Eliminating Congenital Syphilis Through the Use of a Tracking System

State: FL Type: Neither Year: 2016

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Broward County is located in the southeastern portion of the State of Florida. Broward County’s 2014 population estimate of 1.87 million people. Issue: In 2012, 14 mothers gave birth to live infants with congenital syphilis in Broward County. Ten (71.4%) of the mothers were Black, Non-Hispanic, 3 (21.4%) were Hispanic and 1(7.1%) were Asian. In 2012, 10 (71%) of the mothers were born in the United States followed by Haitian born 2 (14%), Cuban born 1 (7%), and Dominican Republic 1 (7%). The mothers’ ages ranged from 21 to 41 years, with a mean age of 29. Eleven (78.6%) reported marital status as single, never married and 3 (21.4%) reported being married. Twelve (85.7%) reported having only 1 sex partner. Seven (50%) had a previous history of a sexually transmitted disease. The 14 mothers resided in 9 zip codes. Six (42.9%) of the mothers reported their residence to be in zip code “33311”. Other residence zip codes reported were 33024, 33025, 33029, 33306, 33309, 33312, 33313, and 33334. Ten (71.4%) had prenatal care, with the number of prenatal visits ranging from 1 visit to 14 visits. Seven (50%) mothers had between 10 to 14 visits. Five had a prenatal visit during their first trimester. Four of the five had tested negative by RPR and were retested at time of delivery. Three were tested in their 2nd trimester, 1 in the 3rd trimester, 6 at time of delivery, and 1 was tested after delivery, 4 of which were tested at 1st trimester, 1 after their delivery and for 2 of the mothers the trimester in which they were tested was unknown. Fourteen (100%) had a nontreponemal test and 13 (93%) had a treponemal test performed. Nine (64.3%) started treatment during pregnancy. Three began treatment during their 2nd trimester, 1 in their third, 1 during delivery, 7 after delivery, and treatment for 2 mothers was unknown. Eleven (78.6) deliveries occurred in 2 hospitals, (Broward General Medical Center and Plantation General Hospital) Goals and objectives: The goal is to have zero congenital syphilis cases.Objective 1) Place all pregnant females who are potentially infected with syphilis in the tracking system. 2) Identify syphilis testing. 3) Determine third trimester syphilis testing. 4) Determine adequate treatment of syphilis prior to delivery. 5) Monthly Congenital team meetings to discuss all possible cases and to maintain open communication between all team members and partners. 6) Surveillance Supervisor performs daily update on the tracking system. Practice Implemented /Activities?: The practice was implemented by the surveillance supervisor. An integrated approach was initiated by the Director of Quality Improvement, STD Surveillance Supervisor, Program Manager, Director, and Deputy Director. As an integrated team, we reviewed the number of syphilis cases and congenital cases to determine the best approach in eliminating congenital syphilis cases. A tracking system was developed and deployed to identify, follow, and case manage all females of childbearing age who are determined to be pregnant and positive for syphilis. The information is updated daily. Once the expected due date is determined, the third trimester date is calculated and input into the tracking system. Thirty days prior to delivery, the Surveillance Supervisor initiates a field activity record which is assigned to a DIS to assure that the client receives a third trimester syphilis test and appropriate treatment. All cases are reviewed and discussed on a monthly basis by a multi-disciplinary team. In the event that the client is unable to be located, the case is immediately escalated to the Communicable Disease Director for immediate intervention. The daily activities involved in this process include: 1) Notification to the STD Surveillance team of a positive syphilis test on a female of child bearing age; 2) the STD Surveillance Clerk contacts the provider to obtain demographic information and determine pregnancy status, diagnosis and treatment; 3) once the information is obtained, the client is placed in the tracking system utilizing the gestational calculator to estimate third trimester date; 4) At the beginning of the client’s third trimester, the DIS contacts the client and verifies third trimester syphilis testing has been performed with the client and provider; 5) If it is determined that the client is a new case of syphilis, the DIS assures appropriate and timely treatment to prevent a congenital case. Results: In 2012, there were 14 cases of Congenital Syphilis reported and in 2015 to present there has been (2) cases reported. From 2012 to 2015 congenital births decrease by 86%. Objectives met?: Yes, all objectives were met. Factors led to the success of this practice: Enhanced surveillance in the identification of all positive pregnant females by the STD Surveillance Team, aggressive case management, and continued communication among DOH-Broward STD Program and community partners has led to the decrease in congenital cases. DOH-Broward STD Program provides ongoing education to all 17 acute care hospitals emergency departments, urgent care centers and local providers on diagnosing, treating and reporting of cases. Impact of Practice: From 2012 to 2015 congenital births decreased by 86%. Website: http://broward.floridahealth.gov/
Statement of Problem/ Public Health Issues: In order to reduce Congenital Syphilis cases, in 2012, a “Congenital Syphilis Tracking System” was developed and implemented. The purpose of the tracking system is to follow and case manage the testing, treatment, care and follow up for cases that need 3rd trimester follow-up testing to ensure the timely identification and treatment of new syphilis cases in pregnant females. In 2013, the STD Program Manager, in collaboration with the Perinatal Director, visited and provided education to more than 96 OB/GYN providers and 103 pediatricians’ in Broward County. This included provision of information regarding syphilis staging and disseminating tools (including the physician guide and toolkit). This process is ongoing. In 2014, the STD team provided the eight (8) delivering hospitals the most current syphilis protocols for diagnosed females of child bearing age. The protocols included the latest public health service guidelines to ensure that all Syphilis positive pregnant women were provided with the best clinical care during delivery and receive adequate treatment. Following labor and delivery procedures, proper documentation needs to be secured and followed up with DOH-Broward. Extensive ongoing education to all medical providers has continued. What target population is affected by problem (please include relevant demographics): Broward County is a minority/majority county demonstrated by its 2014 population by race (White 39.8%, Black 28.9%, Asian/Native American 3.8%, and Hispanic 27.5%). Retrospective and multi-variant analysis was utilized to define the affected population in Broward County. Black pregnant women are disproportionately affected by STDs. In Broward County, the majority of the pregnant HIV positive cases (87%) and congenital cases (90%) affected black women. What percentage did you reach? There were 70 suspected congenital syphilis cases reported to DOH-Broward in 2015. Due to the implementation of the tracking system, DOH-Broward has successfully case managed 86% of suspected congenital syphilis cases reported, with only two diagnosed cases in 2015. What has been done in the past to address the problem? The State of Florida, Bureau of Communicable Disease provides STD summary data by STD type. This report does not provide individual case data and is therefore not effective method for tracking pregnant women with STDs. A manual process was created for internal use to track lab results. The sexually transmitted disease (STD), HIV, TB and Hepatitis Programs conducted individual surveillance because they were stand-alone programs with minimal coordination of activities across programs. The services provided and referrals were a manual process; which made the process slower, fragmented, duplicative, and ineffective. Why is current/proposed practice better? Use of current and emerging technologies allow work flow/referrals to be conducted faster and timely services rendered. DOH-Broward adopted the Program Collaboration and Service Integration (PCSI) model which is a mechanism for organizing and blending interrelated health issues, activities, and prevention strategies to facilitate comprehensive delivery of services. This process has improved continuity of care for STD clients. DOH-Broward provides a free pregnancy test for all women unsure of their pregnancy status, and documents the results in the tracking system. From 2012 to 2015, congenital syphilis decreased by 86%. Is current practice innovative? How so/explain? The Congenital Syphilis tracking system was implemented in 2012, after the identification of a substantial increase in congenital syphilis cases in Broward County. A new method to track and monitor the positive syphilis cases in pregnant females was required. DOH-Broward is unaware of any tracking system in place in other LHDs. There is no evidence of this tracking system in the NACCHO model practices database. The use of PCSI model is a best practice methodology being utilized across DOH-Broward programs. Is current practice evidence-based? This practice is evidence based as outlined in the latest DHHS guidelines for HIV treatment and care for HIV positive pregnant women. (www.AIDSinfo.gov) .We address mother-to-child transmission of HIV and Syphilis by following CDC guidelines for care and treatment.as their babies. The use of PCSI model is a best practice methodology being utilized across DOH-Broward programs.
HIV in the U.S.|Mother-to-Child Transmission of HIV and Syphilis
Goals and objectives of practice: The goal is to have zero congenital syphilis cases.Objective 1) Place all suspected syphilis cases of pregnant females into the tracking system. 2) Identify syphilis testing. 3) Determine third trimester syphilis testing. 4) Determine adequate treatment of syphilis prior to delivery. 5) Monthly Congenital team meetings to discuss all possible cases and to maintain open communication between all team members and partners. 6) Surveillance Supervisor performs daily update on the tracking system. How Was The Practice Implemented /Activities?: The practice was implemented by the surveillance supervisor. An integrated approach was initiated by the Director of Quality Improvement, STD Surveillance Supervisor, Program Manager, Director, and Deputy Director. As an integrated team, we reviewed the number of syphilis cases and congenital cases to determine the best approach in eliminating congenital syphilis cases. A tracking system was developed and deployed to identify, follow, and case manage all females of childbearing age who are determined to be pregnant and positive for syphilis. The information is updated daily. Once the expected due date is determined, the third trimester date is calculated and input into the tracking system. Thirty days prior to delivery, the Surveillance Supervisor initiates a field activity record which is assigned to a DIS to assure that the client receives a third trimester syphilis test and appropriate treatment. All cases are reviewed and discussed on a monthly basis by a multi-disciplinary team. In the event that the client is unable to be located, the case is immediately escalated to the Communicable Disease Director for immediate intervention. The daily activities involved in this process include: 1) Notification to the STD Surveillance team of a positive syphilis test on a female of child bearing age; 2) the STD Surveillance Clerk contacts the provider to obtain demographic information and determine pregnancy status, diagnosis and treatment; 3) once the information is obtained, the client is placed in the tracking system utilizing the gestational calculator to estimate third trimester date; 4) At the beginning of the client’s third trimester, the DIS contacts the client and verifies third trimester syphilis testing has been performed with the client and provider; 5) If it is determined that the client is a new case of syphilis, the DIS assures appropriate and timely treatment to prevent a congenital case. Results: In 2012, there were 14 cases of Congenital Syphilis reported and in 2015 to present there has been (2) cases reported. From 2012 to 2015 congenital births decrease by 86%.  Any criteria for who was selected to receive the practice? The practice was target to all syphilis positive females of childbearing age., What was the timeframe for the practice? The timeframe for the practice is December, 2012 and is ongoing. Were other stakeholders involved?  The practices involved other stakeholders including OB/GYNs, urgent care centers, labor and deliver hospitals, and other medical providers.   What was their role in the planning and implementation process? DOH-Broward worked with other community stakeholders to coordinate testing, diagnosis and treatment services to syphilis positive women of childbearing age. In 2013, the STD Program Manager, in collaboration with the Perinatal Director, visited and provided education to more than 96 OB/GYN providers and 103 pediatricians’ in Broward County. This included provision of information regarding syphilis staging and disseminating tools (including the physician guide and toolkit). This process is ongoing. In 2014, the STD team provided the eight (8) delivering hospitals the most current syphilis protocols for diagnosed females of child bearing age. The protocols included the latest public health service guidelines to ensure that all Syphilis positive pregnant women were provided with the best clinical care during delivery and receive adequate treatment. Following labor and delivery procedures, proper documentation needs to be secured and followed up with DOH-Broward. Extensive ongoing education to all medical providers has continued.   What does the LHD do to foster collaboration with community stakeholders? DOH-Broward has strong relationships with public and private health care providers, faith-based organizations, local governmental agencies, and the Miccosukee and Seminole tribal nations in Broward County. DOH-Broward staff serves on many committees including the Broward County Medical Association, Children’s Services Council, Health Care Access Community, Broward County School Health Advisory Committee, Broward Healthy Start Coalition, the Urban League, Maternal and Child Health Committee and Medical Services Planning Committee. DOH-Broward collaborates with its community partners to plan, implement and coordinate services across the care continuum. Describe the relationship(s) and how it furthers the practice goal(s)DOH-Broward County leads monthly meetings to provide education and update on new processes, procedures and/or protocols on a variety of health issues or concerns that affect the residents and visitors of Broward County. No start up costs for this project as it involved internal DOH-Broward program processes and partnerships with community stakeholders only.  
What did you find out?The DOH-Broward STD program tracking system is an effective methodology in following and case managing syphilis positive pregnant females. This system allows all women to be monitored for testing, treatment and re-testing. Enhanced collaboration and communication with existing and new community partners as well as across DOH-Broward internal programs, has reduced congenital syphilis cases by 86% from 2012 to 2015 and improved overall client health outcomes in Broward County. Through this collaboration and open communication, enhanced reporting by community providers has been realized. To what extent were your objectives achieved? Please re-state your objectives from the methodology section. The practice was implemented by the surveillance supervisor. An integrated approach was initiated by the Director of Quality Improvement, STD Surveillance Supervisor, Program Manager, Director, and Deputy Director. As an integrated team, we reviewed the number of syphilis cases and congenital cases to determine the best approach in eliminating congenital syphilis cases. Objective 1) to place all suspected syphilis cases of pregnant females into the tracking and Objective 2) to identify syphilis testing were both met. A tracking system was developed and deployed to identify, follow, and case manage all females of childbearing age who are determined to be pregnant and positive for syphilis. Objective 6) Surveillance Supervisor performs daily update on the tracking system has been met as the information is updated daily. Once the expected due date is determined, the third trimester date is calculated and input into the tracking system. Objective 3) Determine third trimester syphilis testing and Objective 4) to determine adequate treatment of syphilis prior to delivery were also met. Thirty days prior to delivery, the Surveillance Supervisor initiates a field activity record which is assigned to a DIS to assure that the client receives a third trimester syphilis test and appropriate treatment. Objective 5) Lead monthly integrated team meetings to discuss all possible cases and to maintain open communication between all team members and partners was met. All cases are reviewed and discussed on a monthly basis by a multi-disciplinary team. In the event that the client is unable to be located, the case is immediately escalated to the Communicable Disease Director for immediate intervention. The daily activities involved in this process include: 1) Notification to the STD Surveillance team of a positive syphilis test on a female of child bearing age; 2) the STD Surveillance Clerk contacts the provider to obtain demographic information and determine pregnancy status, diagnosis and treatment; 3) once the information is obtained, the client is placed in the tracking system utilizing the gestational calculator to estimate third trimester date; 4) At the beginning of the client’s third trimester, the DIS contacts the client and verifies third trimester syphilis testing has been performed with the client and provider; 5) If it is determined that the client is a new case of syphilis, the DIS assures appropriate and timely treatment to prevent a congenital case. Results: In 2012, there were 14 cases of Congenital Syphilis reported and in 2015 to present there has been (2) cases reported. From 2012 to 2015 congenital births decrease by 86%. Did you evaluate your practice? List any primary data sources, who collected the data, and how (if applicable) Data, including electronic lab reporting (through the Florida Department of Health’s Patient Reporting Investigating Surveillance Manager (PRISM)), fax reporting from providers, U.S. mail and telephone reports, are collected and documented by the DOH-Broward STD program. Data is then continuously collected and monitored by program staff through the tracking system to ensure all syphilis positive pregnant female clients are maintained in care and transmission from mother to baby is maintained at zero. List performance measures used (include process and outcome measures): The metric used to measure the success of this methodology is the number of congenital cases born in each year. The goal is zero congenital births. Describe how results were analyzed?:The STD Surveillance team collects data on a daily basis and documents all pregnant syphilis positive cases in the tracking system. They also document all congenital births. The Epidemiology Program analysis the data collected by the STD surveillance. The analysis performed by the Epidemiology Program includes descriptive, trend and multivariate. The Director of Communicable Disease performs a yearly analysis of congenital cases. Were any modifications made to the practice as a result of the data findings?: Pregnant females that were found to be Syphilis biological false positives were added to the tracking system as an additional variable data point as a result of the findings of the analysis.  
Lessons learned in relation to practice The DOH-Broward STD program tracking system is an effective methodology in following and case managing syphilis positive pregnant females. This system allows all women to be monitored for testing, treatment and re-testing. Enhanced collaboration and communication with existing and new community partners as well as across DOH-Broward internal programs, has reduced congenital syphilis cases by 86% from 2012 to 2015 and improved overall client health outcomes in Broward County. Through this collaboration and open communication, enhanced reporting by community providers has been realized. Lessons learned in relation to partner collaboration (if applicable):  Increase and enhanced communication and collaboration with our partners has been critical to the success of this practice and consequently in the reduction of congenital syphilis cases in Broward County. Routine partner reporting of positive syphilis results has increased. The appropriate timing of testing and treatment has also increased. Describe the relationship(s) and how it furthers the practice goal(s)DOH-Broward County leads monthly meetings to provide education and update on new processes, procedures and/or protocols on a variety of health issues or concerns that affect the residents and visitors of Broward County. Did you do a cost/benefit analysis? If so, describe. A cost/benefit analysis was not conducted for this practice as it involved internal DOH-Broward program processes and partnerships with community stakeholders only. . Is there sufficient stakeholder commitment to sustain the practice? Describe sustainability plans:  • The Syphilis101 pocket guide and the development, training and implementation of labor and delivery protocols for HIV and Syphilis continue to ensure that consistent care and treatment standards will be maintained.• All 17 acute care hospitals, which include 8 labor and delivery hospitals, will fax the lab results to the DOH-Broward STD Program (detailing delivery date and medical record numbers of mother and child) when a delivery of a syphilis positive woman occurs.
Colleague in my LHD|NACCHO website
 
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