title: Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians.
abstract: To assess whether clinical skills training in cervical dilation and paracervical anesthesia, as well as the introduction of a clinical protocol for difficult insertions, increased intrauterine device (IUD) insertion success rates among advanced practice clinicians (APCs) including women's health and family practice nurse practitioners, physician assistants and certified nurse midwives.
  
  
  
  This prospective study assessed an intervention to improve IUD insertions among APCs at six family planning clinics in Utah. We collected data on IUD insertions performed by participating clinicians during two observation phases: preintervention (Phase 1) and postintervention (Phase 2). Using electronic medical records, we tracked patient characteristics, IUD insertion success, difficulties and failures. We constructed a mixed-effects logistic regression model to control for provider and patient demographics influencing insertion success rates.
  
  
  
  Nine clinicians participated in both preintervention and postintervention phases. The analysis included 428 IUD insertion procedures (242 preintervention and 186 postintervention). During Phase 1, 31/242 (12.8%) insertions failed. Insertion rates in Phase 2 improved with only 8/186 (4.3%) failures. Using mixed-effects logistic regression, the odds of a successful insertion postintervention was 4.8 times greater than preintervention (aOR=4.8.95% CI 1.8-12.7) when controlling for provider and patient characteristics. Increased risk of insertion failure was associated with nulliparity and younger age during Phase 1, but not during Phase 2.
  
  
  
  A brief training for APCs and the use of a clinical protocol for difficult insertions may be able to improve IUD insertion rates.
  
  
  
  Clinics with high rates of IUD insertion failure can improve care with a simple intervention, which may yield significant benefits in IUD service delivery.
authors.affiliation: Planned Parenthood Greater, Texas, USA.
authors.forename: Amna
authors.initials: A
authors.lastname: Dermish
authors.affiliation: The University of Utah Department of Obstetrics and Gynecology, USA.
authors.forename: David K
authors.initials: DK
authors.lastname: Turok
authors.affiliation: Planned Parenthood of Orange and San Bernardino Counties, USA.
authors.forename: Janet
authors.initials: J
authors.lastname: Jacobson
authors.affiliation: The University of Utah College of Nursing, USA.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Murphy
authors.affiliation: The University of Utah Department of Obstetrics and Gynecology, USA.
authors.forename: Hanna M
authors.initials: HM
authors.lastname: Saltzman
authors.affiliation: The University of Utah Department of Obstetrics and Gynecology, USA. Electronic address: Jessica.sanders@utah.edu.
authors.forename: Jessica N
authors.initials: JN
authors.lastname: Sanders
mesh_terms: D000328:Adult; D002983:Clinical Competence / Q000592:standards; D004493:Education / Q000592:standards*; D004868:Equipment Failure / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007435:Intrauterine Devices, Copper; D016015:Logistic Models; D009721:Nurse Midwives / Q000193:education*; D009722:Nurse Practitioners / Q000193:education*; D010823:Physician Assistants / Q000193:education*; D011446:Prospective Studies; D014589:Utah; D055815:Young Adult
keywords: Advanced practice clinician; Cervical dilation; Family planning clinics; IUD insertion; Intervention; Paracervical lidocaine