1. 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

2. 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.

3. 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?

4. Project Objective Develop a protocol for telephone triage of vaginitis complaints from non-pregnant, adult females

5. Diagnosis of Yeast Vaginitis Sign or symptom SensitivitySpecificity Increased discharge 5967 Itching50-9137-64 Vulvar swelling2492 Clinician: curdy discharge and inflammation 77-8195-100

6. Triage Protocol Design Literature review Assessment of our clinical practice Stakeholder input

7. Literature review Previously created protocols Sensitivity and specificity of signs and symptoms Correlation between telephone and in-person interviews

8. 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

9. Pilot protocol Evidence based material Expert opinion Took previously summarized calls and put them through pilot protocol

10. Phone Calls Sent to Physician/NP

11. Office Visits Required for 30 Calls 11 7

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

13. 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

14. Protocol Revisions Regularly checked in with staff regarding their opinions and patient feedback after trying protocol Many found protocol too long

15. User feedback Keep/revise – 2/3 Toss – 1/3

16. Lessons learned Practices vary considerably Expert opinion vs EBM Implementation requires buy-in Success requires feedback and revision

17. 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

18. 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?