Background/Purpose:

This quality improvement project was conducted to increase
patient education and routine pregnancy screening in girls of childbearing age
prescribed teratogenic medications in the pediatric rheumatology clinic.  There is currently no standard model for
providing reproductive health education to young female patients taking
teratogenic medications.  We aimed to
adapt the education and pregnancy screening practices recommended by
Mycophenolate REMS (Risk Evaluation and Mitigation Strategy) to apply to all
reproductive age girls prescribed teratogenic medications in our pediatric
rheumatology clinic.

Methods:

This project was initiated in a single center tertiary care
rheumatology clinic comprised of 7 providers averaging 3500 visits per year.  The medical records of 89 consecutive female
patients age 10 and older receiving teratogenic medications were reviewed for
documentation of teratogen education and pregnancy screening to establish our
baseline practice.  Six Plan-Do-Study-Act
(PDSA) cycles were completed. 
Interventions included 1) visible project reminders in the clinic space,
2) targeted physician and 3) nurse education, 4) monthly progress updates, 5)
pre-visit planning, and 6) development of an education template in the
electronic health record (Figure 1). 
Ongoing chart review was performed throughout the project.   Run charts were created for each aim to
display improvement over time, and data reflecting overall improvement was
analyzed by chi-square analysis.

Results:

At baseline, 42/89 (47.2%) female patients age 10 and older
taking teratogenic medications had education documented within the last 12
months, and 21/89 (23.6%) had pregnancy screening performed at the visit.  Implementation of our interventions resulted
in improvement in documentation of ongoing teratogen education (616/767, 80.3%)
and in routine pregnancy screening (630/767, 82.1%), both statistically
significant (p<0.0001).  Figure 1
depicts annotated run charts, which both contain shifts indicating special
cause. 

Conclusion:

Mindfulness of the teratogenic risks of immunosuppressive
medications is important when managing adolescent patients with rheumatic
disease.  The interventions made through
this quality improvement project increased the frequency of both teratogen
education and urine pregnancy screening in these patients.   Development of a simple, standardized
education template in the electronic health record has helped sustain these
improvements over time.