Increasing the efficiency of sti clinics by tailoring services based on a risk triage system
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Increasing the Efficiency of STI Clinics by Tailoring Services Based on a Risk Triage System. Julie A. Subiadur, BSN, CCRC BC Brandy Mitchell, RN Dean McEwen Cornelis A. Rietmeijer, MD, PhD Denver Public Health. Presented at the 2006 National STD Prevention Conference

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Increasing the Efficiency of STI Clinics by Tailoring Services Based on a Risk Triage System

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Increasing the efficiency of sti clinics by tailoring services based on a risk triage system

Increasing the Efficiency of STI Clinics by Tailoring ServicesBased on a Risk Triage System

Julie A. Subiadur, BSN, CCRC BC

Brandy Mitchell, RN

Dean McEwen

Cornelis A. Rietmeijer, MD, PhD

Denver Public Health

Presented at the 2006 National STD Prevention Conference

Jacksonville, May 10, 2006


Objectives

Objectives

  • To evaluate the effectiveness of a triage system which guides client services based on risks and chief complaints.

  • To introduce the “Express Visit” as an alternative to comprehensive patient evaluations.


Denver metro health clinic

Denver Metro Health Clinic

  • Largest STI clinic and HIV testing facility in Rocky Mountain region

  • Diagnose and treat STIs, provide family planning services and HIV counseling and testing

  • In 2005: 15,471 clinic visits


Denver metro health clinic1

Denver Metro Health Clinic

Staffing:

  • Registered Nurses: 6.5 FTE

  • Clinical support staff: 1 FTE, 6 back-ups

  • Med Tech: 1 FTE, 1 back-up

  • Clerks: 3


Background

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.


Express visits

Express Visits

  • In 2004, The Denver Metro Health Clinic (DMHC) introduced the “Express Visit” (EV) 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.


Triage

Triage

  • 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.


Introduction of triage

Introduction ofTriage

BEFORE

AFTER

Patient presents to the clinic

Patient interviewed by Triage Nurse 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


Express visit

Express Visit

  • Asymptomatic

  • Low Risk (not a contact to a STI, non-MSM/ IVDU/ sexworker, etc.)

  • Or, requesting only an HIV test

    All clients who participate in the EV are offered HIV, RPR, and CT/GC (urine) tests.

Most clients who are offered EV are:


Express vs standard visits april 2005 march 2006

Express vs. Standard VisitsApril 2005 – March 2006


Express vs standard visits april 2005 march 20061

Express vs. Standard VisitsApril 2005 – March 2006


Evaluation results

Evaluation Results

  • We evaluated the effects of a fully implemented system during a 3-month time-frame:

    Sept – Nov, 2005.

  • A total of 2,637 visits were evaluated. Of these, 684 (25.9%) were Express Visits (EV).

  • The proportion of EV was similar for women (33.9%) and men (35.6%).


Evaluation results1

Evaluation Results

Express Comprehensive

VisitVisit

  • Chlamydia

    • Women 20/203 (9.8%) 111/696 (15.9%)

    • Men 31/347 (8.9%) 230/1150 (20.0%)

  • Gonorrhea

    • Women 2/203 (0.9%) 28/696 (4.0%)

    • Men 1/214 (0.5%) 111/1152 (9.6%)

      p values for all comparisons <0.01.


Chlamydia rates express vs exam

Chlamydia RatesExpress vs. Exam

Women Men

EV Exam EV Exam


Gonorrhea rates express vs exam

Gonorrhea RatesExpress vs. Exam

Women Men

EV Exam EV Exam


Conclusions

Conclusions

  • Based on the rates of the two most common curable STDs, risk-based triage appeared to improve clinic efficiency while effectively identifying those at highest risk for STDs.

  • The prevalence of chlamydia in those having EV was similar to prevalence rates among other high-risk asymptomatic men and women and sufficiently high to warrant screening.


Acknowledgements

Acknowledgements

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


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