Walk-in Visits Research Articles

O5-S1.06 STD clinic triage based on computer-assisted self interview: the king county experience

BackgroundTriaging patients to different service levels based on responses to computer-assisted self interview (CASI) could increase the cost-efficiency of providing care in STD clinics.MethodsIn October 2010 we began having all...

Mandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames

We determine whether mandatory formal triage of walk-in emergency department (ED) patients provides timely recognition of the most acutely ill. This retrospective cross-sectional study was conducted at a US urban academic ED, annual census 39,000, which uses Emergency Severity Index-5 triage (ESI-5) for all arriving patients. ESI-5 recommends that level 1 and 2 patients be treated by a physician immediately or within 10 minutes, respectively. For all high-acuity (ESI 1 or 2) patients presenting between January 1 and December 31, 2008, data from electronic medical records and registration and tracking systems were used to determine elapsed time from arrival to completion of triage (median, range, 95th percentile), proportion of these intervals that met ESI-5 recommendations, and whether triage throughput differed during peak arrival hours. For 3,932 high-acuity walk-in visits (ESI 1=63; ESI 2=3,869), median time from arrival to triage completion was 12.3 minutes, range 0 to 128 minutes. Twenty-seven percent (95% confidence interval [CI] 26% to 29%) of high-acuity patients were taken to rooms on arrival; 41% (95% CI 40%, 43%), including those roomed immediately, completed triage within 10 minutes. Twenty-five percent (95% CI 24% to 26%) completed triage in greater than 20 minutes and 10% (95% CI 9% to 11%) greater than 30 minutes after arrival. Between 10 am and 10 pm (peak arrival hours), triage took longer for level 2 patients, and fewer met ESI recommendations. Less than half of high-acuity patients in this urban ED completed triage within time frames recommended by the ESI-5, resulting in potentially unsafe delays. Although mandatory formal triage theoretically identifies patients who should be treated most quickly, the value and safety of this process should be reassessed.

Primary Care Providers' Reports of Time Alone and the Provision of Sexual Health Services to Urban Adolescent Patients: Results of a Prospective Card Study

Confidential care is an essential element of quality adolescent primary care. Twenty-one primary care providers tracked provision of confidential care (time alone with adolescent) and sexual health services in clinics serving low-income, primarily minority communities. Over 144 visits attended by a parent, 68% involved time alone with the adolescent. Time alone was 18 times higher for physicals than same day or walk-in visits, and 3 times higher if teen presented a sex complaint. Provision of sexual health services was 3 times higher for those who had time alone with the provider, especially among girls. The results indicate some missed opportunities to deliver needed services to at-risk populations, especially among boys.

Alcohol Use, Comorbidities, and Receptivity to Treatment in Hispanic Farmworkers in Primary Care

Primary care is a promising setting for alcohol screening and intervention with low-income Hispanic farmworkers, yet no research has been conducted that estimates the prevalence of harmful and hazardous drinking, psychiatric comorbidities, or receptivity to treatment in this population. This study investigates rates of alcohol misuse, depression, anxiety, somatization, and cigarette use in a convenience sample of low-income Hispanic farmworkers and farmworker spouses in Florida making walk-in visits to a rural community health center. Results indicated a high prevalence of alcohol use but also a strong willingness to receive treatment. Forty-four percent (44%) screened positive for harmful and hazardous alcohol use; over half (58%) screened positive for one or more comorbidity risks. Receptivity to alcohol treatment was high (75%). These results strongly support the need for and potential utility of alcohol intervention in primary care for this population.

Applying Workflow Analysis Tools to Assess Immunization Delivery in Outpatient Primary Care Settings

As health care organizations face increasing pressure to institute quality assurance activities, the already-underfunded community clinics that treat the poor and underserved are challenged to perform these activities within tight constraints of human and financial resources. With pediatric immunizations as a marker, a workflow observation tool was used to identify causal processes affecting immunization delivery. Ten clinics and five private practices, located in areas designated as health professional shortage areas, participated in the study, gaining access to a tool that would have been unaffordable to them from the private sector. Trained observers followed families through the clinic, using a 127-item workflow observation form--the Observational Checklist of Patient Encounters (OCPE)--assessing discrete activities that families encountered during the checkin/pre-exam, exam, discharge, and billing processes. A convenience sampling of the targeted population--children younger than three years of age--included observations of scheduled acute, scheduled well-child, follow-up, and walk-in visits. In the feedback session, a summary of each clinic's immunization delivery patterns was presented, with an emphasis on the individual health center's operational issues. The workflow observation tool was used to identify operational errors affecting both clinical and fiscal processes in each of the clinics that had not been previously apparent to either clinic management or the quality improvement (QI) teams. Feedback addressed and encouraged process-oriented improvements in response to the workflow observations, which were incorporated into the clinics' QI procedures. Twelve of the 15 clinics have formed process action teams to address QI issues on an ongoing basis.

Outcomes of telephone medical care.

To document the outcomes of a telephone coverage system and identify patient characteristics that may predict these outcomes. Telephone survey. An academic outpatient medical practice that has a physician telephone coverage service. All patients (483) who called during the 3-week study period to speak to a physician were evaluated, and for the 180 patients with symptoms, attempts were made to survey them by telephone 1 week after their initial telephone call. The mean age of the 180 patients was 41 years, 71% were female, and 56% belonged to commercial managed care plans. In the week after the initial telephone call, the following outcomes were reported: 27% of the patients had no further contact with the practice; 9% filled a prescription medication; 19% called the practice again; 48% kept an earlier appointment in the practice; 3% saw an internist elsewhere; 8% saw a specialist; 8% went to an emergency department; 4% were admitted to a hospital. Of the 180 patients who called with symptoms, 160 (89%) were successfully contacted for survey. Eighty-seven percent of these 160 patients rated their satisfaction with the care they received over the telephone as excellent, very good, or good. In multivariate analysis, patients' own health perception identified those most likely to have symptom relief (p = .002), and symptom relief, in turn, was a strong predictor of high patient satisfaction (p = .006). Thirty-three percent of the 160 patients reported that they would have gone to an emergency department if a physician were not available by telephone. In the present study, younger patients, female patients, and patients in commercial managed care plans used the telephone most frequently. Also, the telephone provided a viable alternative to emergency department and walk-in visits. Overall satisfaction with telephone medicine was high, and the strongest predictors of high patient satisfaction were symptom relief and patients' own health perception.

Effectiveness of a Specialized Asthma Clinic in Reducing Asthma Morbidity in an Inner-City Minority Population

Asthma is the most common chronic disease of childhood and a leading cause of morbidity in adults. Despite significant advances in medical therapy, asthma morbidity and mortality rates have risen dramatically over the past two decades, especially in minority and socioeconomically disadvantaged populations. Numerous intervention programs have been designed in an attempt to reduce asthma morbidity but few have targeted poor or minority populations. The purpose of this study was to assess whether an outpatient intervention program specifically targeted at a high-minority population in East Harlem, in New York City, was successful in reducing asthma morbidity. A retrospective chart review of 84 patient records was conducted. The patients were divided into two groups, an intervention group (n = 45), who were followed by an asthma specialist (allergist/immunologist), and a nonintervention group, followed by a general internist or pediatrician. Outcome variables including clinic walk-in visits, emergency room visits, and hospitalizations were determined and compared in the pre- and postintervention period in both groups. Patients in the intervention group had reduced total walk-in visits (73 vs. 27, p < 0.001), emergency room visits (30 vs. 5, p < 0.001), and hospitalizations (16 vs. 2, p < 0.001). In contrast, patients in the nonintervention group had no change in total walk-in visits (88 vs. 72), increased emergency visits (7 vs. 22, p < 0.05), and no change in hospitalizations (5 vs. 2), respectively. The outpatient intervention program has been successful in reducing asthma morbidity in the high-risk minority community of East Harlem. Future larger studies are warranted to extend this pilot program to other high-risk minority populations.

Is Continuity of Care Preserved in Children Who Utilize the Pediatric Emergency Department?

Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained? Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis. During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period. Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.

Access of Medicaid recipients to outpatient care.

Visits to the emergency department by Medicaid recipients for nonemergency problems are common and contribute to rising health care costs. However, such patients may have few alternatives. We conducted a telephone survey of 953 ambulatory care sites in 10 cities to determine the availability of appointments for Medicaid recipients with common problems. Research assistants telephoned all ambulatory care clinics and a stratified sample of private primary care practices in the catchment area served by the hospital emergency department in each city. The assistants identified themselves as Medicaid recipients seeking care for one of three problems (low back pain, dysuria, or sore throat) and asked a standardized series of questions. Data were collected on appointments or walk-in visits authorized at any time, within two days after the call, or after 5 p.m.; copayment requirements; and reasons appointments could not be made. If an appointment was made, it was canceled at the end of each call or shortly thereafter. Several weeks later, private-practice sites in six of the cities were recontacted; the research assistants identified themselves as patients with private insurance and the same problem. An appointment or an authorization for a walk-in visit was obtained from 418 of the 953 practice sites (44 percent); 47 of the sites (5 percent) could not be contacted. Appointment rates for the different types of sites ranged from 72 percent for free-standing urgent care centers to 34 percent for private practices. "Not accepting Medicaid" was the most common reason given for not granting an appointment or walk-in visit. Only 72 of the sites (8 percent) offered after-hours care within two working days after the call without a cash copayment. Sixty percent of the 330 private practices that were recontacted agreed to see a patient with private insurance within two working days, but only 26 percent agreed to see a patient with Medicaid within two days (P < 0.001). Medicaid recipients in urban areas have limited access to outpatient care apart from that offered by hospital emergency departments.

Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting.

To assess whether we could export a successful multifaceted influenza vaccination program from an academic medical center to a community setting. Pre/post study using concurrent control groups. Clinics in a staff model Health Maintenance Organization (HMO). One urban and one suburban clinic were chosen as intervention clinics, while two similar clinics were selected as control clinics. All patients aged 65 and over enrolled in the four clinics. An informational mailing to patients, a standing-order policy allowing nurses to administer vaccine, a vaccination reminder on daily appointment lists, and availability of walk-in visits for vaccination. Patients in the control clinics received usual care. Vaccination rates were determined using a validated postcard survey of 150 randomly selected patients at each clinic both at baseline (1988-89) and after the intervention (1989-90). The baseline vaccination rates ranged from 51.4% to 74.6%, with nearly all vaccinations taking place at the HMO. In one intervention clinic, the vaccination rate improved from 56.4% to 72.3%, P = 0.01. In the other, the baseline rate was 74.6% and did not change significantly after the intervention. There was no change in the vaccination rate in the control clinics after the intervention period. An influenza vaccination program that combines several organizational interventions may be successfully exported from an academic to a community setting and may serve as a useful model for others.

A Randomized Controlled Trial of Academic Group Practice

We conducted a controlled trial of the adoption of a group-practice model within an academic department of medicine. Ongoing randomization yielded similar groups of patients and residents. To determine the effect of the intervention on medicine-clinic operation, we monitored the hospital outpatient activity of 28 residents and 2299 patients during an 11-month study period. The group-practice clinics generated 20% more patient encounters per month than did the traditional, control clinics (328 vs 273 encounters), primarily because twice as many voluntary, overflow clinic sessions were scheduled (20.2 vs 9.7 sessions). Yet, because group-practice registration was decentralized, patients spent 15% less time in completing scheduled visits (93.2 vs 109.9 minutes). Regular utilizers of the group practices made 7% more scheduled clinic visits on average (3.27 vs 3.05 visits), but 39% fewer walk-in visits (0.14 vs 0.23 visits). Hospital-wide, continuity of care was not affected. We conclude that adoption of a group-practice model at our institution improved clinic productivity, enhanced patient flow, and decreased unscheduled clinic visits.

Conversion reactions in adolescents.

Few situations in practice present as more frustrating for busy pediatrician than an adolescent who appears for ten-minute walk-in visit with prolonged history of unexplained abdominal pain or headache. Obtaining brief history of the symptom may contribute little to timely diagnosis, and physical examination is often unrewarding in understanding the If the adolescent9s demeanor suggests little discomfort, the pediatrician is often left with the impression that the pain is psychosomatic and/or that the adolescent is exploiting physical symptom for some secondary gain. A diagnosis of conversion reaction is seldom considered. The focus of this article will be to aid the pediatrician in identifying conversion reactions, differentiating conversion reactions from other disorders (eg, hypochondriasis, malingering), and outlining an approach to the treatment and referral of patients with conversion reactions. DESCRIPTION AND PREVALENCE Conversion reactions represent form of communication of the uncomfortable, or as Engel1 writes: a psychic mechanism whereby an idea, fantasy, or wish is expressed in bodily rather than in verbal terms and is experienced by the patient as physical symptom rather than as mental symptom. The idea or wish is psychologically threatening to the individual or unacceptable for him or her to express directly.

Conversion Reactions in Adolescents

Few situations in practice present as more frustrating for a busy pediatrician than an adolescent who appears for a ten-minute walk-in visit with a prolonged history of unexplained abdominal pain or headache. Obtaining a brief history of the symptom may contribute little to a timely diagnosis, and physical examination is often unrewarding in understanding the symptom. If the adolescent's demeanor suggests little discomfort, the pediatrician is often left with the impression that the pain is "psychosomatic" and/or that the adolescent is exploiting a physical symptom for some secondary gain. A diagnosis of conversion reaction is seldom considered. The focus of this article will be to aid the pediatrician in identifying conversion reactions, differentiating conversion reactions from other disorders (eg, hypochondriasis, malingering), and outlining an approach to the treatment and referral of patients with conversion reactions. DESCRIPTION AND PREVALENCE Conversion reactions represent a form of communication of the uncomfortable, or as Engel1 writes: "a psychic mechanism whereby an idea, fantasy, or wish is expressed in bodily rather than in verbal terms and is experienced by the patient as a physical symptom rather than as a mental symptom." The idea or wish is psychologically threatening to the individual or unacceptable for him or her to express directly.

Measuring Physical and Psychosocial Function in Patients with Low-Back Pain

Techniques for assessing daily function in Patients with back pain are generally crude and limited in scope. We therefore examined a "health status" questionnaire, the Sickness Impact Profile (SIP) to assess its measurement characteristics in such patients. Eighty patients with mechanical low-back pain completed the SIP and a physical examination at a walk-in visit and again three weeks later. Test-retest reliability of the SIP was substantial. Biologic validity was confirmed by significant correlations with age, pain duration, spine flexion, straight leg raising, and pain severity. Validity of psychosocial subscales was confirmed by significant associations with patient anxiety and psychiatric problems. Scores changed in the expected directions when patients were evaluated three weeks later. The SIP is thus valid, reliable, sensitive to clinical changes, and comprehensively assesses a wide range of dysfunctions.