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Why was change needed?
Increasing demands for long-acting reversible contraception (LARC) within NHS Lothian had led to long waits for women requesting intrauterine contraception (IUC). As insertion of LARC to reduce unplanned pregnancy was viewed as a top priority, the Sexual and Reproductive Health (SRH) Service in Lothian wished to simplify access to this highly effective method of contraception. The aim was to improve the pathway to insertions, and reduce the number of visits required to the Chalmers Sexual Health Centre.
What needed changing?
In common with most other UK services, we traditionally insisted that women attend two appointments: the first for counselling about IUC followed by a second booked appointment for insertion of a device at a clinic dedicated to IUC insertion.
In an attempt to streamline this process, it was first agreed that the Chalmers Centre would insert IUC at all general SRH clinics; this would be at the morning, afternoon and evening drop-in and booked clinics rather than solely at dedicated IUC insertion clinics, as had previously been the case. Women requiring emergency intrauterine device (IUD) insertion are identified at triage and seen at same-day appointments.
In an effort to reduce waiting times, we then offered women the option of a telephone consultation as an alternative to attending in person for the clinic counselling appointment. Women booking an appointment for an IUC consultation for elective insertion were given a convenient time when they would be telephoned by a specialist nurse, and if they were suitable, they would then be given a booked appointment for insertion. Telephone consultations (staffed by a nurse and thus taking up clinical time) were audited for 1 year, which revealed that rather than reducing waiting times for IUC insertion, the group of women who had a telephone consultation actually waited longer than those who attended the service in person. As a result these telephone consultations were subsequently abandoned.
What change was made?
With assistance from our Department of Medical Photography and a local film company, we developed a short film in digital video disk (DVD) format based on the Faculty of Sexual & Reproductive Healthcare (FSRH) guidance document on IUC.3 This DVD was developed by a senior SRH consultant, and reviewed by the NHS Communications Team, who deemed it suitable for patient viewing. The DVD described the types of IUC, the risks and benefits, the suitable timing of insertion and potential side effects; the film's duration was 11 minutes.
This short DVD film was uploaded onto the NHS Lothian Sexual Health website and displayed prominently on the home page.4 A self-assessment form that asked women to indicate that they understood the instructions for IUC insertion and the risks associated with insertion was also uploaded onto the website alongside the DVD (Box 1).
Details on the self-assessment form that women wishing to proceed with intrauterine contraception insertion after watching the DVD are asked to sign and bring to the clinic
I have watched the DVD on IUD/IUS or read the leaflets or I already have an IUD/IUS and am familiar with the method.
I am using an effective method of contraception and haven't had any problems (e.g. burst condom, missed pills, IUD overdue for change). I have not had unprotected sex (or used withdrawal) since my last period.
I understand that it is not safe to insert an IUD/IUS if I might be pregnant.
I will make sure that I have had breakfast/lunch on the day of the appointment. A painkiller can be taken around an hour in advance.
I am not at risk of STIs (e.g. I do not have a new partner) or I have been tested recently for chlamydia/gonorrhoea.
I understand that no method is 100% effective and that the IUD/IUS has a very small risk of failure (less than 1 in 100 chance of pregnancy).
I understand that there is a 1 in 1000 risk of perforation of the womb at the time of insertion of the device.
I understand that there is a 1 in 20 chance of the device falling out.
I understand that the IUD/IUS will not protect against STIs and condoms in addition are recommended for this if, for example, I have a new partner.
I understand that there is a small risk of infection (1 in 100) in the first few weeks following insertion of a device.
I know that a copper IUD will make my periods slightly heavier, longer and more painful.
I know that an IUS (Mirena®) will make my periods much lighter but causes erratic bleeding and spotting in the first few months of use.
DVD, digital video disk; IUD, intrauterine device; IUS intrauterine system; STI, sexually transmitted infection.
All women who contacted the service requesting IUC were directed to the DVD film on the website which they were able to watch at home, and were instructed to print and complete the self-assessment form and bring this with them when they visited the Chalmers Centre. Women could then attend any drop-in clinic or book a general clinic or dedicated IUC clinic appointment, which offered them a far greater flexibility of attendance options. At the ‘one-stop’ appointment most staff simply documented in the women's computer records that the DVD film had been viewed and the self-assessment form completed as evidence that the women had received appropriate information on IUC, and any outstanding issues were clarified at that time.
There was significant staff concern that this model of a single-visit IUC fitting service (i.e. with website DVD and self-assessment) would result in a large number of women attending for IUC inadequately prepared or unsuitable for device fitting.
How was this change evaluated?
A retrospective computer case note review was undertaken. Computer case records were examined for the first 100 fittings in pre-booked IUD clinics from January 2013, before the change was implemented, and for the first 100 IUC fittings over the same time period in 2014, after the introduction of the online DVD and self-assessment form. This excluded emergency IUD fittings and women who chose to attend drop-in clinics for fitting. Case notes were examined to ascertain (1) the number of clinical contacts leading to IUC insertion, (2) whether counselling prior to IUC fitting had been delivered face-to-face, by telephone or by website DVD and (3) whether in fact the woman was able to have the IUC fitted as planned and, if not, the reason for this (Table 1).
Was the change beneficial?
There was no significant difference between the two groups in the number of women proceeding to IUC fitting on the day of the scheduled insertion, which was very reassuring. However, the number of clinical contacts per fitting was significantly more in 2013 compared to 2014. In total, 79/100 women had a clinical consultation (face-to-face or by telephone) in 2013 compared to 7/100 women before IUC insertion in 2014 (p<0.0001 using Fisher's exact test).
In terms of a busy clinical service, this significant reduction in the number of clinical encounters being utilised for IUC counselling has been highly beneficial, as it increases the opportunities for clinic staff to see more individuals with other priority SRH conditions.
An evaluation of women's satisfaction with the online DVD and self-assessment form is underway. Verbal feedback has been positive.
Advice to others considering change
We would suggest that other SRH services seriously consider the use of online technology such as that described to counsel and prepare women for IUC insertion, and to help streamline access pathways and reduce barriers to uptake.
While there is inevitably some increase in time pressure for the clinician at IUC insertion visits if a woman has not attended previously (given the need for documentation of the woman's history), our ‘one-stop’ visit IUC insertion service was achieved without any concomitant increase in the length of the existing 30-minute appointments.
We recognise the limitations of this partial service evaluation. A possible future research project could compare the satisfaction and knowledge recall of women undergoing face-to-face versus DVD counselling.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.