John Ruedy Immunodeficiency Clinic: Providence Health Care

The John Ruedy Immunodeficiency Clinic (IDC) at St. Paul’s Hospital, Providence Health Care, has made significant improvements in screening and immunization by identifying areas in need of improvement and implementing a structured approach to tackle the challenges.

The interdisciplinary team from the John Ruedy IDC, within the HIV/AIDS program at St. Paul’s Hospital, had initially focused on clinic re-design to provide accessible, flexible and quality patient-centred HIV/AIDS care. In the process, the team adopted the Chronic Care Model (Barr et al., 2002) as a template for service delivery which included the introduction of a patient registry. The patient registry enabled the team to track patient data and identify areas in need of improvement.

In 2005, the first data output from the registry showed that only 30 per cent of John Ruedy IDC enrolled patients were being screened and receiving immunization as recommended. There are currently no Canadian-based benchmarks for the immunization of highly marginalized populations such as HIV/AIDS, resulting in best practices being drawn from other resources. The resulting target was set to increase uptake of screening and immunizations from 30 to >95 per cent among a cohort of active patients receiving HIV care at the IDC.

A comprehensive analysis of this problem was completed to identify the reasons for the low rates at the IDC. Two barriers to immunization were identified: 1) Lack of consistent immunization protocols, and 2) lack of a reliable vaccine supply. Six key process changes were introduced to tackle these barriers and achieve success in the stated goal:

• Introduction of immunization and screening protocols: Although immunization is part of the training received by physicians and nurses, immunization of the immunocompromised patient infected with HIV requires particular considerations. The IDC team undertook a comprehensive review of existing immunization guidelines and a summary protocol was added to the IDC guidelines.
• Change in vaccine supply: The team worked with St. Paul’s pharmacy department to ensure that a stable supply of vaccines was on-site to ensure prompt access.
• Recall and flagging system: A reminder, recall and flagging system was introduced as a means to enhance uptake of immunization and screening.
• Task shifting: Nursing staff ensured that all patients received counselling on immunization/screening and, if safe (as per protocol), offered these two interventions to consenting patients.
• Improving screening uptake as per clinical guidelines: A clinic protocol was developed and included in the IDC protocol binder.
• Pre-printed laboratory requisitions and on-site blood drawing: Pre-printed laboratory requisitions with all the screening tests were developed as per guidelines and patients were offered on-site blood drawing.

Results of these changes were presented to the IDC staff during operations meetings and results were posted in common clinical areas to promote staff and patient awareness of the progress of the quality improvement initiatives.

Using rapid PDSA (Plan-Do-Study-Act) cycles to implement the interventions outlined above, the team has been able to achieve the following results as of December 2008:

• 57 per cent increase in documented Syphillis Screening
• 57 per cent increase in documented Pneumoccocal vaccination rates;
• 67 per cent increase in patients (female) with a documented cervical Pap smear;
• 55 per cent increase in documented chest x-rays; and
• 61 per cent increase in patients with >200 CD4s with a documented TB Skin Test.

The target of 95 per cent for all of these measures remains a stretch goal, but one that the interdisciplinary IDP team is committed to achieving.

This model of service delivery and clinical quality has served as a framework of innovation for others within Providence Health Care (PHC) and the community at large. Within PHC, the model has been shared with a number of programs, including Renal and Medicine, to serve as a framework for their ambulatory clinic redesigns. Externally, this model has been adopted by the Vancouver Native Health Clinic in the Downtown Eastside.

For more information, please contact Camille Ciarniello ( Director, Risk Management & Patient Safety Providence Health Care) or visit the John Ruedy IDC website.