Clinical Practice Guideline Standard Operating Procedure

Transcription

1 1 of Purpose 1.1. To increase testing options for marginalized, mobile and underserved populations at risk for gonorrhea and chlamydial pharyngeal or rectal infections. 2.0 Scope and Goal 2.1. Pharyngeal & rectal testing to screen for chlamydia and gonorrhea may be offered to clients who meet the Pharyngeal & Rectal Testing Eligibility Criteria, by Public Health Nurses (PHNs) with the Healthy Sexuality and Harm Reduction (HSnHR) team who have the competency to perform these practices. 3.0 Background 3.1. The prevention and control of sexually transmitted infections (STIs) are important components of a comprehensive communicable disease control strategy. While it is beneficial for all citizens of the Winnipeg Health Region to have a regular primary care provider, many people do not access care due to health, social and/or economic inequities. Not accessing care poses a potential health risk to the individuals themselves and to the community. In order to improve and focus efforts to test and treat vulnerable and mobile populations at risk for chlamydia and gonorrhea infections, Public Health Nurses (PHNs) with competency to do this practice may offer pharyngeal and rectal testing for chlamydia and gonorrhea to eligible clients encountered at eligible venues (Winnipeg Remand Centre, Street Connections, bathhouses, other venues where men who have sex with men congregate) These guidelines and standard operating procedures are based on shared competencies and collaboration between the Medical Officer of Health and PHNs with the knowledge and skill to perform these practices Support of staff competency for these practices include access to all current STI guidelines and resources (Healthy Sexuality and Harm Reduction team s practice guidelines, Manitoba Health and Health Living s Communicable Diseases Management Protocols, Public Health Agency of Canada s Canadian Guidelines on Sexually Transmitted Infections). Where there are differences between provincial and national guidelines, provincial guidelines apply. The MOH or designated back-up MOH is available by pager for consultation as required. Mechanisms to maintain quality and safety will include regular peer review at team meetings, regular consultation with the MOH through the CD Coordinator, and an annual random chart audit by the CD Coordinator (at least 5 charts per nurse to be reviewed). Every month, the PHN will send the AY3 a list of clients who received a delegated function by the PHN. When guidelines and delegations are not followed, this will be documented, investigated and evaluated with the PHN by the MOH in collaboration (as appropriate) with a designated individual (Team Manager, Clinical Nurse Specialist, CD Coordinator). Bi-annual performance reviews with the team manager are required All WRHA guidelines for documentation and storage of records will be followed according to existing WRHA standards and protocols Continued and ongoing competence will be maintained through ongoing education and review of practice. Reliable provincial and national guidelines are available and updated regularly, and are used by PHNs for each delegated function. PHNs are competent healthcare professionals with skills in teaching about risks, benefits, side effects and reporting of adverse events. 1

2 2 of Procedure 4.1. Determine client s eligibility with the Pharyngeal & Rectal Testing Eligibility Criteria Assess client s health status Pharyngeal and/or rectal testing will be either health care provider-administered or selfadministered. See appendix A for information regarding Supplies needed for Pharyngeal & Rectal Testing. For self-administered testing, ensure client has appropriate instructions and supplies Ensure the standards of care (below) are met PHN may interview client for sex contacts at this time for the purposes of partner notification if results are positive PHN may assess eligibility as per the Urine Testing for Chlamydia and Gonorrhea Genital Infection and/or Antibiotic Treatment for Uncomplicated Chlamydia and Gonorrhea Practice Guidelines with Delegations of Function. 5.0 Standards of Care The PHN will: 5.1. Offer chlamydia and gonorrhea pharyngeal and rectal testing to clients who meet the Pharyngeal & Rectal Testing Eligibility Criteria Review risks of infection along with the risks/benefits of testing/ treatment and the value of Primary Care for all health/stbbi needs Review the testing process Obtain informed consent ensuring appropriate information & capacity to give such consent Follow manufacturer s instructions re: use of supplies to obtain specimen Make a plan with the client for the sharing of results Offer risk/harm reduction and prevention information and resources Manage results as follows: o Original test results will be retained in the client record o No results will be given to third parties except as required by law or with the informed consent of the client in accordance with PHIA o Arrangements will be made for medical follow-up/referral as needed o Arrange/refer for social support services as needed with client s consent Document on the WRHA Client Record: o Pharyngeal & Rectal Testing Eligibility Criteria reviewed o Primary Care for STBBI recommended/supported by PHN o Client provided informed consent o and time that specimen obtained o Plan for follow-up and sharing of results o Risk/harm reduction education and resources offered and/or provided. 6.0 Pharyngeal & Rectal Testing Eligibility Criteria People within populations of high priority to the HSHR Team due to higher than average STBBI rates, and/or fewer social resources or supports for sexual health (e.g. incarcerated people, sex workers, patrons of bathhouses and MSM sexual hookup venues) Client identifies sexual practice that has resulted in potential exposure of their pharynx or rectum to gonorrhea or chlamydia. 2

3 3 of 5 Client has the capacity to provide informed consent, that is, has the ability to understand: o The information relevant to the decision to be tested o The nature and the anticipated effect(s) of the proposed testing; and o The alternatives and risks, including the consequence(s) of not proceeding with the proposed testing. If there are any doubts about the individual s capacity to provide informed consent, the testing should not be performed by the PHN, and the client should be referred to a physician/nurse practitioner for medical assessment Client is at least 16 years of age. For those clients between the ages of 13 and 15, a determination should be made as to whether the client has the capacity to provide informed consent (see above). If it is determined that the client has capacity to provide informed consent, the parent or legal guardian can only be contacted with the consent of the client. Notwithstanding the above, it is recommended that a reasonable attempt be made by the nurse to encourage the client to consent to parental/ legal guardian involvement in testing discussions. If it is determined that a client does not have the capacity to provide informed consent, and the client refuses to disclose legal custody/guardianship arrangements, the PHN should seek further advice as to whether to involve Child and Family Services. 7.0 References 7.1. College of Physicians and Surgeons of Manitoba and College of Registered Nurses of Manitoba (2002), (Guideline No. 132) Guidelines for Shared Competencies and Delegated Physician Services revised Manitoba Health and Healthy Living (2008), Communicable Disease Management Protocols Public Health Agency of Canada (2006). Canadian Guidelines on Sexually Transmitted Infections. 3

4 4 of 5 Acknowledgment of Shared Competency and Collaborative Practice for Pharyngeal & Rectal Testing for Chlamydia & Gonorrhea Infections. Dr. Pierre Plourde PHN (sign and print name) 4

5 5 of 5 Appendix A Gonorrhea Collection Adults A swab in Amies charcoal transport medium from anus, throat, eye, vagina, cervix or urethra for culture, where culture can be started same day. Dry swabs are unsuitable. A rectal swab can be obtained without an anoscope, by inserting a dacron swab approximately 1 inch into the anal canal. The swab is then moved from side to side to sample the crypts and left for 10 to 30 seconds to allow absorption of organisms onto the swab. Note: Culture for this organism is useful when the specimen can be processed in the laboratory within 24 hours of procurement. It is one way of detecting in the cervix, urethra or eye and the only satisfactory way at present for detection from other sites, i.e. throat, vagina or rectum. Note: If purulent material is present in the urethra or if other lesions are present these should be cultured, in addition to the cervix. Supplies needed: Swabs in Amies charcoal transport medium Chlamydia Collection Tests Available The two detection methods readily available at CPL are: 1. NAAT used for urines from males, cervical and urethral specimens. 2. Direct fluorescent antibody (Microtrak) used for all other specimens (e.g. throat, rectal, nasopharyngeal). All other sites (throat, anus) require fluorescent antibody testing (Microtrak). If Microtrak kits are not available, make a smear approximately 1/4 inch (10 mm) in diameter on a clean glass slide and air dry. See manufacturer s instructions (Microtrak) for handling and collection Supplies needed: Microtrak collection kits Information obtained from Cadham Provincial Laboratory: Guide to Services 5