As part of a NICE Scholarship project we aimed to improve awareness and uptake of Hepatitis B Screening and Vaccination in at-risk groups attending sexual health services, in line with recommendation 2 and 7 in NICE guideline PH43 "Hepatitis B and C testing: people at risk of infection".
We established Key Performance Indicators for Hepatitis B screening and vaccination and utilised a real-time clinically-led benchmarking system to continuously monitor and drive the service improvement process.
Aims and objectives
Hepatitis B is a common infection that is often asymptomatic and can have chronic and serious outcomes, including chronic hepatitis, fulminant liver failure and hepatocellular carcinoma. Onward transmission occurs via sexual intercourse and blood-blood contact. Hepatitis B is preventable with pre-exposure vaccination. It is therefore important to screen patients for Hepatitis B infection to enable earlier identification of Hepatitis B and to vaccinate at-risk groups to prevent acquisition of infection. In accordance with NICE PH43 guidance, we aimed to improve the awareness and uptake of testing and vaccination for Hepatitis B infection and for high-risk patients attending the sexual health clinic.
These at-risk groups included Men who have sex with Men (MSM), injecting venous drug users (IVDU), commercial sex workers (CSW) and people who change partners frequently. The national targets for these at-risk groups were as follows:
• Patients who are not already known to be immune to HBV (Hepatitis B virus), should have serology for HBV done on their initial attendance (Goal: 90%)
• Patients who are not already known to be immune to HBV (Hepatitis B virus), should receive a dose of HBV vaccine on their initial attendance (Goal: 90%)
• Patients who are not already known to be immune to Hepatitis B virus (HBV) and who on testing are not found to be either infected or immune to HBV, should receive 3 doses of HBV vaccine within 6 months of their initial attendance (Goal: 50%)
Reasons for implementing your project
Vaccination uptake has been a longstanding issue in many sexual health services across the UK. When the project commenced in April 2015, UHB Sexual Health service was a large city-centre clinic serving a Birmingham population, including people from diverse ethnic and cultural backgrounds, young and vulnerable individuals. Utilising an Information Technology (IT) system for real-time monitoring that extracted data continuously from the electronic patient record (EPR), we established Key Performance Indicators (KPI) to monitor the current uptake of screening and vaccination in high-risk patients. This baseline assessment showed under-performance in all of the KPI for screening and vaccination in these risk groups and improvements were required.
A retrospective case review of the EPR was performed to identify reasons that the national targets were not being met. During the project the Trust won the tender for sexual health across Birmingham which posed some barriers for the project, but through adapting the project, this service reconfiguration also provided an opportunity for extension of the improvement measures across the wider community. Stakeholders were involved by conducting personal interviews and holding forums with nurses, doctors and healthcare professionals in the clinic. Informal feedback was gained from patients attending the clinic.
Feedback demonstrated confusion amongst staff in several areas: the serological tests that were required for screening for Hepatitis B, a failure to offer opportunistic vaccination when at-risk patients attended for initial appointments, variability in staff assessment of ongoing risk for Hepatitis B acquisition, lack of understanding of Hepatitis B in general, and the importance of vaccination in preventing onward transmission and risk of longterm sequelae from Chronic Hepatitis B infection.
Further feedback from patients and staff highlighted the following issues: additional waiting times in the clinic for patients to receive their vaccination, variability in staff willing to vaccinate suitable patients within the consultation and patients failing to attend for follow-up vaccination. Benefits were identified for Public Health (improved awareness, reduced HBV acquisition and spread of HBV), the NHS Trust (improved service performance), staff (education, and engagement in service improvement) and the individual patient (improved patient care and awareness).
How did you implement the project
The implementation process was discussed at the department’s Quality Improvement meeting to gain approval from the consultants. We improved our public sexual health service website (Umbrella – www.umbrellahealth.co.uk) and created links for at-risk groups accessing the website that would take the user to the Hepatitis B pages. Links to book appointments and signposting to clinics were included on the webpage. We added Twitter feeds to promote screening and vaccination.
A clear, user-friendly information leaflet was produced aimed at patients and staff alike. We improved access to further information on Hepatitis B by incorporating a QRS link to our website. This also provided an opportunity to promote awareness regarding other sexual health problems. The leaflet included a credit-card sized appointment card to record follow-up appointments for patients.
A rolling education program was established. Band 2-3 nurses were given separate training to bands 5-8 nurses. This was to encourage nurses who were involved with different aspects of the patient journey to be able to receive appropriate education and give constructive feedback. The overriding issue encountered was that this project was being implemented at a time when sexual health services across Birmingham were being reconfigured on a massive scale, involving the integration of sexual and reproductive healthcare and closer integrated working between secondary care, community and primary care (including community pharmacists).
The heterogeneity of IT systems across the various organisations made the collection and analysis of data more problematic. It also impacted upon the delivery of education to a much larger and more diverse group of healthcare providers. During this reconfiguration staff turnover rates have been high, creating a further challenge in finding ways to educate staff and disseminate information. To overcome this challenge, we added an ‘at a glance’ page on our intranet, providing key summary points for guidance.
An idea was to promote vaccination uptake by offering a super-accelerated vaccination course (0,7,21 days, 12 months ) to improve attendance for follow-up doses. Community education for the accelerated (0,1,2,12 months) vaccination schedule was already in place, and it was felt that a change in the vaccination schedule would cause staff confusion. We therefore adapted the emphasis to focus on health promotion through the website and leaflet as discussed above.
This project has been implemented concurrently with my one year NICE scholar role, but is one part of a service reconfiguration, and service improvement is on-going. I will focus on the current stage of the project, and how we are planning to make further improvements going forward. Progress is being monitored through our continuous real-time monitoring system.
The baseline real-time monitoring confirmed underperformance for the all KPI (See attached full report in the supporting material).
Through retrospective case note analysis, variability in clinicians offering vaccination to at-risk groups was identified according to a subjective measurement of on-going risk and educational issues were identified. These nuances were not being identified through the real-time monitoring due to the structuring of electronic patient record (EPR), highlighting some of the limitations of electronic data monitoring.
The EPR is being modified to include mandatory sections to record whether there is on-going risk for Hepatitis B acquisition, whether staff are offering vaccination to at-risk patients, and whether patients are declining vaccination. We have decided that the Hepatitis B component of the EPR needs fine-tuning to reflect the real-life complexity of healthcare to further improve the accuracy of real-time monitoring. These modifications will be incorporated into the monitoring to allow us to establish where the barriers to vaccination lie. As the current Information Technology systems used in the community and our hospital system do not currently integrate, links need to be made to enable accurate monitoring of uptake of Hepatitis B vaccination as follow-up vaccinations will be given within the community.
Our current real-time monitoring report suggests a lack of improvement in uptake of screening and vaccination (See attached full report in the supporting material): Screening: IVDU (62.5%), MSM (86.8%), CSW (66.4%), multiple partners (73.8%); First dose vaccine: IVDU (22%), MSM (59.8%), CSW (36.3%), multiple partners (42%); 3 doses of vaccination: IVDU (6.89%), MSM (33%), CSW (22.1%), multiple partners (17.9%), yet staff awareness seems to have improved thus highlighting the limitations of relying on data monitoring alone. A re-audit of the EPR is planned.
Key learning points
UNDERSTAND the workings of your organisation:
• Gain approval and engagement from the Clinical Service Lead
• Discuss with the Consultants and Senior Management
• Hold staff forums and engage the wider staff early
• Consider the patient journey through the clinic
• Review the available educational resources for the workforce and patients - can accessibility or content be improved?
• Review the guidance – can it be simplified? We adopted a “screen and vaccinate policy” at the first visit
• Obtain patient and staff feedback (meetings, personalised interviews), to understand how patient experience can be improved
• Explore the ways that various staff promote screening and vaccination to at-risk patients to promote shared learning eg. One outcome from our shared learning – consider pointing out to patients that Hepatitis B is also a travel vaccine that patients would pay for at a GP or travel clinic, but that the vaccine is free to at-risk groups attending sexual health services
• Deliver interactive educational sessions adapted for different staff groups according to skill level/ service role
• Provide simple, clear advice for patients via a variety of media (posters, leaflets, websites) and in different languages (eg. Russian leaflet useful for CSW’s attending our service)
• Regular, clear, succinct communication to the workforce through a variety of media
• Look at whether there are missed opportunities to offer and deliver vaccination. Consider establishing links with pharmacists/ primary care to promote/ deliver vaccination
• Use communications that link with further knowledge opportunities
DON’T: Assume a level of staff knowledge - likely to vary between individuals and this project demonstrated a surprising lack of staff awareness regarding Hepatitis B infection, prevention and serological testing for the infection. Difficult to successfully promote vaccination if knowledge about the disease you wish to prevent is lacking!
Umbrella Website Links:
Hepatitis B Information webpage: