A Comparison Between Computer-Assisted Self-Triage by Patients and Triage Performed by Nurses in the Emergency Department

How Virtual Triage Can Improve Patient Experience and Satisfaction: A Narrative Review and Look Forward

Objective

To complete a review of the literature on patient experience and satisfaction as relates to the potential for virtual triage (VT) or symptom checkers to enhance and enable improvements in these important health care delivery objectives.

Methods

Review and synthesis of the literature on patient experience and satisfaction as informed by emerging evidence, indicating potential for VT to favorably impact these clinical care objectives and outcomes.

Results/Conclusions

VT enhances potential clinical effectiveness through early detection and referral, can reduce avoidable care delivery due to late clinical presentation, and can divert primary care needs to more clinically appropriate outpatient settings rather than high-acuity emergency departments. Delivery of earlier and faster, more acuity level-appropriate care, as well as patient avoidance of excess care acuity (and associated cost), offer promise as contributors to improved patient experience and satisfaction. The application of digital triage as a front door to health care delivery organizations offers care engagement that can help reduce patient need to visit a medical facility for low-acuity conditions more suitable for self-care, thus avoiding unpleasant queues and reducing microbiological and other patient risks associated with visits to medical facilities. VT also offers an opportunity for providers to make patient health care experiences more personalized.

Triage and Diagnostic Accuracy of Online Symptom Checkers: Systematic Review

BACKGROUND

In the context of a deepening global shortage of health workers and, in particular, the COVID-19 pandemic, there is growing international interest in, and use of, online symptom checkers (OSCs). However, the evidence surrounding the triage and diagnostic accuracy of these tools remains inconclusive.

OBJECTIVE

This systematic review aimed to summarize the existing peer-reviewed literature evaluating the triage accuracy (directing users to appropriate services based on their presenting symptoms) and diagnostic accuracy of OSCs aimed at lay users for general health concerns.

METHODS

Searches were conducted in MEDLINE, Embase, CINAHL, Health Management Information Consortium (HMIC), and Web of Science, as well as the citations of the studies selected for full-text screening. We included peer-reviewed studies published in English between January 1, 2010, and February 16, 2022, with a controlled and quantitative assessment of either or both triage and diagnostic accuracy of OSCs directed at lay users. We excluded tools supporting health care professionals, as well as disease- or specialty-specific OSCs. Screening and data extraction were carried out independently by 2 reviewers for each study. We performed a descriptive narrative synthesis.

RESULTS

A total of 21,296 studies were identified, of which 14 (0.07%) were included. The included studies used clinical vignettes, medical records, or direct input by patients. Of the 14 studies, 6 (43%) reported on triage and diagnostic accuracy, 7 (50%) focused on triage accuracy, and 1 (7%) focused on diagnostic accuracy. These outcomes were assessed based on the diagnostic and triage recommendations attached to the vignette in the case of vignette studies or on those provided by nurses or general practitioners, including through face-to-face and telephone consultations. Both diagnostic accuracy and triage accuracy varied greatly among OSCs. Overall diagnostic accuracy was deemed to be low and was almost always lower than that of the comparator. Similarly, most of the studies (9/13, 69 %) showed suboptimal triage accuracy overall, with a few exceptions (4/13, 31%). The main variables affecting the levels of diagnostic and triage accuracy were the severity and urgency of the condition, the use of artificial intelligence algorithms, and demographic questions. However, the impact of each variable differed across tools and studies, making it difficult to draw any solid conclusions. All included studies had at least one area with unclear risk of bias according to the revised Quality Assessment of Diagnostic Accuracy Studies-2 tool.

CONCLUSIONS

Although OSCs have potential to provide accessible and accurate health advice and triage recommendations to users, more research is needed to validate their triage and diagnostic accuracy before widescale adoption in community and health care settings. Future studies should aim to use a common methodology and agreed standard for evaluation to facilitate objective benchmarking and validation.

TRIAL REGISTRATION

PROSPERO CRD42020215210; https://tinyurl.com/3949zw83.

The use of kiosks to improve triage efficiency in the emergency department

Triage is a system used to prioritise patients as they enter the emergency department (ED) based on their need for urgent care. In recent decades, EDs have becoming increasingly overcrowded, leading to longer pre-triage waiting times for patients. E-triage interventions like kiosks have been proposed as a solution to overcrowding. We conducted a literature review into the effectiveness of kiosks in improving triage efficiency. After rigorously searching five biomedical databases and screening candidate articles in Endnote, we identified nine papers pertaining to the introduction of kiosks in emergency departments. Six articles had positive findings-with E-triage interventions improving some aspect of the triage process-such as reducing pre-triage times. Conversely, only three articles reported negative findings, such as low uptake. Consequently, EDs should consider introducing kiosks to complement the current nurse-led triage process and thereby promote better patient outcomes.

Triage Capability of Laypersons: Retrospective, Exploratory Analysis (Preprint)

Background

Although medical decision-making may be thought of as a task involving health professionals, many decisions, including critical health–related decisions are made by laypersons alone. Specifically, as the first step to most care episodes, it is the patient who determines whether and where to seek health care (triage). Overcautious self-assessments (ie, overtriaging) may lead to overutilization of health care facilities and overcrowded emergency departments, whereas imprudent decisions (ie, undertriaging) constitute a risk to the patient’s health. Recently, patient-facing decision support systems, commonly known as symptom checkers, have been developed to assist laypersons in these decisions.

Objective

The purpose of this study is to identify factors influencing laypersons’ ability to self-triage and their risk averseness in self-triage decisions.

Methods

We analyzed publicly available data on 91 laypersons appraising 45 short fictitious patient descriptions (case vignettes; N=4095 appraisals). Using signal detection theory and descriptive and inferential statistics, we explored whether the type of medical decision laypersons face, their confidence in their decision, and sociodemographic factors influence their triage accuracy and the type of errors they make. We distinguished between 2 decisions: whether emergency care was required (decision 1) and whether self-care was sufficient (decision 2).

Results

The accuracy of detecting emergencies (decision 1) was higher (mean 82.2%, SD 5.9%) than that of deciding whether any type of medical care is required (decision 2, mean 75.9%, SD 5.25%; t_>90=8.4; P<.001; Cohen d=0.9). Sensitivity for decision 1 was lower (mean 67.5%, SD 16.4%) than its specificity (mean 89.6%, SD 8.6%) whereas sensitivity for decision 2 was higher (mean 90.5%, SD 8.3%) than its specificity (mean 46.7%, SD 15.95%). Female participants were more risk averse and overtriaged more often than male participants, but age and level of education showed no association with participants’ risk averseness. Participants’ triage accuracy was higher when they were certain about their appraisal (2114/3381, 62.5%) than when being uncertain (378/714, 52.9%). However, most errors occurred when participants were certain of their decision (1267/1603, 79%). Participants were more commonly certain of their overtriage errors (mean 80.9%, SD 23.8%) than their undertriage errors (mean 72.5%, SD 30.9%; t_>89=3.7; P<.001; d=0.39).

Conclusions

Our study suggests that laypersons are overcautious in deciding whether they require medical care at all, but they miss identifying a considerable portion of emergencies. Our results further indicate that women are more risk averse than men in both types of decisions. Layperson participants made most triage errors when they were certain of their own appraisal. Thus, they might not follow or even seek advice (eg, from symptom checkers) in most instances where advice would be useful.