Vaginal Self-Swab PDSA PI Project

The goal of this project is to allow women veterans to collect their own vaginal swabs, when medically prudent, in order to reduce repeated trauma in a population of women with a high incidence of past sexual abuse and violence. Self-collection eliminates the need for an intrusive pelvic examination with speculum insertion. Self-collection occurring during nursing triage or a scheduled nurse visit can also reduce the wait time for women veterans to obtain a proper diagnosis and treatment.

Women veterans have high rates of adverse childhood experiences, sexual assault, and intimate partner violence. Providers often represent military officers and are seen as having power in the relationship. Pelvic examinations can be painful and cause loss of privacy and control, physical touch in intimate areas, and vulnerable physical positioning. Some women veterans are waiting up to two weeks for a provider visit to assess complaints of vaginal discharge or requests for STI (sexually transmitted infection) testing.

Synthesis of evidence: What does the evidence tell you (us)?
Patients prefer self-collected vaginal swabs, rather than provider collected endocervical swabs. There is no statistically significant difference in sensitivity and specificity between the two collection methods. Urine samples are sometimes used in lieu of provider collected swabs but may detect 10% fewer cases of GC and CT compared with vaginal samples. The CDC recommends self-collection for the latter. Patient-collected samples reduce physical contact and eliminate the need for a speculum examination.

Practice change and implementation strategies: What was the practice change? How was it implemented?
We conducted a plan do study act (PDSA) to address patient-generated requests for STI testing. Patients without exclusion criteria collected a vaginal swab in the clinic after receiving instruction by the nurse. There was no change in how the swabs were processed by the labs.

Evaluation: What did you measure? How was it analyzed?
We measured ER or return visits for same or worsening symptoms within 30 days. Inadequate samples reported by the lab. Number of self-swabs performed. Spontaneous patient comments. No technical analysis was required.

Conclusions and implications for practice: We completed 57 self-swabs between August 2020 and March 2021. There was a 100% viable specimen collection success rate. Improved resource utilization and patient access and promotion of trauma-informed care were noted. No reported 30-day return visits or inadequate samples. All patient comments were positive. 58% cost reduction per patient encounter. Nursing clinical skill was designed for sustainment. This process can be expanded to primary care clinics and ER. Self-swab for HPV and STI testing.

Lessons learned: Patients would greatly benefit if the process was expanded throughout the primary care clinics and the ER (one patient took a $50 Uber to WHC to swab herself; vaginal specimen collected from ER provider was insufficient, the patient performed a self-swab at the women’s health clinic). Visual aids are helpful to the patients.

Learning objective for audience (1): Describe how self-collected vaginal swabs produced equal results in women veterans as provider collected swabs.