Increasing prevalence of sexually transmissible infections (STI) in Australia as well as limited resources led NSW health authorities in 2006 to ask that publicly funded sexual health centres target service provision to those most at risk of STIs.

Between 2002 and late 2005 the Sydney Sexual Health Centre (SSHC) triaged all patients who attended without an appointment. In 2006 the system was expanded to include triage of patients telephoning for an appointment and to include triaging against the designated priority populations and presentations as outlined by NSW Health.

In 2001, a total of 13.8% of 1422 new patients who attended SSHC did not fulfill the 2006 criteria necessary for treatment at the Centre. In 2006, after expansion of the triage system as described above, only 4.8% of 1039 new patient presentations were inappropriate.  Therefore, the expanded triage system has effectively reduced the non-priority consultations seen at SSHC by 9%.

Publicly funded Sexual Health services will prioritise access to and focus of services to those priority groups most in need as delineated by NSW Health.

Reorientation of the services provided by SSHC was required in order to meet the demands of the National and State STI strategies. Assessment of appropriateness of patients accessing the service was not conducted therefore it can be assumed that a percentage of patients would not have been appropriate for the service. Further, as SSHC was already working at capacity, if increases in attendances were required by some priority groups, space was required to accommodate them.

We investigated patient triage as a way of both freeing up space for priority groups as well as ensuring those seen were appropriate for the service.

In 1997 a triage nurse position was trialed that aimed to facilitate optimal flow of patients through the sexual health centre by triaging them to different disciplines for care. A pre and post implementation survey showed that post implementation the overall wait time for those attending without an appointment had halved from 24 to 12 minutes and the wait for a doctor had decreased from 40 to 11 minutes (Knight et al, 2006). A staff survey was also conducted post implementation and 98% of staff thought that the triage system had improved patient flow and waiting times and had reduced patient anxiety. This triage system however, did not triage patients out of the service nor did it incorporate triaging new clients who called for appointments.

Triage was looked at as a possible tool to help reorientate the provision of care because it had already been shown to have a positive affect on services at the Centre and had the capacity to take on new processes.

The NSW HIV/AIDS and STI strategies- 2006-2009, clearly articulate that a priority issue is prioritising access to and focus of publicly funded sexual health clinics. They designate 5 priority populations, of which one is Aboriginal people. The National Aboriginal and Torres Strait Islander Sexual Health and Blood Bourne Virus Strategy 2005-2008 and the NSW HIV/AIDS and STI Strategies Implementation Plan for Aboriginal People also seeks to increase access by this group to sexual health services. SESIAHS HIV/AIDS and STI strategies directs this process at an area health level and the Area has set up a working group to progress prioritisation and access as decreed by the National and State strategies.

In 2005, in preparation for the release of the NSW Health STI strategy, Sydney Sexual Health Centre held a staff meeting to discuss triage at the Centre. The in-person triage tool was adapted by a small team of interested staff, to incorporate triaging via designated priorities and triaging by telephone. The tool paralleled the priority populations and presentations outlined in the then final draft of the NSW STI strategy. The draft tool was presented to SSHC staff at the meeting where they discussed and finalised the tool.

When the Strategy was released, representatives of NSW Health were invited to SSHC to present the new strategic direction to staff and answer their questions. In the beginning of 2006, in line with the new Strategy, all clients calling for an appointment began to be triaged utilizing the same tool as used for in person triage.

The triage policy was revised, a competency was developed and piloted and triage training was conducted for the nurses working at the Centre at the time. This allowed them to be recognised as accredited, for the project implementation. Since then each of the new nurses undertakes a training and competency accreditation process before being able to be rostered onto triage. These nurses also attend ongoing education to ensure they are able to use the tool in the most patient focused and patient friendly way.

Review of the new system was planned to ascertain if expansion of the triage system had had an impact on the percent of patients seen from within the priority groups and priority presentations.

SSHC has a computerised database which collects occasion of service data as well as patient medical record data. This database was searched for new patient attendances where the patient did not fit any of the designated priority categories as outlined in the triage tool. The review was conducted in 2006 and for comparison in 2001, which was pre implementation of the priority triage system.

In 2001, pre implementation of the priority triage component of the triage system, a total of 13.8% of 1422 new patients did not fit the criteria of patient presentations appropriate for the Centre. In 2006, post implementation, only 4.8% of 1039 patient presentations were inappropriate.

Each of the new nurses at the Centre undertakes a training and competency accreditation process before being able to be rostered onto triage. All Centre nurses also attend ongoing education to ensure they are able to use the tool in the most patient focused and patient friendly way. Each clinician at the Centre has a minimum of 10% of their medical records reviewed as part of a quality review initiative. As part of this process it is noted if the patient falls within one of the priority presentations. If not the cases are discussed within the nursing unit as a way of reinforcing the tool and the appropriate presentations.

NSW Health, through the NSW Sexually Transmissible Infections Programs Unit (STIPU), is currently streamlining and standardizing sexual health services across NSW, in line with the STI strategy. There are a total of 27 publicly funded services across NSW but only approximately 4 have some degree of triage in place. The triage system discussed above, is being adapted, piloted and tested by other sexual health services throughout NSW and is being held up as the best base model for other services to use. Similarly, the triage guidelines, competency and training process have been taken up by the STIPU working group looking at triage and are being inserted into the NSW Standard Operating Procedures for Publicly Funded Sexual Health Services that is in development.

1. Knight V, McNulty A. Triage in a public outpatient sexual health clinic. Sexual Health 2006; 3: 87–90.

Quality Collaborative Manager, Clinical Governance Unit
South Eastern Sydney Illawarra Area Health Service
Phone: 02 4253 4936