Increasing the Efficiency of STI Clinics by Tailoring Services Based on a Risk Triage System Julie A. Subiadur, BSN-BC, CCRC Dean McEwen, MBA Karen Peterson, MD Denver Public Health STD Clinic

Objectives To describe the current ‘patient routing’ (triage) system used in the DMHC clinic To describe the effectiveness and patient satisfaction with the system To emphasize the ongoing process changes required of clinic staff with ongoing improvements in testing technology, electronic data needs and capabilities

Clinic Description Largest STI clinic and HIV testing facility in Rocky Mountain region Waiting room with capacity for 54 Front desk separates patient care areas Front area for triage, registration and phlebotomy On site stat lab Charting room Medications room including storage, Pyxis for inventory control 7 exam rooms with tables, 1 for male exams only, all with identical supplies and layouts

Denver Metro Health Clinic Staff Registered Nurses: 4.5 FTE + 3 intermittent Clinical support staff: 6 FTE Med Tech: supported by DH lab, 1.2 FTE Clerk: 1 Nurse program manager One physician available to clinicians if needed

Background STI clinics are faced with increasing demands and dwindling resources. Efficiency must be increased while maintaining high level care and quality services. Resources should be focused on those at highest risk for STI and their sequelae.

Development of Express Visits In 2004, The Denver Metro Health Clinic (DMHC) introduced the “Express Visit” as a no-cost option for patients who could not afford the newly required co-pay. This EV included a urine NAAT test for GC and CT for asymptomatic men and women. A brief risk assessment and specimen collection was performed, and clients were asked to call back in 1 week for test results. Clients testing positive were asked to return, and treatment was provided free of charge.

Introduction of Triage BEFORE AFTER Patient presents to the clinic Patient interviewed by Triage Clinician who decides: Patient registers NO Express Visit? YES Patient waits for an exam Patient registers Patient registers Phlebotomy for syphilis and Rapid HIV Phlebotomy for syphilis and Rapid HIV Immunizations Immunizations Patient waits for an Exam Clinician provides full exam and treatment if needed Urine sample collected for Gonorrhea and Chlamydia screening Rapid HIV Results Given Phlebotomy for syphilis and Rapid HIV Clinician provides full exam and treatment if needed Average time: 30- 45 minutes Rapid HIV Results Given Rapid HIV Results Given Clinician Immunizations Average time: 30- 90 minutes Support Staff Average time: 30 minutes – 4 hours

Development of Triage In November 2004, rapid HIV testing was implemented in clinic. In March 2005, DMHC transitioned to a new electronic medical record system. The initial burden of the new system had a significant impact on clinic work flow. In an effort to increase clinic efficiency, a Triage system was introduced, and the Express Visit was modified and expanded.

Express Visit Patients Asymptomatic Low Risk (non-MSM/ IVDU/ sexworker, etc.) though these higher-risk persons are allowed Express if asymptomatic or refuse exam Male contact to STI (test and treat) All clients are offered HIV, RPR, and CT/GC (urine or self-collected vaginal) tests.

Triage Process Why are you here? To determine symptomatic vs. asymptomatic, exam vs. express Have you been here before? while accessing patient record Do you have sex with men, women or both? When was your last HIV test? Order syphilis and HIV tests based on risk; MSM every 3 months maximum, others annually Stat RPR for any c/o rash Urine pregnancy test for all women requesting Emergency Contraception, birth control, c/o pelvic pain

Phlebotomy Station Patient to phlebotomy, red top for RPR, HCV, stat RPR Purple top for rapid HIV (Unigold), sent on for RNA pooling if negative Rapid Unigold HIV positives redone with Oraquick, highly suspicious of false positive if Oraquick negative, sent for unpooled RNA test

Unlicensed Personnel Front desk, phones, clerical duties Triage Registration Phlebotomy, vaccines Express visits Male exams Follow up visits: meds, HPV tx Supply inventory and ordering 4 hour, rotating positions

RN Clinicians Male and female exams Birth control services Teen and continuity care including full head to toe physical assessment (NPs) Treatment with LAB Precepting of visiting or new clinicians

Visits by the Numbers 2004 2005 2006 2007 Exams 13528 12790 11015 11132 Express 1905 3511 4142 Follow-Up 3218 2170 2043 1892 Totals 16746 13055 16569 17166 Family Planning 2117 3907 4686 CTS/ 1064 2187 3024

Visits by Diagnosis 2004 2005 2006 2007 GC 866 800 772 700 CT 1845 1887 1558 1874 Syphilis 76 51 84 60 HIV 66 64 45 41 HSV 282 199 165 204

With All This, They Still May Wait Three Hours to be Seen! There may be up to 30 people at the door at 8am Clinic can process 10-20 patients per hour depending on complexity, staffing Til recently took in 45-50 patients then closed door til 12:30 to get through lunch breaks Reopen at 12:30 and take 30-40 more patients depending on clinician coverage Numbers quite variable depending on who is that day’s charge nurse

Appointment Experiment Recently introduced new appointment system alongside current walk-in Same day or next day appointments 3 nurses, 1 SCCA conducting appointments Appointment coordinator Paper appointment book Same charge nurse daily, in training

How Appointments Work, So Far! At 10-15 patients triaged, start offering choice of appointment for pm or next day, or wait probably > 1 hour By noon, start offering next day appointments or wait Call-ins offered appointments, advised of current approximate wait time Returns for HPV, syphilis treatment offered next week appointments

Our Patients Will Adapt 10-30 appointments per day No show rate 0%-30% Express visits still approximately 25% of total patients seen We have had call-ins to cancel and reschedule appointments!

What’s Next? We started with screening out women with symptoms other than vaginal discharge but already have expanded to allow other symptoms We hope to allow all patients who are interested to schedule a same day/next day appointment, in hopes those at highest risk for STI and their sequelae won’t be discouraged by long waits and leave without being seen IT is working with us to develop an electronic scheduling system to improve efficiency

Acknowledgements Thank you to all the great nurses, physicians, clerks, clinical assistants, and information technologists who are working so hard to create a more efficient and effective clinic for our patients!