1. 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 Jacksonville, May 10, 2006

2. 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.

3. 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

4. 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

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. 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.

7. 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.

8. Introduction of Triage Patient presents to the clinic Patient interviewed by Triage Nurse who decides: Patient waits for an exam Phlebotomy for syphilis and Rapid HIV BEFOREAFTER Immunizations Urine sample collected for Gonorrhea and Chlamydia screening Clinician Support Staff Rapid HIV Results Given Phlebotomy for syphilis and Rapid HIV Immunizations Patient waits for an Exam YESNO Express Visit? Clinician provides full exam and treatment if needed Rapid HIV Results Given Patient registers Phlebotomy for syphilis and Rapid HIV Immunizations Patient registers Clinician provides full exam and treatment if needed Rapid HIV Results Given Average time: 30- 45 minutes Average time: 30- 90 minutes Average time: 30 minutes – 4 hours

9. 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:

10. Express vs. Standard Visits April 2005 – March 2006

12. 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%).

13. 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.

14. Chlamydia Rates Express vs. Exam EV Exam EV Exam Women Men

15. Gonorrhea Rates Express vs. Exam EV Exam EV Exam Women Men

16. 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.

17. 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!