GME Patient Safety Quality and Innovation Symposium

Kelsey B. Loeliger, MD, PhD¹, Tanya Jain, BA², Isabel Warner, BS ², Jessica Rivas, MD³, Rachel Pacyna, MD³, Jerasimos Ballas, MD, MPH⁴, Carla Marienfeld, MD⁵, Julia Cormano, MD³

¹Division of Complex Family Planning, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego;

²University of California, San Diego School of Medicine;

³Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego;

⁴Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego;

⁵Department of Psychiatry, University of California, San Diego

Background

Approximately 8-11% of pregnant women have substance use disorders (SUD). Pregnancy is often a time when people are motivated to engage in SUD treatment, and treatment in pregnancy has been shown to improve both maternal and neonatal outcomes. The process by which pregnant people are screened and referred for treatment and support services can significantly impact outcomes. Although there are screening tools such as the “4 P’s Plus” that have been validated in pregnancy and already incorporated into EPIC, UCSD’s perinatal clinics and Labor & Delivery triage areas do not currently use a validated SUD screening tool. There is an unmet need for and desire among clinicians for validated SUD screening as well as training in how to constructively discuss screening results with patients and refer patients for SUD services. This project aims to: 1) incorporate a validated screening tool such as 4 P’s Plus into our routine screening workflow in clinic and triage settings and 2) train clinicians in motivational interviewing techniques to engage patients in a discussion regarding their positive screening results.

Project Description

A multidisciplinary team of physicians, residents, and medical students within Complex Family Planning, Maternal-Fetal Medicine (MFM), and Addiction Psychiatry worked to identify gaps in the clinical workflow and potential mechanisms to facilitate linkage to SUD treatment within perinatal settings. Based on the literature, a SUD screening tool validated in pregnancy will be selected to be administered alongside other routine perinatal screening tools. The results will be documented in flowsheets to inform their clinicians. Clinical note templates will also be modified to import screening results accompanied by follow-up questions to prompt referral if appropriate. EPIC medical record extraction over a three-month period will then be conducted to evaluate outcomes of interest including proportion of patients 1) with a positive screening, 2) interested in referral to an MFM for further discussion of treatment options, 3) referred to MFM, 4) seen in MFM clinic, and 5) initiated on treatment, if indicated. Long-term outcomes may include postpartum maternal and neonatal outcomes and Department of Children and Family (DCF) involvement. The educational component of this project includes training in motivational interviewing for OBGYN residents (n=24) and interested staff members to better equip clinicians to appropriate respond to a positive SUD screening and engage patients in care. This training will include a pre-training needs assessment survey, a 1-hour online module on motivational interviewing followed by a 1-hour didactic lecture by an Addiction Psychiatry specialist, and a post-training survey. Paired Wilcoxon tests of Likert scales will be used to compare pre- and post-training clinician comfort levels.

Expected Outcomes

Through the implementation of standardized, unbiased, trauma-informed, and non-stigmatizing SUD screening accompanied by motivational interviewing, we anticipate that patients with SUDs can be identified and engaged in care in a way that strengthens patient-provider relationships and improves health outcomes for the maternal-fetal dyad.

Next steps

Standardized questionnaires are currently under review for incorporation into the routine obstetric intake workflow. Once a tool has been selected, we will begin the implementation and outcomes evaluation process described above, with guidance from clinical staff and directors.