Online triage tool improves the efficiency of a sexual health service

Keywords: HIV, LGBTQI, PLHIV, public health, PWID, screening, sexual behaviours, sexual health, sexuality, STIs, triage, website.

Demand for publicly funded¹ sexual health services is rising in New South Wales (NSW), Australia.² In order to achieve the goal of a 90% reduction in the rate of preventable HIV infection by 2025, populations at higher risk need to test more frequently.³ Sexually transmissible infection (STI) notifications in NSW have been rising, attributed to increased and well-targeted testing as well as possible rising incidence.⁴ These drivers require publicly funded sexual health services to reorient service delivery in order to expand their capacity to see additional consumers.

To meet these challenges, Sydney Sexual Health Centre (SSHC), the largest public sexual health clinic in NSW,⁵ developed an online triage tool hosted on the SSHC website called ‘Am I OK?’ (newly renamed in July 2021 as ‘Time to Test?’; https://www.sshc.org.au/timetotest/). The aim of the online triage tool is to stream non-priority populations, or those who are priority but outside of the geographical area that the SSHC services, to more appropriate services. It asks questions about relevant risk behaviours and demographics, similar to the Computer Assisted Sexual Interview (CASI) questions that all consumers complete when they visit SSHC in person. This paper outlines the findings of a quality improvement project that examined the use of the triage tool from a service perspective.

Located in inner-city Sydney, the centre of Australia’s HIV epidemic,⁶ SSHC triages in symptomatic consumers within its catchment area, as well as contacts of individuals who have tested positive for an STI, and those from higher-risk populations: men who have sex with men (MSM), sex workers, people who inject drugs, people living with HIV, Aboriginal and Torres Strait Islander peoples, and young people (aged <25 years). SSHC has initiated innovative strategies to expand the range of testing options and venues in a manner acceptable and attractive to consumers.^5,7–9 Through these service delivery innovations, the total number of SSHC consumers has increased significantly from 17 315 attendances in 2006, to 44 374 attendances among 16 589 consumers in 2017. In 2017, the centre received 16 960 calls to the triage nurse (median 67 calls per day).

This study was a retrospective cross-sectional analysis of consumers using the Am I OK? triage tool on the SSHC website in 2017. It examined the use of the tool which was defined as the flow of consumers using the Am I OK? tool from initial triage to call back, or direct contact with a service. This study examined whether the tool was efficiently triaging out consumers who were non-priority for SSHC services.

The Am I OK? tool was created in 2011. The tool consists of questions about demographics (age, post code, Aboriginal and/or Torres Strait Islander identification), symptoms (asymptomatic/symptomatic), being a contact of a diagnosed STI, HIV status, and presence of certain risk practices. The information is used to triage consumers as either priority or not priority for SSHC services. The tool also uses location to stream priority populations who reside in another local health district to a free statewide phone service, the NSW Health Sexual Health Infolink (SHIL), who refer to appropriate services in the consumer’s local area.

Those triaged as ‘probably OK’ are considered non-priority for SSHC and they are encouraged to seek testing with a general practitioner (GP). They can download a GP referral letter with recommended screening tests. Those who ‘might not be OK’ who need post exposure prophylaxis (PEP) outside of SSHC hours are directed to Health Direct (a 24 h health advice line); our triage nurses assist those who call during business hours. Priority populations who are asymptomatic are referred to SSHC’s Xpress clinic, a fast-track express clinic specifically for asymptomatic consumers that offers testing without a physical examination. Priority populations who have symptoms are referred to the SSHC phone triage nurse for further assessment.

Fig. 1 provides a summary of Am I OK? enquiries and referral pathways for each entry.

Fig. 1.  Am I OK? algorithm referral pathways.

Electronic line data from 1 January to 31 December 2017 was provided from the SSHC website for all complete Am I OK? triage tool entries. The data was analysed with linked, de-identified demographic information.

During analysis it was noted that 11.7% of records had identical time and date created stamps. This may indicate that these were not unique consumers, though it is not possible to determine if this is the case. We refer to these as ‘entries’, not ‘consumers’.

The Am I OK? tool potentially diverted up to 22 105 calls. These entries were not provided with the clinic triage phone number and it was difficult to find the number elsewhere on the website. The authors believe these consumers would have been unlikely to contact the SSHC triage nurse instead.

In 2017 the mean phone triage telephone call time was 2 min 46 s. There were 22 105 entries that were diverted to SHIL, Xpress, Health Direct, or a GP. It is not known whether all consumers using Am I OK? would have attempted to call the clinic if the Am I OK? tool was not available, or whether some of those who were diverted via the Am I OK? tool still chose to call SSHC. However, assuming these Am I OK? users would instead have been a triage call, the phone triage nurses’ time saved can be estimated: in 2017 the tool saved up to 1019 h (equivalent to 6.2 months) of triage nurse time. For those who called with a referral from the Am I OK? tool, their relevant information was pre-populated in the SSHC computer system saving further time on the phone.

A total of 1141 consumers called SSHC or SHIL directly with their Am I OK? reference number, representing 5.2% of those triaged as ‘might not be OK’. A total of 1182 entries requested a call back which is 5.4% of those who ‘might not be OK’.

Most requests for call backs were attempted by SSHC or SHIL staff (98% for phone triage, 100% for both Xpress and SHIL), however only some of these requests were successfully contacted despite two attempts (59% for phone triage, 70% for Xpress and 68% for SHIL). On weekdays the median times for a call back was 124 min for SHIL, 313 min for SSHC, and 17 min for Xpress. There was a median of 38 min between the first and second attempted call back.

Overall, 1916 entries requested and received a call or directly contacted the service. This represents 6.8% of all Am I OK? entries, and 8.8% of those who ‘might not be OK’.

Almost four out of five entries (77.7%) were triaged as ‘might not be OK’ and recommended for further assessment. We are unable to determine if these consumers made contact with another service, which is a limitation of this study.

It is noteworthy that only a small number of these ‘might not be OK’ entries requested a call back or made direct contact with SSHC or SHIL. Although this study is unable to determine reasons for the high loss to follow up, various possibilities exist. Inherently a triage system is a barrier to access; it provides services to a pre-defined group of people. One concern is that the triage tool and system of call backs created barriers to access for some who ‘might not be OK’. Another explanation may be under reporting; not everyone who calls SSHC is asked if they have completed the Am I OK? tool, and consumers may not provide their reference number when contacting SSHC. Additionally, some of these consumers could have been using the tool as part of their own ‘Dr Google’ research and had no intention to book an appointment. The tool does not record those that did not complete the tool in its entirety, so this may have limited the number of entries from those who were simply browsing. Language barriers may have meant that some consumers did not complete the tool as intended, though it is designed to be accessible for those with low health literacy and information is available on the SSHC website in the two most common languages of SSHC consumers: Chinese and Thai.

Finally, call wait time may have been a factor for some consumers. In 2017 the mean wait time for phone triage was 2 min 57 s, and the abandoned call rate by SSHC consumers on hold was 18%. Of those who did request call back, the delay between time of request and attempt may have contributed to a lower success rate.

Further investigation with consumers to capture their perspectives of the efficiency and effectiveness of the tool is recommended.

The tool has achieved its purpose in triaging out non-priority populations and referring those who are priority but outside of SSHC’s service area to a service closer to their geographical location, assumedly saving a significant amount of SSHC phone triage nurse time. Overall there were 16 960 calls to the phone triage nurses in 2017 and 1916 successful contacts through Am I OK?. This suggests the tool contributed to 11.3% of ‘SSHC contact for local consumers from priority populations, despite the low proportion of contact with consumers who ‘might not be OK’. This may be an important aide for new consumers accessing the SSHC. The high loss to follow up suggests more could be done to ensure these consumers are linked to sexual health services.

Data was extracted from the digital phone system and is not publicly available. Any questions about the data may be forwarded to the corresponding author.

The authors do not have any conflicts of interest to declare.

There has been no funding for this project.