

• Spreadsheet of 5 telephone encounters from each
  physician and NP (total of 30 calls)
• Summarized phone advice given and any related
  visits next two months

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Pilot protocol

• Evidence based material
• Expert opinion
• Took previously summarized calls and put them
  through pilot protocol

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Phone Calls Sent to Physician/NP
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Office Visits Required for 30 Calls
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Meetings with stakeholders

• Met twice with doctors, nurses, MAs and front
  desk staff
• Presented info on vaginitis diagnosis
• Listened to their concerns and preferences

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EMR installation

• Created a Smart Phrase of protocol in our
  electronic medical record (EPIC)
• Recruited computer-savvy nurse to assist in
  loading Smart Phrase in all staff computers

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Protocol Revisions

• Regularly checked in with staff regarding their
  opinions and patient feedback after trying
  protocol
• Many found protocol too long

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User feedback

• Keep/revise 2/3
• Toss 1/3

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Lessons learned

• Practices vary considerably
• Expert opinion vs EBM
• Implementation requires buy-in
• Success requires feedback and revision

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Conclusion

• Vaginitis diagnosis difficult low predictive
  value of signs and symptoms.
• Protocol can be developed for an urban family
  medicine clinic
• treat a few patients over the phone
• avoid delay in scheduling office visits
• decrease uncompensated physician time

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Future

• Does this protocol simply help clinic triage
  issues or does it lead to more accurate diagnosis
  and appropriate treatment of women with vaginitis
  symptoms?