Should more adolescents get tested for STIs in pediatric emergency departments?

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Despite the recommendations of the American Academy of Pediatrics and the CDC to annually screen all sexually active female adolescents for sexually transmitted infections (STIs), many teenagers do not receive these screenings. A 2019 National Youth Risk Behavior Survey reported that only 20% of sexually active high school students reported testing for STIs in the year prior.

Barriers to testing included adolescents having trouble building rapport during infrequent encounters with counselors and health care providers; not understanding or knowing minor consent laws and confidentiality; language, cultural, or religious differences; discomfort with behavioral counseling; and insufficient training on reproductive health.

Additionally, many adolescents do not have a primary care provider, and so seek medical help through an ED. This population group is also less likely to have regular well visits and more likely to engage in risky behaviors. As a result, the investigators of a recent study published in Pediatrics felt the ED was an important setting to address the sexual health of adolescents.

“Access to primary care worsened during the COVID-19 pandemic, and this led to many adolescents seeking care in the ED,” noted Tatyana Vayngortin, MD, division of emergency medicine, Rady Children’s Hospital, San Diego, California, and lead author of the study. “We identified that our ED was rarely performing STI testing in adolescents, and we sought to address this issue with a quality improvement initiative.” The specific aim of the study was to increase chlamydia and gonorrhea testing from 12% to 50% in adolescents presenting with at-risk chief complaints over a 12-month period. Secondary aims included increasing sexual history documentation in at-risk patients from 46% to 75% and increasing documentation of confidential phone numbers in patients tested from 23% to 75%.

Project implementation began in July 2020, and was presented at the Division of Emergency Medicine monthly meeting and the ED Nursing Staff monthly meeting. Among other feedback, nurses and physicians discussed time constraints as a barrier to collecting teen contact information, which led researchers to meet with registration staff to standardize this into their workflow.

To facilitate testing and treatment, investigators also created a new electronic medical record (EMR) order set that included STI testing, antibiotic treatment of STIs and pelvic inflammatory disease, and post sexual assault prophylaxis. Chlamydia and gonorrhea testing were added to existing order sets and panels for patients aged more than 12 years.

The primary outcome measure was the proportion of at-risk patients aged 13 to 17 years with urine chlamydia and gonorrhea testing completed weekly. Investigators identified sexual history-taking as an area for improvement, and used teen phone number documentation as a metric to improve treatment rates. Investigators collected demographic data, including age, sex, race, and ethnicity.

A total of 5539 eligible patients aged 13 to 17 years were screened during the 2-year study period. Positive test results per month increased throughout the project from 1.8 to 3.4. Roughly one-third of patients testing positive had behavioral chief complaints and the majority (89%) of those testing positive were contacted to arrange treatment.

Investigators successfully increased chlamydia and gonorrhea testing in at-risk patients presenting to the ED, surpassing their goal by increasing testing for chlamydia and gonorrhea to 59%, sustained for 4 months from the last intervention.

Finally, the researchers noted that optimizing the EMR was more effective than education and feedback in enacting changes to testing rates. “We initiated multiple interventions to improve chlamydia/gonorrhea testing in adolescents,” noted Vayngortin. We were surprised that provider education and reminders did not improve testing. Our most effective intervention was the implementation of preselected test orders in high-risk patients. We were also surprised that about one-third of positive tests were in patients with behavioral health complaints.”

“The most important lesson of this study was that the most effective quality improvement interventions ease workflow. Once we created preselected test orders and providers did not have to remember to order the test, the testing rates significantly increased,” concluded Vayngortin.

Reference

Vayngortin T, Gracia M, Clark K, et al. Increasing chlamydia and gonorrhea testing for adolescents in the pediatric emergency department. Pediatrics. 2024;153(1):e2022059707. doi:10.1542/peds.2022-059707