Improving Fecal Immunochemical Test Collection for Colorectal Cancer Screening During the COVID-19 Pandemic
Background: Colonoscopy is a first-line method for colorectal cancer (CRC) screening. However, cost-effective noninvasive tests, such as high-sensitivity guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT), are also used. The COVID-19 pandemic had a substantial negative impact on CRC screening rates. The James A. Haley Veterans Affairs Hospital (JAHVAH) continued socially distant CRC screening using FITs, but encountered inefficiencies due to high rates of incorrectly collected FIT samples. A quality improvement (QI) project was conducted to increase correctly collected and testable FIT kits upon initial laboratory submission.
Observations: The ambulatory QI project sought out root causes for incorrectly returned FITs and proposed Plan-Do-Study-Act (PDSA) cycles based on a series of approved action plans. A multidisciplinary team of laboratory, nursing, administrative, and primary care staff worked together to discover 6 major root causes. Our multipronged PDSA cycle attempted to set up redundant patient reminders, centralize the FIT dispersal process, and make the patient-FIT interface more user-friendly. All PDSA solutions were implemented over 4 months. Lack of collection date was the most common reason for incorrectly returned FIT kits and the focus of PDSA improvements. The rate of FITs with missing collection dates dropped from 24% prior to PDSA to 14% in April 2021. The rate of correctly returned FIT kits rose from 38% before the project to 72% afterwards, surpassing the 20% improvement goal.
Conclusions: FIT is a useful method for CRC screening that can be particularly helpful when in-person visits are limited, as seen during the COVID-19 pandemic. The increase in demand for FITs during the pandemic revealed process deficiencies and gave JAHVAH an opportunity to improve workflow.
Discussion
Proper collection and return of FIT samples are vital for process efficiency for both physicians and patients. This initiative aimed to improve the rate of correctly returned FIT kits by 20%, but its final numbers showed an improvement of 33.6%. Operational benefits from this project included early detection of CRC, improved laboratory workflow, decreased FIT kit waste, and increased patient satisfaction.
The multipronged PDSA cycle attempted to increase the rate of correctly returned FIT kits. We improved kit comprehension and laboratory accessibility, and instituted redundant return reminders for patients. We also centralized a new process pathway for FIT distribution and educated physicians and support staff. Sampling and FIT return may seem like a simple procedure, but the FIT can be cumbersome for patients and directions can be confusing. Therefore, to maximize screening participation, it is essential to minimize confusion in the collection and return of a FIT sample.14,15
This QI initiative was presented at Grand Rounds at the University of South Florida in June 2021 and has since been shared with other VA hospitals. It was also presented at the American College of Gastroenterology Conference in 2021.
Limitations
This study was a single-center QI project and focused mostly on FIT kit return rates. To fully address CRC screening, it is important to ensure that individuals with a positive screen are appropriately followed up with a colonoscopy. Although follow-up was not in the scope of this project, it is key to CRC screening in general and should be the subject of future research.
Conclusions
FIT is a useful method for CRC screening that can be particularly helpful when in-person visits are limited, as seen during the COVID-19 pandemic. This increase in demand for FITs during the pandemic revealed process deficiencies and gave JAHVAH an opportunity to improve workflow. Through the aid of a multidisciplinary team, the process to complete and return FITs improved and surpassed the goal of 20% improvement. Our goal is to continue to fine-tune the workflow and troubleshoot the system as needed.
