1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. 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: minutes
Rapid HIV Results Given
Rapid HIV Results Given
Clinician
Immunizations
Average time: minutes
Support Staff
Average time: 30 minutes – 4 hours

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 patients per hour depending on complexity, staffing
Til recently took in patients then closed door til 12:30 to get through lunch breaks
Reopen at 12:30 and take more patients depending on clinician coverage
Numbers quite variable depending on who is that day’s charge nurse

17. 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

18. How Appointments Work, So Far!
At 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

19. 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!

20. 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

21. 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!