Clinic flow for STI, HIV, and TB patients in an urban infectious disease clinic offering point-of-care testing services in Durban, South Africa

Abstract

BackgroundMany clinics in Southern Africa have long waiting times. The implementation of point-of-care (POC) tests to accelerate diagnosis and improve clinical management in resource-limited settings may improve or worsen clinic flow and waiting times. The objective of this study was to describe clinic flow with special emphasis on the impact of POC testing at a large urban public healthcare clinic in Durban, South Africa.MethodsWe used time and motion methods to directly observe patients and practitioners. We created patient flow maps and recorded individual patient waiting and consultation times for patients seeking STI, TB, or HIV care. We conducted semi-structured interviews with 20 clinic staff to ascertain staff opinions on clinic flow and POC test implementation.ResultsAmong 121 observed patients, the total number of queues ranged from 4 to 7 and total visit times ranged from 0:14 (hours:minutes) to 7:38. Patients waited a mean of 2:05 for standard-of-care STI management, and approximately 4:56 for STI POC diagnostic testing. Stable HIV patients who collected antiretroviral therapy refills waited a mean of 2:42 in the standard queue and 2:26 in the fast-track queue. A rapid TB test on a small sample of patients with the Xpert MTB/RIF assay and treatment initiation took a mean of 6:56, and 40% of patients presenting with TB-related symptoms were asked to return for an additional clinic visit to obtain test results. For all groups, the mean clinical assessment time with a nurse or physician was 7 to 9 min, which accounted for 2 to 6% of total visit time. Staff identified poor clinic flow and personnel shortages as areas of concern that may pose challenges to expanding POC tests in the current clinic environment.ConclusionsThis busy urban clinic had multiple patient queues, long clinical visits, and short clinical encounters. Although POC testing ensured patients received a diagnosis sooner, it more than doubled the time STI patients spent at the clinic and did not result in same-day diagnosis for all patients screened for TB. Further research on implementing POC testing efficiently into care pathways is required to make these promising assays a success.

Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response

“…If health facility factors are not properly taken into consideration, then implementation of decentralized HIV viral load testing will be jeopardized (105,106). Introducing new diagnostic devices into clinics with heavy workloads may cause disruptions in the clinical workflow (107), which can result in a loss of efficiency and a decline in service quality (108,109). Alternatively, the experience of staff in primary health facilities with routine use of rapid diagnostic tests (RDTs) for HIV diagnosis may facilitate the expansion of POC HIV viral load testing (110).…”

Prescribing, care and resistance: antibiotic use in urban South Africa

“…Women usually delayed presenting to the clinic not only because of home management, but because of protracted clinic waiting times and bottle necks (Egbujie et al, 2018;Sastry et al, 2015;Stime et al, 2018;Swart et al, 2018). As many women explained, it seemed pointless to present to the clinic and wait for some hours, with no resolution at the end of the day: "You'd rather try helping yourself at home, rather than coming to the clinic".…”

Systems thinking for health emergencies: use of process mapping during outbreak response

“…1 4-6 It was used in South Africa to understand how the use of point of care tests for sexually transmitted infections, tuberculosis and HIV impacted care at large urban public healthcare clinics. 7 Additionally, process mapping has been used to improve…”

“… 1 4–6 It was used in South Africa to understand how the use of point of care tests for sexually transmitted infections, tuberculosis and HIV impacted care at large urban public healthcare clinics. 7 Additionally, process mapping has been used to improve collaboration at the human-animal interface across a variety of sectors through the One Health Systems Mapping and Analysis Resource Toolkit (OH-SMART). 8 …”