Assessing communication skills of clinical call handlers working at an out-of-hours centre: development of the RICE rating scale

BACKGROUND

Out-of-hours centres provide telephone support to patients with medical problems. In most of these centres specially-trained nurses handle incoming telephone calls. They assess patients' needs, the degree of urgency, and determine the level of care required. Assessment of the medical problem and the quality of 'care-by-phone' depend on the medical and communication skills of the call handlers.

AIM

To develop a valid, reliable, and practical rating scale to evaluate the communication skills of call handlers working at an out-of-hours centre and to improve quality of communication.

DESIGN OF STUDY

Qualitative study with focus groups followed by validation of the rating scale and measurement of reliability (internal consistency).

SETTING

Out-of-hours centres in the Netherlands.

METHOD

A focus group developed the rating scale. Experts with experience in training and evaluating communication skills of medical students and GPs commented on the scale to ensure content validity. The reliability of the rating scale was tested in a pilot in which ten specially-trained assessors scored six telephone calls each.

RESULTS

The scale, known as the RICE rating scale, has 17 items divided over four different phases of the telephone consultation: Reason for calling; Information gathering; Conclusion; and Evaluation (RICE). Content validity of the scale was assessed by two experts. Reliability of the scale tested in the pilot was 0.73 (Cronbach's alpha).

CONCLUSION

Establishing a rating scale to assess the communication skills of call handlers which meets common scientific demands, such as content validity and reliability, proved successful. This instrument can be used to give feedback to call handlers.

Evaluation of telephone CPR advice for adult cardiac arrest patients

INTRODUCTION

Telephone cardiopulmonary resuscitation (CPR) advice aims to increase the quality and quantity of bystander CPR, one of the few interventions shown to improve outcome in cardiac arrest. We evaluated a current telephone protocol (based on 2000 ILCOR guidelines) to assess the effectiveness of verbal CPR instructions.

METHODS

Emergency calls were identified from AMPDS codes for cardiac arrest and checked against the ambulance patient record form to confirm the diagnosis. Calls over a seven month period were analysed retrospectively, and the time taken to perform interventions calculated.

RESULTS

176 calls were analysed; of those 145 (82.4%) were confirmed cases of cardiac arrest. CPR was already underway in 11 cases (7.5%), 101 callers (69.7%) agreed to attempt CPR with telephone instructions. The median time to open the airway was 128s (62-482s), to perform the first ventilation was 247s (80-633s), and to perform the first chest compression was 315s (153-750s). Of those attempting CPR, 21 (20.8%) stopped because they were unable to move the patient onto a hard surface, and 28 (27.7%) required multiple attempts to perform effective ventilations. In the telephone CPR group 42/101 (40.6%) did not receive any chest compressions before the arrival of the ambulance crew.

CONCLUSIONS

Although current telephone-CPR instructions significantly improve the numbers of patients in whom bystander CPR is attempted, significant delays and poor quality CPR are likely to limit any benefits.

Analysis of a national toll free suicide crisis line in South Africa

The first national toll free suicide crisis line for South Africa was launched in October 2003 with the aim of providing a service dedicated to the prevention of suicide in this country. The intervention was motivated by South Africa's suicide rate which had risen higher than the global suicide rate, with the majority of attempted suicides occurring among people younger than 35 years of age (WHO, 2002). Demographic characteristics of callers were identified to evaluate the perceived helpfulness of this crisis line, so as to inform planning and implementation of future suicide prevention programs. Results showed that the majority of callers were female; between the ages of 16 and 18 years; and lived in the provinces of Gauteng, North West, or KwaZulu Natal. Callers were more likely to be from urban than rural areas; were still at school, unemployed, or studying at a tertiary institution; and had not previously attempted suicide. The majority of participants did perceive the crisis line as helpful. The continued collection of demographic data from the crisis line is recommended so that South Africa can create an updated database of areas and sectors of the population that require suicide intervention, and for planning and implementing suicide prevention programs in this country.

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: determinants of a negative evaluation

OBJECTIVE

The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives.

METHODS

A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands.

RESULTS

The total response was 49.3% (2583/5239). Negative evaluations were most frequently encountered for the general information received on the GP cooperative (35%). When patients expected a centre consultation or home visit, but only received a nurse telephone consultation, they were more negative about the accessibility (OR 1.7, CI 1.4-2.1) and nurse telephone consultation (OR 4.2, CI 3.2-5.6). In the presence of a special supervising telephone doctor at the cooperative's call centre, nurse telephone consultation was evaluated significantly less negative (OR 0.4, CI 0.2-0.8).

CONCLUSION

Expectation of care mode was most strongly associated with a negative evaluation of nurse telephone consultation. The presence of a supervising telephone doctor may lead to a better evaluation of nurse telephone consultations.

PRACTICE IMPLICATIONS

More attention should be paid to the provision of patient information on the GP cooperative and discrepancies between the care expected and the care offered.

Impact of a continuing education activity on the quality of telephone interventions by nurses in an adult asthma client base

The objectives of this study were to evaluate the effect of a continuing education activity on the clinical evaluation and advice provided by nurses working for a telephone triage service with an asthmatic client base, and to measure the number of referrals to Asthma Education Centers (AECs). The results suggest a positive impact on the quality of the telephone intervention in the short term, but this was not sustained over time. Few patients were referred to an AEC.

Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Rheumatology telephone helplines: patient and health professionals' requirements

OBJECTIVES

The aim of this study was to ascertain patients' and health professionals' requirements from a rheumatology helpline and how such a service should be delivered.

METHODS

Self-completed questionnaires were administered to both users of rheumatology helplines, patients and health professionals (HPs), and providers of rheumatology services at five UK NHS trusts. Additional data were sought from experts in the field. Information was elicited on access to the service, preferred waiting time for response to a call, acceptability of an answerphone and choice of HP responding. Quantitative data were analysed using percentages and Chi-squared tests. Open questions were analysed as free text responses, and organized into clusters of themes.

RESULTS

A total of 607 questionnaires were returned, 523 from users (411 patients, 112 health professionals) and 84 from providers. There were no significant differences across the five Trusts. The top six reasons for patients contacting the helpline were: advice on changes in condition, drug information, understanding symptoms, blood results, information on diagnosis, and appointment queries. All groups recommended a return call on the same day and were happy to leave an answerphone message. HP users requested additional access via e-mail and fax. Rheumatology practitioners were deemed the most appropriate personnel to staff a helpline.

CONCLUSIONS

The findings of this study have contributed a valuable insight into the essential components of a rheumatology helpline service from a user and provider perspective. These data will add to existing recommendations for the management of a rheumatology helpline service and ultimately contribute to a proposal for national guidelines.

A critical account of obtaining research governance approval

Research governance strategies, as currently operated are potentially limiting the conduct of research, especially multi-centre studies. The authors provide an overview of the current research governance framework in the UK and, using the example of one study as an illustrative case, describe and discuss a research team's experience of gaining research governance approval for a multi-centre study.

Use and effectiveness of tobacco telephone counseling and nicotine therapy in Maine

BACKGROUND

Since 2001, the Maine Bureau of Health has offered free evidence-based treatment for tobacco dependence, including telephonic counseling and nicotine replacement therapy (NRT). This study examined the utilization of treatment services, evaluated quit outcomes, and estimated the population impact of treatment.

METHODS

This is a descriptive study of tobacco users receiving treatment services from the Maine Tobacco HelpLine from January 2003 to December 2004. Demographics of callers were compared to adult smokers statewide, and NRT utilization was examined among callers eligible for therapy. Quit outcomes were assessed by telephone interview among a sample of callers registered November 15, 2003 to January 31, 2004 (n=535), 6 months after assistance. The population impact of treatment was estimated by applying intent-to-treat (30-day point prevalence) quit rates to services delivered in 2003 and 2004. Analyses were conducted in 2005.

RESULTS

A total of 12,479 adult smokers (3% of smokers annually) utilized Maine's tobacco services during 2003 and 2004. Compared to smokers statewide, callers were more likely to be aged 45 to 64, female, or uninsured. A total of 82.3% of callers who were eligible for NRT and received counseling obtained free NRT. Intent-to-treat quit rates at 6 months were 12.3% (95% confidence interval [CI]=8.1-17.6) for counseling, and 22.5% (95% CI=19.1-26.3) for counseling plus NRT. An estimated 1864 smokers calling in 2003-2004 had successfully quit.

CONCLUSIONS

The Maine Tobacco HelpLine and NRT programs have demonstrated effectiveness and population outreach, particularly to uninsured smokers. This study suggests that for quit lines to maximize their impact, tobacco medication access may be important.

It's good to talk: comparison of a telephone helpline and website for cancer information

The Internet plays an important role in the information gathering process for people affected by cancer. This paper presents the results of a study comparing two sources of cancer information; a website and a telephone helpline. Data were captured on the use of one section of the UK charity CancerBACUP's website, and systematically compared to data collected from every fifth user of the charity's helpline. Subjects of enquiry for 994 telephone enquiries and 3096 web enquiries were comparable. The majority of enquiries to both services were about women and/or patients aged 50 or older. Website users were more likely than helpline users to request factual information and less likely to request information on sensitive topics. This study provides valuable information about the types of health information people seek from different sources and how the sources may complement each other.

In the public interest: autonomy and resistance to methods of standardising nurses' advice and practices from a health call centre in Perth, Western Australia

The history of nursing is replete with examples of nurses battling for autonomy over their education, knowledge and work practices. The latest battleground is HealthDirect, Australia's first medial call centre, where nurses are required to meet externally imposed clinical standards while satisfying legal and financial obligations. These objectives are arguably achieved when nurses assess callers' health problems via computerised algorithms that determine an appropriate plan of action. That way, nurses' subjective responses to callers are ruled out. To ensure nurses comply with the standard processes, calls are monitored randomly and surreptitiously in formal and informal ways. This paper explores how nurses respond to standard procedures and surveillance, in order to argue that nurses' input partially drives reform processes. Nurses continue to seek autonomy over the advice they give and how their work is evaluated but are constrained by structural power relations.

Outcomes of a nurse-led telephone triage service in Australia

This paper reports on a study which comprised the first comprehensive evaluation of the Kids Kare Line telephone triage service in which experienced registered nurses respond to parents' requests for health-care advice for their child. This service is located in an acute care hospital in regional New South Wales, Australia. One hundred and one parents who telephoned the Kids Kare Line responded to a telephone-administered survey designed to determine the service's efficiency and effectiveness. Responses demonstrated that parents sought advice about a range of issues, of which the management of fever was the most frequent. All but five parents considered their call to have been answered promptly, all parents understood the advice provided to them and 96% of parents were satisfied with this advice. Fifty parents identified that they had not used another service or health practitioner for the same issue subsequent to their Kids Kare Line telephone call.

Evaluation of the Dutch AIDS information helpline: an investigation of information needs and satisfaction of callers

AIDS telephone hotlines have an important function in AIDS education, HIV prevention and counselling. In this study, consults of the Dutch AIDS information helpline were evaluated to determine the AIDS information needs of the callers and callers' satisfaction with the telephone-delivered information and consultation. Immediately after their telephone consult, callers (N = 309) were redirected to co-workers of an independent telephone survey. They participated in an interview on content and evaluation of the telephone consult. This study shows that most telephone calls concerned questions about personal risk of HIV transmission, HIV transmission in general and HIV testing. Callers were very satisfied with the services of the helpline. Furthermore, helpline employees' counselling and conversation skills were evaluated very positively. These results are discussed within the scope of the professional organization of the Dutch AIDS information helpline.

Outcomes associated with pediatric after-hours care by call centers: a multicenter study

OBJECTIVES

To assess 1) parental opinion regarding appropriateness of triage, 2) utilization outcomes, and 3) the frequency of underreferral with subsequent hospitalization for children triaged by nurses at pediatric call centers.

DESIGN/METHODS

From August 19 to October 1999, after-hours calls were randomly sampled from computerized records at 4 call centers at children's hospitals. Telephone surveys were conducted 3 to 7 days after the index calls. An expert panel to assess appropriateness of disposition reviewed audio recordings of calls given a nonurgent disposition and then hospitalized within 24 hours.

RESULTS

Surveys were completed for 70.5% (N = 1561). Parental agreement with urgent or home care recommendations was >70% but with intermediary recommendations was <50%. Hospitalizations were more common among children urgently referred (4.6% vs 0.45%; P =.0003). Calls judged urgent by call center nurses and referred to a physician for secondary triage had lower rates of urgent visits (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.53-0.65; P <.0001) and higher rates of never having a visit (OR 1.37; 95% CI 1.24-1.51; P <.0001) than those referred directly by nurses. The weighted rate of underreferral with hospitalization was 0.3% (95% CI 0.1-0.7%) or 1 in 481 calls (95% CI 1/152 to 1/1538).

CONCLUSIONS

Our data demonstrate an underreferral rate with subsequent hospitalization of 1 in 500 calls and a significant reduction in visits when those cases judged urgent by call center nurses undergo secondary triage by physicians.

Advice nursing practice: on the quality of the evidence

OBJECTIVE

The primary objective was to review the research regarding advice nursing practice to determine the content areas investigated and the quality of the evidence.

METHODS

A systematic review of advice nursing research was done in electronic databases, reference lists, and the literature identified by experts (N = 527). After deletion of duplicates and clinical and theoretical articles, full text reviews were done on 62 studies.

RESULTS

Eight thematic content areas were identified: delivery and continuity of care to populations, appropriateness of advice given, patient/provider satisfaction, disposition/utilization after calls, reason for calling, cost analysis, process of decision-making, and documentation. The most frequently investigated subject was delivery/continuity of care (n = 16).

IMPLICATIONS

For certain chronic disease populations, interventions using telephone advice for social support, education, and symptom management improve clinical outcomes. Availability and use of protocols and guidelines do not guarantee standardized care or ensure that appropriate advice will be given. Consumer satisfaction with advice nursing is high, and appears to be related to the intervention component of the nursing process. The priority for future research should be given to those studies that describe the character and suitable dose of the nursing intervention that is advice nursing.

NHS Direct: consistency of triage outcomes

OBJECTIVES

To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct.

METHODS

119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System.

RESULTS

The overall level of agreement between the nurses using the four systems was "fair" rather than "moderate" or "good" (kappa=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services.

CONCLUSIONS

There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved.

Computerized telephone nurse triage. An evaluation of service quality and cost

The current reimbursement structure of health care in the United States motivates the providers of health care services to deliver these services with a cost-conscious mentality without compromising quality. This has led to the development of alternative methods of delivering health care services, one of which is computerized telephone nurse triage. This study investigates service quality from the perception of callers who used this system on behalf of a pediatric client. Cost was evaluated by comparing what the caller would have done if they did not speak with nurse triage with what they actually did after their interaction. A modified version of the SERVQUAL tool was administered via telephone survey to members of a managed health care plan who recently used nurse triage services for a pediatric patient. Findings were that the majority of callers--employed female parents--rated the level of service quality very highly. Education, employment status, age of the caller, child gender, birth order among siblings, and age of child did not affect the rating of service quality. Relationship to the child had an effect on the rating of service quality as men/fathers rated the level of service quality slightly lower than their female/mother counterparts. The evaluation of cost revealed that the action taken by the caller after they spoke with the nurse resulted in significant cost savings. Computerized telephone nurse triage is a well-accepted cost-saving alternative method of health care delivery that can effectively serve a variety of callers and pediatric patients.

A model for examining predictors of outcomes of telephone nursing advice

Although telephone advice nursing is the fastest-growing nursing specialty, useful information to guide managers' decisions about how best to structure and support advice services to achieve desired outcomes is unavailable. We identified issues and variables relevant to outcomes of telephone advice from the perspectives of callers, nurses, and the system. Subsequently, we derived a model for studying factors affecting nursing advice outcomes that will help managers identify modifiable factors to improve outcomes of care.

Caller satisfaction with after-hours telephone advice: nurse advice service versus on-call pediatricians

OBJECTIVE

To compare caller satisfaction with after-hours medical advice provided by a for-profit nurse advice service with advice provided by on-call pediatricians.

METHODS

The study setting was the general pediatrics faculty practice of an urban university medical center. Participants were parents or guardians of a population of approximately 6000 children calling for after-hours medical advice over a 10-month period from January 18 to November 20, 2000. After-hours medical advice calls were randomized to either a nurse advice service or the on-call pediatrician. Caller satisfaction and subsequent health care utilization were measured by a telephone survey of callers and review of all health care visits within 3 days of the initial telephone advice call.

RESULTS

Five hundred sixty-six (48%) callers were enrolled in the on-call pediatrician group, and 616 (52%) were enrolled in the advice nurse group. Caller satisfaction was rated as very good or excellent significantly more often for the on-call pediatrician than for the nurse advice service as follows: telephone call overall (68.5% vs 55.0%; 95% confidence interval [CI] of difference: 8.0%-19.0%), thoroughness and competence of the person they spoke with (74.0% vs 59.1%; 95% CI of difference: 9.6%-20.2%), courtesy and friendliness of the person they spoke with (77.4% vs 73.9%; 95% CI of difference: -1.4%-8.4%), length of time spent waiting (70.8% vs 60.1%; 95% CI of difference: 5.4%-16.2%), time spent talking with the on-call pediatrician or advice nurse (68.2% vs 52.4%; 95% CI of difference: 10.2%-21.3%), and the medical advice given (68.6% vs 53.9%; 95% CI of difference: 9.2%-20.1%). Compliance with the advice given was significantly higher for office care in the on-call pediatrician group (51.5% vs 29.6%; 95% CI of difference: 8.9%-34.2%). Repeat calls for advice were significantly more frequent for the nurse advice service, both within 4 hours (13.0% vs 4.8%; 95% CI of difference: 5.0%-11.4%), and within 72 hours (23.4% vs 13.3%; 95% CI of difference: 5.8%-14.5%).

CONCLUSION

Callers were less satisfied with medical advice provided by a nurse advice service compared with the traditional on-call pediatrician. The lower satisfaction was associated with somewhat poorer compliance with recommended triage dispositions and more frequent repeat calls for medical advice.

Evaluating quality of telehealth advice nursing

Despite an increased interest in advice nursing, the quality of care has not been addressed. This article examines the quality of the nursing process (including problem identification, care planning, intervention, and evaluation) and its relationship to patient (consumer) outcomes. A sample of 157 nonredundant telephone calls from adults with medical-surgical problems were audiotaped, with providers' and callers' consent, and were rated through an implicit review method by registered nurse raters. The quality of the nursing process was found to be the best in the area of intervention. Patient (consumer) satisfaction was high with 95.4% of the consumers rating the calls as completely or at least somewhat satisfying, and 93.2% stating the advice was very or somewhat helpful. This study pioneers a way to rate the quality of advice nursing and lays the groundwork for further investigations of health care provider behavior and consumer outcomes.