How safe is triage by an after-hours telephone call center?

Factors associated with undertriage and overtriage in telephone triage in Danish out-of-hours primary care: a natural quasi-experimental cross-sectional study of randomly selected and high-risk calls

OBJECTIVES

We aim to explore undertriage and overtriage in a high-risk patient population and explore patient characteristics and call characteristics associated with undertriage and overtriage in both randomly selected and in high-risk telephone calls to out-of-hours primary care (OOH-PC).

DESIGN

Natural quasi-experimental cross-sectional study.

SETTING

Two Danish OOH-PC services using different telephone triage models: a general practitioner cooperative with GP-led triage and the medical helpline 1813 with computerised decision support system-guided nurse-led triage.

PARTICIPANTS

We included audio-recorded telephone triage calls from 2016: 806 random calls and 405 high-risk calls (defined as patients ≥30 years calling with abdominal pain).

MAIN OUTCOME MEASURES

Twenty-four experienced physicians used a validated assessment tool to assess the accuracy of triage. We calculated the relative risk (RR) for clinically relevant undertriage and overtriage for a range of patient characteristics and call characteristics.

RESULTS

We included 806 randomly selected calls (44 clinically relevant undertriaged and 54 clinically relevant overtriaged) and 405 high-risk calls (32 undertriaged and 24 overtriaged). In high-risk calls, nurse-led triage was associated with significantly less undertriage (RR: 0.47, 95% CI 0.23 to 0.97) and more overtriage (RR: 3.93, 95% CI 1.50 to 10.33) compared with GP-led triage. In high-risk calls, the risk of undertriage was significantly higher for calls during nighttime (RR: 2.1, 95% CI 1.05 to 4.07). Undertriage tended to be more likely for calls concerning patients ≥60 years compared with 30-59 years (11.3% vs 6.3%) in high-risk calls. However, this result was not significant.

CONCLUSION

Nurse-led triage was associated with less undertriage and more overtriage compared with GP-led triage in high-risk calls. This study may suggest that to minimise undertriage, the triage professionals should pay extra attention when a call occurs during nighttime or concerns elderly. However, this needs confirmation in future studies.

To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study

National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote healthcare services going forward.

A Curriculum to Improve Pediatric Residents' Telephone Triage Skills

INTRODUCTION

Telephone triage systems are frequently used due to their success in decreasing emergency department utilization, reduction of health care costs, and high levels of satisfaction among patients and providers. Despite phone triage's prevalence, few residency programs have designated curricula for residents to learn this vital skill.

METHODS

We designed a phone triage curriculum initially piloted with senior residents at one of our continuity clinics. The curriculum consisted of a didactic session, a just-in-time simulation training session, and an experiential component of being on call during the ambulatory rotation. Retrospective pre-post self-assessments evaluated resident perceptions of their skills in taking histories and triaging care over the phone in addition to obtaining qualitative feedback from faculty and residents immediately after the curriculum and 1-2 years postgraduation.

RESULTS

Of 11 eligible residents, 10 (91%) chose to participate in the pilot curriculum. Residents reported that their skills in history taking over the phone improved from 20% to 90% and their ability to triage patients over the phone improved from 0% to 80%. This led to a quality improvement initiative to increase patient calls and has continued for 5 years, with continued positive feedback from residents and attendings.

DISCUSSION

Phone triage skills are a necessity for pediatric providers, but few residency programs have training curricula in place. Through an experience-based phone triage program, residents significantly improved their self-reported skills at history taking and triaging. Similar curricula could easily be adopted at other institutions.

Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasi-experimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls

Background

To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities.

Methods

Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage.

Results

The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s).

Conclusions

Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

An exploratory case study of the organizational functioning of a decision-making and referral support call center for frontline providers of maternal and new born care in the Greater Accra Region of Ghana

A call center was designed and started implementation in the Greater Accra Region of Ghana in 2015, to support frontline provider decision-making and referral for maternal and new born care. This study aimed to understand the organizational functioning of the center and lessons for design improvement, implementation, and scale-up. The study design was a single case study. Data collection involved participant and nonparticipant observation, conversations, and in-depth interviews with call center staff. Data were coded and analyzed manually. Findings showed a high adherence to call center protocols, good client service skills, a strong local sense of ownership of the center, and staff resilience in performing their functions despite a context of scarce resources and no prior experience with running a call center. Perceptions of lack of involvement of some call center staff in decision-making, and the resource constrained working conditions sometimes hampered the functioning of the center. The locally driven bottom-up process used to establish the center appeared to be an important element in sustaining it despite the resource constraints. More attention to locally driven bottom-up approaches, organizational functioning, and resilience are critical to develop and sustain innovations for health outcome improvement in resource-constrained contexts.

Influence of awareness and availability of medical alternatives on parents seeking paediatric emergency care

AIMS

Direct seeking of care at paediatric emergency departments may result from an inadequate awareness or a short supply of medical alternatives. We therefore evaluated the care-seeking patterns, availability of medical options and initial medical assessments - with overall reference to socioeconomic status - of parents at an urban paediatric emergency department in a Scandinavian country providing free paediatric healthcare.

METHODS

The parents of children assessed by paediatric emergency department physicians at a Swedish university hospital over a 25-day winter period completed a questionnaire on recent medical contacts and their reasons for attendance. Additional information was obtained from ledgers, patient records and population demographics.

RESULTS

In total, 657 of 713 eligible patients (92%) were included. Seventy-nine per cent of their parents either failed to or managed to establish medical contact before the emergency department visit, whereas 21% sought care with no attempt at recent medical contact. Visits with a failed telephone or primary care contact (18%) were more common outside office hours ( p=0.014) and were scored as less urgent ( p=0.014). A perceived emergency was the main reason for no attempt at medical contact before the visit. Direct emergency department care-seeking was more common from the city district with the lowest socioeconomic status ( p=0.027).

CONCLUSIONS

Although most parents in this Swedish study tried to seek medical advice before attending a paediatric emergency department, perceived emergency, a short supply of telephone health line or primary care facilities and lower socioeconomic status contributed to direct care-seeking by almost 40% of parents. Pre-hospital awareness and the availability of medical alternatives with an emphasis on major differences in socioeconomic status should therefore be considered to further optimize care-seeking in paediatric emergency departments.

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study

Background

Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call.

Methods

Records of calls to the Australian healthdirect helpline (July 2008–December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice “Attend ED immediately”; “See a doctor (immediately, within 4 hours, or within 24 hours)”; “Self-care”; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics.

Results

This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices “Attend ED immediately”, “See a doctor” and “Self-care” were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice “Attend ED immediately” was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice “See a doctor” was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient’s behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice “Self-care”. The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED.

Conclusions

Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2458-y) contains supplementary material, which is available to authorized users.

Emergency Department Attendance after Telephone Triage: A Population-Based Data Linkage Study

OBJECTIVE

To investigate compliance with telephone helpline advice to attend an emergency department (ED) and the acuity of patients who presented to ED following a call.

DATA SOURCES/COLLECTION METHODS

In New South Wales (NSW), Australia, 2009-2012, all (1.04 million) calls to a telephone triage service, ED presentations, hospital admissions and death registrations, linked using probabilistic data linkage.

STUDY DESIGN

Population-based, observational cohort study measuring ED presentations within 24 hours of a call in patients (1) with dispositions to attend ED (compliance) and (2) low-urgency dispositions (self-referral), triage categories on ED presentation.

PRINCIPAL FINDINGS

A total of 66.5 percent of patients were compliant with dispositions to attend an ED. A total of 6.2 percent of patients with low-urgency dispositions self-referred to the ED within 24 hours. After age adjustment, healthdirect compliant patients were significantly less likely (7.8 percent) to receive the least urgent ED triage category compared to the general NSW ED population (16.9 percent).

CONCLUSIONS

This large population-based data linkage study provides precise estimates of ED attendance following calls to a telephone triage service and details the predictors of ED attendance. Patients who attend an ED compliant with a healthdirect helpline disposition are significantly less likely than the general ED population to receive the lowest urgency triage category on arrival.

Pursuit of Value in Connected Healthcare

INTRODUCTION

Potential for direct patient care through remote exchange of health-related information has expanded enormously with the proliferation of technologies leveraging ubiquitous connectivity, but implementation of connected care has been slow and controversial.

MATERIALS AND METHODS

This review demonstrates that controversy regarding connected care arises largely from the fact that proponents and critics are generally considering distinctly different care models. Differences are highlighted to mitigate controversy and to distinguish capacities of these different models.

RESULTS

Distinguishing capacities is essential for establishing the evidence base supporting safety, effectiveness, and efficiency. In care of a particular patient's problem, value is achieved when resources allocated meet requirements for diagnosis and intervention but do not exceed them. Robust evidence supports the value of some well-defined connected care models, exemplified by the Health-e-Access Telemedicine Model.

CONCLUSIONS

The pursuit of value in connected care is fundamentally the same as with in-person care. Provider organizations, legislators, regulators, and payers face not only a complex task in defining standards and enabling appropriate use, but also a heavy burden of responsibility for unleashing connected care that will benefit the entire community.

Standardization of Telephone Triage in Pediatric Oncology

Nurses in pediatric oncology are often the main resource for overwhelmed parents and deal with complex patient issues over the telephone but often not without concerns about best patient care, liability, and accountability for the advice given. The question is whether using standardization of telephone triage practices can provide opportunities for improvement in the care of pediatric oncology patients. A review of the literature pertaining to telephone triage, standardization of practice, and the practice in outpatient oncology was conducted. The utilization of easy-to-use, accessible yet nonrestrictive resources and a well-designed documentation tool can help guide the decision-making process while addressing legal concerns and ensuring best possible patient care. An advantage that nurses in outpatient oncology settings have in performing telephone triage is the knowledge they have of their patient population and the disease process and treatments. Using a balanced approach to standardization of telephone triage practices can provide opportunities for improvements in care while still capitalizing on the intuitive knowledge and experience of the nurses involved.

Using Video from Mobile Phones to Improve Pediatric Phone Triage in an Underserved Population

BACKGROUND

Video-capable mobile phones are widely available, but few studies have evaluated their use in telephone triage for pediatric patients. We assessed the feasibility, acceptability, and utility of videos sent via mobile phones to enhance pediatric telephone triage for an underserved population with asthma.

MATERIALS AND METHODS

We recruited children who presented to an urban pediatric emergency department with an asthma exacerbation along with their parent/guardian. Parents and the research team each obtained a video of the child's respiratory exam, and the research team conducted a concurrent in-person rating of respiratory status. We measured the acceptability of families sending videos as part of telephone triage (survey) and the feasibility of this approach (rates of successful video transmission by parents to the research team). To estimate the utility of the video in appropriately triaging children, four clinicians reviewed each video and rated whether they found the video reassuring, neutral, or raising concerns.

RESULTS

Among 60 families (78% Medicaid, 85% Black), 80% of parents reported that sending a video would be helpful and 68% reported that a nurse's review of a video would increase their trust in the triage assessment. Most families (75%) successfully transmitted a video to the research team. All clinician raters found the video reassuring regarding the severity of the child's asthma exacerbation for 68% of children.

CONCLUSIONS

Obtaining mobile phone videos for telephone triage is acceptable to families, feasible, and may help improve the quality of telephone triage in an urban, minority population.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Performance analysis and improvement of a typical telephone response system of VA hospitals

Purpose

– Telephone response system is the frontline of hospital operations. The purpose of this paper is to analyze a representative telephone response system of Veterans Affairs (VA) hospitals, address the existing inefficiency issues such as long call waiting time, and improve system resilience to changes.

Design/methodology/approach

– Resource sharing schemes are proposed to improve the system performance in answering calls related to appointment booking and medication renewal. Discrete event simulation is adopted to model the current system and the resource sharing schemes.

Findings

– The resource sharing schemes dramatically improve system performance reflected by the decrease of call waiting time and queue, as well as the extreme high utilization of agents in a key unit. Compared with the less desired alternative of hiring additional employees to mitigate the performance issues, the resource sharing schemes perform at par or even better. Sharing more resource during the peak hours can further balance the agent workload.

Practical implications

– The resource sharing schemes could alleviate staffing shortage, long waiting time, and high-abandonment rate in the bottle-beck unit of the system, and lead to better utilization of scarce resources on the hospital floor. The concept reflects localized centralization efforts in traditionally highly decentralized telephone operations in hospital systems.

Originality/value

– This research provides a structured approach to analyze the operations of a VA telephone response system. The developed simulation model is validated, and this provides a valuable tool for management to analyze the complicated telephone operations of the telephone systems of other VA and non-VA hospitals. Resource sharing constitutes a cost-effective solution for improving system performance and resilience.

The US emergency care system: meeting everyday acute care needs while being ready for disasters

The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish "surge capacity" when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals' needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system.

Safety of clinical and non-clinical decision makers in telephone triage: a narrative review

Patient safety is a persistent problem in telephone triage research; however, studies have not differentiated between clinicians' and non-clinicians' respective safety. Currently, four groups of decision makers perform aspects of telephone triage: clinicians (physicians, nurses), and non-clinicians (emergency medical dispatchers (EMD) and clerical staff). Using studies published between 2002-2012, we applied Donabedian's structure-process-outcome model to examine groups' systems for evidence of system completeness (a minimum measure of structure and quality). We defined system completeness as the presence of a decision maker and four additional components: guidelines, documentation, training, and standards. Defining safety as appropriate referrals (AR) - (right time, right place with the right person), we measured each groups' corresponding AR rate percentages (outcomes). We analyzed each group's respective decision-making process as a safe match to the telephone triage task, based on each group's system structure completeness, process and AR rates (outcome). Studies uniformly noted system component presence: nurses (2-4), physicians (1), EMDs (2), clerical staff (1). Nurses had the highest average appropriate referral (AR) rates (91%), physicians' AR (82% average). Clerical staff had no system and did not perform telephone triage by standard definitions; EMDs may represent the use of the wrong system. Telephone triage appears least safe after hours when decision makers with the least complete systems (physicians, clerical staff) typically manage calls. At minimum, telephone triage decision makers should be clinicians; however, clinicians' safety calls for improvement. With improved training, standards and CDSS quality, the 24/7 clinical call center has potential to represent the national standard.

Attributes and circumstances that induce inappropriate health services demand: a study of the health sector in Brazil

Background

The current economic and social context has required health systems to provide top quality services and to be efficient in controlling costs. An obstacle to achieve these goals is the inappropriate health services demand. This study aims to present these inappropriate health service demand determinants from data on telephone calls made to a medical advice call centre.

Methods

This study used a Brazilian medical advice call centre data sample in the period of November and December 2012 (n = 19690), which supplied data on the user’s initial request, the physician’s recommendation, information on the patient and circumstances (the day and time of the day of the telephone call). The convergence between user intent and medical recommendation consists in adequate demand; otherwise the divergence consists in an inadequate one. In this way, using a logistic regression model, the critical factors that determine inappropriate health services request could be estimated.

Results

In general, the user’s initial intent is the most critical for the inappropriate health system demand occurrence: the greater the complexity of the patient’s initial intent, the greater the chance the intent is wrong: (OR: 1.160; 95% CI: 1.113-1.210). With regard to the social characteristics, men are more likely to make inappropriate requests (OR: 1.102; 95% CI: 1038-1169); as well as youngsters are more likely to use the system incorrectly (OR = .993; 95% CI: .992 - .994). Regarding the circumstances (day and time of the call), requests in the final hours of the day and on days close to the weekend are more likely to be the inappropriate ones (OR: 1.082 for each six hour increase; 95% CI: 1.049-1.116) and weekday (OR: 1.017 for each day increase; 95% CI: 1.002-1.032).

Conclusions

The critical profile for the inappropriate use occurrence consists of males and youngsters, who use the health service in the final hours of the day and at weekends, and mainly want to use more complex services. A practical implication of this research is to provide health systems managers, supporting information to the most critical users in order to assist them in making a decision when asking for health care.

Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support

Background

Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN^©.

Methods

We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety.

Results

Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68).

Conclusions

CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.

Teleconsultation in children with abdominal pain: a comparison of physician triage recommendations and an established paediatric telephone triage protocol

Background

Quality assessment and continuous quality feedback to the staff is crucial for safety and efficiency of teleconsultation and triage. This study evaluates whether it is feasible to use an already existing telephone triage protocol to assess the appropriateness of point-of-care and time-to-treat recommendations after teleconsultations.

Methods

Based on electronic patient records, we retrospectively compared the point-of-care and time-to-treat recommendations of the paediatric telephone triage protocol with the actual recommendations of trained physicians for children with abdominal pain, following a teleconsultation.

Results

In 59 of 96 cases (61%) these recommendations were congruent with the paediatric telephone protocol. Discrepancies were either of organizational nature, due to factors such as local referral policies or gatekeeping insurance models, or of medical origin, such as milder than usual symptoms or clear diagnosis of a minor ailment.

Conclusions

A paediatric telephone triage protocol may be applicable in healthcare systems other than the one in which it has been developed, if triage rules are adapted to match the organisational aspects of the local healthcare system.

[Paediatric emergency triage in Spanish primary care using mobile phones. Analysis of a model in a health area]

OBJECTIVES

To conduct a pilot study of telephone consultation in the paediatric population of an urban health centre. To evaluate the telephone consultation as an effective tool when it comes to exercising prior triage of patients requiring urgent attention.

MATERIAL AND METHODS

The study was conducted in two phases. In the first, data were collected from all calls received for six months. In a second phase, we conducted a telephone intervention study to analyse what a random sample of users remembered of the care provided. All those who requested a telephone consultation were included in the study. Demographic, social-welfare, epidemiological, and clinical features, of each patient were recorded. Data were processed using a statistical package SPSS version 17.0 for Windows.

RESULTS

There were 439 telephone inquiries in our pilot project, of which 35.1% were attended by residents, 36% by paediatricians, and 28.9% by paediatric nurses. There were more telephone calls in the afternoons and on weekends. Patients less than or equal to 2 years accounted for 57.9% of cases handled, and there were no differences between sexes. The most frequent reasons for consultation were gastrointestinal symptoms, fever and respiratory problems. The health problem was resolved in 85.8% of cases, requiring only home care instructions, and only 13.3% of children were referred to emergency services. We obtained a mean score of satisfaction of 9.2.

CONCLUSIONS

The pilot project had a high level of satisfaction and resolution, demonstrating cost savings by reducing 55% of face to face visits, with a saving of 35.2 euros per telephone consultation. A teleconsultation model for dealing with emergencies in primary care by telephone would be comparable to a practice staffed by trained paediatric nurses.

Telehealth nurse practitioner student clinical experiences: an essential educational component for today's health care setting

In order to meet the continuous changes and innovations within the health care system, nurse practitioner faculty must look to the future and prepare nurse practitioner graduates who deliver safe, quality patient care addressing the realities of a global society with a fast-paced expansion of technologies. Preparing nurse practitioner students for practice must include more than information technology knowledge in graduate nursing programs. Formal clinical experiences using various telehealth applications must be integrated into nurse practitioner training. Innovative strategies must be explored by nurse practitioner faculty to assure that graduates can meet the demanding technological demands of our current health care society.

The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis

AIM

This paper is a report of the synthesis of evidence on the appropriateness of, and compliance with, telephone triage decisions.

BACKGROUND

Telephone triage plays an important role in managing demand for health care. Important questions are whether triage decisions are appropriate and patients comply with them.

DATA SOURCES

CINAHL, Cochrane Clinical Trials Database, Medline, Embase, Web of Science, and Psyc Info were searched between 1980-June 2010.

DESIGN

LITERATURE REVIEW

Rapid Evidence Synthesis.

REVIEW METHODS

The principles of rapid evidence assessment were followed.

RESULTS

We identified 54 relevant papers: 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision, and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44-98% and compliance ranged from 56-98%. Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care may have lower compliance than decisions to contact emergency services or self care.

CONCLUSION

Telephone triage services can offer appropriate decisions and decisions that callers comply with. However, the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged.

Patient compliance with telephone triage recommendations: a meta-analytic review

OBJECTIVE

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

METHODS

Findings from 13 studies identified through interdisciplinary research databases (1990-2010) were meta-analyzed. Separate pooled analyses compared patients' compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

RESULTS

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients' intentions and health beliefs.

CONCLUSION

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

PRACTICE IMPLICATIONS

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.

Safety of telephone triage in out-of-hours care: a systematic review

OBJECTIVE

Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.

METHODS

A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem).

RESULTS

Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5-97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7-90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7-49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6).

CONCLUSIONS

There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.

For children leaving the emergency department before being seen by a physician, counseling from nurses decreases return visits

BACKGROUND

Nurses counsel the parents of patients leaving without being seen by a physician (LWBS) about common childhood illnesses. This strategy's impact is not known.

OBJECTIVE

To assess the impact of nurse counseling on ED return visits and outcomes for children who LWBS.

METHODS

This retrospective cohort study used the computerized database of a tertiary care pediatric ED. Participants were all triaged children who LWBS between April 1st 2008 and March 31st 2009. Parents who notified nurses of their intention to leave received information and counseling on when to return. This counseling's occurence was this study's exposure of interest. The control group included patients who LWBS without notification and thus were not counseled. The primary outcome was a return visit to the ED within 48h. Triage level and referral status were used as severity indicators. To demonstrate a 2% difference in return visits (α value 0.05, power 80%), 3213 participants were needed per group.

RESULTS

During the study period, 60,525 patients consulted the ED and 10,323 LWBS; of these, 4639 (45%) received nurse counseling and 5684 (65%) did not. There was a 2.0% (95% CI 1.0, 3.0) decrease in ED return visit proportions between groups. On multiple logistic regression, the counseled group was less likely to return to the ED within 48h.

CONCLUSION

This study suggests that, of patients who LWBS, those who receive counseling by a nurse have less return visits in the following 48h.

Referral to the emergency department by a primary care provider predicts severity of illness

OBJECTIVE

The purpose of this study was to assess whether referral to a pediatric emergency department (PED) by a primary care provider was associated with greater severity of illness, as determined on the basis of clinical measures and increased resource utilization.

METHODS

A retrospective study of data for 121 088 children who presented to a PED with abdominal pain, fever, or respiratory complaints during a 5-year period was performed. Demographic data, referral status, and proxy markers of illness severity were collected from the medical records and analyzed.

RESULTS

A total of 26.3% of all patients seen in the PED presented with these 3 complaint categories. With adjustment for age, gender, race, and insurance class, referred patients were significantly more likely to have high triage acuity designations, higher rates of very abnormal vital signs, and higher admission rates, compared with patients who were self-referred. Referred patients were more likely to undergo testing (laboratory or radiologic), to receive intravenous fluid therapy and pain medications, and to be assigned higher-severity discharge diagnoses, such as appendicitis, septic shock, or status asthmaticus.

CONCLUSIONS

Referral by a primary care provider to a PED was significantly and independently associated with greater severity of illness and resource utilization. Referral status should be considered in algorithms used to triage cases for evaluation in the PED.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median child's age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or caller's part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.

How serious are the symptoms of callers to a telephone triage call centre?

Adverse events such as deaths following telephone triage calls are rare, suggesting that the process is basically safe. However, if calls tend to concern mostly minor illnesses, then adverse events following calls would be uncommon even if the triage process itself was flawed. We investigated hospitalization rates following triage calls and compared them to hospitalization following two other types of medical access, emergency department (ED) visits and office visits. For the Ask Mayo Clinic telephone triage centre, hospitalization rates for adult calls concerning chest pain and abdominal pain were each 13%. Based on national survey data, hospitalization for adult ED visits concerning the same symptoms were 33% (chest pain) and 19% (abdominal pain). Office visits had hospitalization rates significantly lower than triage calls in all age groups, while ED visits had higher hospitalization rates than triage calls in all age groups. There are both qualitative and quantitative similarities between triage calls and ED visits and, using hospitalization as an indicator, some subgroups of triage calls are nearly as serious as ED visits.

Follow-through after calling a nurse telephone advice line: a population-based study

BACKGROUND

Nurse telephone advice (NTA) lines, a major initiative in primary health care reform, provide symptom triage and health information. Compliance studies utilizing database analysis are frequently limited to a defined population, such as children or Emergency Department (ED) users.

OBJECTIVES

To explore caller characteristics associated with following NTA advice to go to the ED, see a health care professional or self-care for Calgary, Canada (population 1 million).

METHODS

NTA data were linked with utilization data to assess ED and physician visits following a call. Four nurse advice categories were defined: go to ED, health care provider in 24 hours, health care provider in 72 hours if symptoms persist and self-care. Follow-through was defined based on health care utilization within specified time periods following the call. Logistic regression identified characteristics associated with follow-through of NTA nurse advice; characteristics included age, sex, neighbourhood income, health status, time of call and type of care protocol.

RESULTS

Follow-through was highest for self-care advice (83.7%), followed by ED advice (52.3%) and then 24-hour advice (43.2%). Lower follow-through on ED or 24-hour advice was associated with age <4 years, and having lower income, and the opposite was true for self-care advice. Patients with a cardiac complaint had the highest odds of following ED advice. Patients with a gastrointestinal or obstetrics/gynaecology/genitourinary complaint were less likely to follow 24-hour advice. Patients with fever were less likely to follow self-care advice.

CONCLUSIONS

Understanding characteristics associated with lower follow-through may help the NTA service to refine its approaches to clients.

The appropriateness of referrals to a pediatric emergency department via a telephone health line

OBJECTIVE

We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral.

METHODS

A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED.

RESULTS

Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, and 347 were physician-referred. Groups were similar at baseline for sex, but health line-referred patients were significantly younger. Using explicitly set criteria, there was no significant difference in visit appropriateness among the health line-referrals (66%), the self- or parent-referrals (77%) and the physician-referrals (73%) (p = 0.11). However, when the examining physician determined visit appropriateness, physician-referred patients (80%) were deemed appropriate significantly more often than those referred by the health line (56%, p < 0.001) or by self- or parent-referral (63%, p = 0.002). There was no significant difference between these latter 2 referral routes (p = 0.50). In keeping with their greater acuity, physician-referred patients were significantly more likely to have investigations, receive some treatment, be admitted to hospital and have longer lengths of stay. Patients who were self- or parent-referred, and those who were health line-referred were similar to each other in these outcomes.

CONCLUSION

There was no significant difference in visit appropriateness based on the route of referral when we used set criteria; however, there was when we used treating physician opinion, triage category and resource use.

Patient safety and telephone medicine : some lessons from closed claim case review

OBJECTIVES

The telephone can facilitate medical care but also result in adverse outcomes leading to telephone-related malpractice suits. Analyzing claims might identify errors amenable to prevention. The objective of the study was to describe medical errors involving the telephone in patient-clinician encounters that significantly impacted medical care and medico-legal outcomes.

DESIGN

The design of the study was a descriptive, retrospective case review of telephone-related closed malpractice claims that included depositions, expert witness testimony, medical records, allegations, injuries, and outcomes.

PATIENTS/PARTICIPANTS

Forty defendants from 32 cases coded specifically as telephone related by a major provider of malpractice insurance. Leading specialists sued: Internists, pediatricians, and obstetricians.

MEASUREMENTS AND MAIN RESULTS

Cases were reviewed by a physician experienced in telephone medicine and independently checked by a risk management nurse specialist and discussed by 2 additional risk management analysts before arriving at full agreement. Twenty-four (60%) cases were settled or awarded to the plaintiff. The most common allegation was failed diagnosis (68%), most common injury was death (44%), and most common setting was general medicine ambulatory practice. Leading errors were documentation (88%) and faulty triage (84%). The average indemnity was $518,932, with a total indemnity of $12,454,375.

CONCLUSIONS

Telephone-related claims were costly; injuries were catastrophic. Poor documentation and faulty triage were major factors influencing care and legal outcome. Telephone errors may represent the tip of the iceberg in patient safety in ambulatory practice; however, these preliminary results need to be confirmed in a larger sample of cases.

The host hospital 24-hour underreferral rate: an automated measure of call-center safety

OBJECTIVES

The goals were to (1) define and illustrate an automated method of monitoring the safety of telephone triage, (2) demonstrate that this method approximates reasonably a more-global safety measure, and (3) describe the month-to-month variability of this automated measure for the call center studied.

METHODS

From October 2005 through March 2006, hospitalizations at a tertiary care pediatric hospital after calls to its call center were matched with their respective call-center dispositions. The host hospital 24-hour underreferral rate was defined as the percentage of total admissions to the study institution within 24 hours after a call to the call center for treatment of the same illness or injury that had been assigned a nonurgent disposition by the call center. A convenience sample of call-center calls was surveyed for admissions to other facilities. This sample was then combined with admissions to the pediatric hospital to estimate a true 24-hour underreferral rate. Underreferrals were subjected to clinical and statistical analyses.

RESULTS

The host hospital 24-hour underreferral rate was 5.2%. The estimated true 24-hour underreferral rate was 5.95% +/- 2.75%. Diagnoses frequently associated with underreferral were gastroenteritis, croup, asthma, and bronchiolitis. Underreferred patients admitted to the study institution were hospitalized for an average of 1.6 +/- 1.1 days, compared with 2.8 +/- 3.1 days for patients referred by the call center to a higher level of care. The monthly SD of the host hospital 24-hour underreferral rate was 1.56%.

CONCLUSIONS

For the call center studied, the host hospital 24-hour underreferral rate could be determined easily and objectively and approximated reasonably the true 24-hour underreferral rate. The month-to-month variability of the host hospital 24-hour underreferral rate was sufficiently small to allow for meaningful internal trending analyses.

Pediatric telephone call centers: how do they affect health care use and costs?

OBJECTIVES

After-hours call centers have been shown to provide appropriate triage with high levels of parental and provider satisfaction. However, few data are available on the costs and outcomes of call centers from the perspective of the health care system. With this study we sought to determine these outcomes.

METHODS

Parents who called the Pediatric After-hours Call Center at the Children's Hospital of Denver from March 19, 2004, to April 19, 2004, were asked an open-ended question before triage: "We would like to know, what you would have done if you could not have called our call center this evening/today?"

RESULTS

The response rate for the survey was 77.8% (N = 8980). Parents reported that they would have (1) gone to an emergency department or urgent care facility (46%), (2) treated the child at home (21%), (3) called a physician's office the next day (12%), (4) asked another person for advice (13%), (5) consulted a written source (2%), or (6) other (7%). Of the 46% of callers who would have sought emergent care, only 13.5% subsequently were given an urgent disposition by the call center. Fifteen percent of cases in which the parents would have stayed at home were given an urgent disposition by nurses. Assuming that all callers followed the advice provided, the estimated savings per call, based on local costs, was 42.61 dollars per call. Savings based on Medical Expenditure Panel Survey national payment data were 56.26 dollars per call.

CONCLUSIONS

Two thirds of the cases in which parents reported initial intent to go to an emergency department or urgent care facility were not deemed urgent by the call center, whereas 15% of calls from parents who intended to stay home were deemed urgent. If call-center triage recommendations were followed in even half of all cases, then these results would translate into substantial cost savings for the health care system.