Response letter to BASHH National Syphilis Audit 2017: Quality Improvement Report

The 2017 BASHH National Audit was conducted following the 2015 revised BASHH UK guidelines on syphilis management. Standards were met for percentage of patients receiving appropriate first line treatment (97%, standard 97%) and contacts seen and tested per index case within four weeks (0.9, standard: 0.6). Only 74% of index cases had an agreed contact action(s), or decision not to contact, documented for all contacts, below the 97% standard. Repeat HIV testing in those diagnosed with syphilis (i.e. potentially high risk) was also explored: clinics with a documented policy of repeat HIV testing were twice as likely to repeat HIV test after the window period.

The BASHH National Audit Group (NAG) conducted a National Quality Improvement Survey to analyse local responses to the audit results.

The email-based survey was conducted between January and March 2018 via regional audit leads. Clinics were consulted regarding the presentation of their local audit results, awareness of failing one of the partner notification (PN) standards, and changes made following the audit.

Of 161 clinics that took part in the audit, 43 (27%) responded. The majority (35/43) of clinics had presented their audit findings in a formal meeting; three clinics sent written information to all staff. The remaining five clinics were scheduled to present the findings in the near future.

Most (35/43) clinics were aware of PN outcomes falling short of standards; 33 clinics decided to make changes. Among the 8 clinics not planning changes, three said their PN outcomes were very good or met standards.

Forty percent (17/43) of clinics had experienced declining Health Advisor (HA) provision, both due to a reduction in HA numbers as they are diverted to more clinical roles and HAs not being replaced, or lack of a designated HA role within the service.

When asked about ensuring an agreed contact action, or decision not to contact, is documented for all early syphilis contacts, most clinics (39/43) had made changes or were already doing this. Changes included modification of clinic templates, new proformas, using ‘task viewer’ in electronic records to improve PN, introduction of a PN proforma and robust pathway for patients who do not attend, re-training all staff and local re-audit.

A majority (35/43) of clinics had made changes or had no need to change regarding repeat HIV testing in patients presenting with early syphilis. Changes included recall procedures, guideline for recalling at risk/defaulted patients, staff education and changes in follow-up forms.

In modern sexual health clinics, which are mostly integrated services, HA roles are amalgamated into clinical roles. With the time constraints in clinics and an increasing number of contacts being met via online sites, contact tracing is becoming more difficult. PN is a vital tool to control the rising STI epidemic. Clinics should prioritise HA roles and aim to maintain a high standard of PN.

This quality improvement work has shown that a proportion of clinics have acted on the national audit outcome. Continued national surveillance of PN standards is pivotal to high-quality sexual health care.