An observational study comparing quality of care in walk-in centres with general practice and NHS Direct using standardised patients

OBJECTIVES

To compare the quality of clinical care in walk-in centres with that provided in general practice and by NHS Direct.

DESIGN

Observational study involving assessment of clinicians by standardised patients.

SETTING

20 walk-in centres, 20 general practices, and 11 NHS Direct sites.

PARTICIPANTS

297 consultations with standardised patients, 99 in each setting, carried out by professional role players trained to play five clinical scenarios (postcoital contraception, chest pain, sinusitis, headache, and asthma).

MAIN OUTCOME MEASURES

Primary outcomes were mean scores on consensus derived checklists of essential items for the management of the clinical scenarios. Data were also collected on access to and referral by walk-in centres, general practices, and NHS Direct.

RESULTS

Walk-in centres achieved a significantly greater mean score for all scenarios combined than general practices (difference between groups 8.2, 95% confidence interval 1.7 to 14.6) and NHS Direct (10.8, 5.5 to 16.1). There was considerable between scenario variation, with walk-in centres performing particularly well on postcoital contraception and asthma scenarios. In contrast to general practices, walk-in centres and NHS Direct referred a higher proportion of patients (26% and 82%, respectively).

CONCLUSION

Walk-in centres perform adequately and safely compared with general practices and NHS Direct for the range of conditions under study, but the impact of referrals on workload of other healthcare providers requires further research.

HealthConnect: a trial of an after-hours telephone triage service

This paper describes HealthConnect, an after-hours telephone triage and advice service which operated for 15 months in 2000 and 2001. We describe the service, discuss utilisation and implementation issues, and conclude with a description of the key lessons learned from the trial. The service received over of 12,000 calls, of which over half were for information rather than immediately seeking care. Continuing marketing appears to be required in order to ensure ongoing demand for services of this kind. Quality assurance is essential to ensure that an optimal service is provided, and staff recruitment and training are critical to this. A national standardised approach to services of this kind is desirable to provide a consistent service to consumers and realise economies of scale.

Dialing 911: a call to action

Cardiovascular disease and stroke are the nation's leading causes of disability and death. Scientific advances have provided newer treatments that, when applied effectively and in time, save a significant number of lives. Multiple factors in our system of delivery impede our ability to apply effective treatments, but with an analysis of the components of care, each of us can take leadership roles in our communities to improve the chain of survival. These elements and the science supporting each are briefly reviewed.

Use of protocols and guidelines by telephone nurses

Changes in health care delivery, specifically the addition of telephone advice, affect how nurses work and how patients perceive care. It is important to understand the resources available to these nurses, the process by which they provide care, and patient outcomes. This descriptive study describes one type of resource, the availability and use of protocols. It also describes relationships between protocols and the quality of the nursing process and patient outcomes. Two-hundred-three taped calls to 32 advice RNs and 156 patient follow-up calls were used to measure protocol usage, nursing process quality, and patient outcomes. Although protocols were available for 78.8% of the calls, nurses varied in their extent of use (63.9% not fully used). There was a negative relationship (r = -0.395, p < 0.000) between the availability of protocols and overall quality of the nursing process. Protocol availability and use did not affect patient outcomes.

Review of the function of a telephone helpline in the treatment of outpatients with rheumatoid arthritis

OBJECTIVES

To examine the role, acceptability, and cost effectiveness of a telephone helpline organised and run by specialist nurses in a district general hospital outpatient rheumatology department.

MATERIAL AND METHODS

Patients accessed the telephone helpline by leaving a taped message on an answer phone with a 24 hour response time. Assessment included an audit of the nature and outcome of helpline calls, patient satisfaction with the helpline, and a health economic analysis of the helpline operation. A postal questionnaire was used to assess patient satisfaction; this was sent to the 87 patients who called the helpline during one month, and overall satisfaction with the helpline was assessed. The nature and outcome of all calls was analysed retrospectively using a helpline record book for February and October of one year and February of the following year. From the results of the retrospective analysis and an estimate of the number of general practitioner consultations avoided by provision of the helpline, the cost effectiveness of the helpline was calculated.

RESULTS

Of those returning questionnaires, 61/63 (97%) were satisfied with the response time, 63/63 (100%) with the courtesy, and 60/63 (95%) felt that their questions were answered directly and to their satisfaction in 62 (98%) of cases. Had the helpline not been available, 38/63 (60%) patients would have made an appointment with their GP. When these figures were extrapolated to an annual estimation, a basic cost analysis showed that the helpline produced a cost saving to the NHS, largely as a result of GP consultations avoided.

CONCLUSION

Clinical advice and support can be provided by a rheumatology helpline set up as an adjunct to a standard outpatient service. The results of a postal questionnaire suggested more than 95% satisfaction with all aspects of the helpline service and that 99% of callers would call the helpline again. The provision of the helpline service contributes to the quality of care provided by an outpatient department and provides benefit to the NHS.

Telephone advice nursing--callers' experiences

We studied telephone callers' experiences of contacting a medical call centre. A questionnaire was administered to 203 persons. It was completed by 144 (71%), of whom 81 (56%) chose to comment on their experience in the space provided. The comments were analysed using a qualitative method and were categorized as relating to either the practical or the emotional aspects of the call. Sixty-nine per cent of comments described a satisfactory experience. The unsatisfactory comments mostly concerned access problems. The callers emphasized the importance of receiving appropriate advice and being treated in a kindly manner. In addition, there were dimensions of security and insecurity in nearly all the categories. The findings highlight the telephone nurses' communication skills and their ability to deal with callers as individuals, to make them feel more secure. The selection, education and training of telephone nurses should place more emphasis on their supportive and communicative roles.

Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance

BACKGROUND

Despite the rapid growth of centralized call centers to provide after-hours triage to patients of multiple providers, little is known about the perceptions of parents regarding this type of care and their compliance with triage disposition recommendations.

DESIGN/METHODS

From August through September 1999, randomized samples of after-hours calls were selected each day from computerized records at 4 pediatric call centers at 1) Children's Hospital, Denver, Colorado; 2) Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; 3) Rainbow Babies and Children's Hospital, Cleveland, Ohio; and 4) All Children's Hospital, St Petersburg, Florida. All participating call centers use the same triage software. Calls were randomly selected to yield at least 250 callers with nonurgent dispositions and 100 with urgent dispositions from each site. Telephone surveys to callers were conducted by an external survey unit 3 to 7 days after the call to the call center.

RESULTS

Surveys were completed for 70.5% of those sampled (N = 1561). Parents indicated they were very satisfied or satisfied with aspects of care received from 92.6% (waiting time) to 99.4% (nurse courteousness) of the time. Satisfaction did not differ by site or by recommended disposition of the index call. Most parents (65.2%) reported no preference about speaking with a physician or nonphysician for after-hours care, whereas 27.7% preferred to speak with a physician. Usually speaking with a physician during office hours (odds ratio [OR]: 1.48), feeling it was important that provider knows child's medical history (OR: 3.47), and respondent having an educational level of college graduate or higher (OR: 1.30) were significant predictors of preferring to speak with a physician. Of the 37.0% (N = 723) of parents who reported any change in their relationship with their primary provider as a result of the after-hours call center, 95.7% (N = 691) assessed the change to be positive. Reported compliance with the call center disposition recommendation was 83.3% for urgent referral, 41.0% for next day, 4.5% for visit at a later time, and 78.2% for home care. The major reason given by parents for noncompliance was reporting that they heard a different disposition (76.9% for urgent to 100% for visit at a later time).

CONCLUSIONS

Parental satisfaction with pediatric call centers was uniformly high in 4 different geographic locations, and almost all parents who reported any effect on their relationship with their primary provider assessed it as positive. Compliance with recommendations for urgent evaluation or home care was relatively high but for intermediary dispositions was low. In most cases in which noncompliance occurred, parents reported hearing a different disposition. Additional study is needed to clarify whether noncompliance, especially in cases in which an urgent recommendations was made, is attributable to poor nurse communication of the recommended disposition, parental misinterpretation, or parental difference of opinion.

Perceived support needs of family caregivers and implications for a telephone support service

The purposes of this study were: to identify the perceived support needs of family caregivers of persons living with chronic illness (physical or cognitive) and receiving home-care services, and to describe the types of telephone services that would meet the expressed needs of caregivers. The qualitative design used semi-structured interviews. A total of 34 caregivers (mean age 62 years) participated in the study. The care recipients (mean age 78 years) were primarily the husband/wife or parent of the caregiver. The most commonly expressed caregiver needs were: a social life, instrumental support (e.g., respite, assistance with physical care, financial compensation), informational support, and emotional support. Most caregivers said they would use a telephone support service provided by a professional (71%) or a fellow caregiver (59%) if available. The results of this study support a pilot study and evaluation of a telephone support service for family caregivers.

Assessing therapeutic intervention used by NHS Direct nurse advisers

The National Service Framework for Mental Health has identified NHS Direct as a "new point of access" to appropriate mental health services. Mental health calls account for approximately 4% of all calls received by NHS Direct but raise the greatest level of anxiety among advisers and take twice as long to deal with as other calls. In order to provide adequate advice, it is essential to ensure nurse advisers can deal with this type of call. As a first step in meeting these needs this short research article reports on the types of interventions deployed by 18 nurse advisers during role-plays with a mental health "client" expressing self-harm.

Assessment of a telephone helpline on infertility provided by a patient association

An assessment was made of 161 telephone calls to volunteers of the Dutch association of infertility patients 'Freya'. The unpaid volunteers all had personal experience with infertility. The majority of callers were childless women. On average the callers had been experiencing infertility for 4 years and had already a considerate history of medical examinations. Calls were made throughout the day until late at evening. Most calls were focused at information gathering, especially about the real experience of treatment and the behaviour and quality of medical staff. Also, emotions regarding infertility were an important topic of the conversation. Sometimes informative questions were an introduction for bringing up emotional problems. The telephone helpline appears to be an easily accessible and empathic source of information and help for infertile persons.

Cancer Information Services: a pre-/post-evaluation of training to promote nationwide consistency of information

The object of this study was to evaluate whether an integrated training package improved the consistency and accuracy of advice about breast cancer to callers of Cancer Information Services (CIS) in Australia. The study followed a pre-/post-evaluation design and the participants were all CIS officers from the state-based CIS. A computerized database was used which contained the current best advice about breast cancer combined with a 1-day interactive training workshop for all officers of participating CIS. The proportion of responses that accorded with predetermined model answers for each of five scenarios employed by simulated callers during normal working hours at pre-and post-evaluation were then calculated. There were 95 simulated calls during pre-evaluation, and 104 calls post-evaluation. In some cases, such as breast reconstruction, accordance with model answers was high at both pre- and post-test. The proportion of responses on an item that related to a description of lymphoedaema differed from pre-to post-test with P = 0.007; while an item on the appropriateness of discussing genetic testing with general practitioners differed from pre-to post-test with P = 0.003. There was less concordance, both pre- and post-test, for issues related to surgery, hospitalization, familial aspects and Tamoxifen. We concluded that the intervention presents a method of disseminating consistent information across a number of independent CIS. Some areas were identified that require more targeted intervention.

Telephone contacts with a cancer nurse specialist

AIM

The objective of this study was to audit the nature of telephone consultations with a Macmillan nurse specialist.

METHOD

All calls made to or by a Macmillan nurse over a period of 20 days were analysed in respect of three main areas: symptom management, psychological support and treatment. Information was recorded on a data sheet and then data were collected and descriptive statistics were produced.

RESULTS

The mean length of call was eight minutes. Most calls were incoming and involved patients, followed by relatives and healthcare professionals. The majority of calls involved psychological support, followed by symptom management then treatment.

CONCLUSION

The data show that the Macmillan nurse specialist spends a large amount of time in telephone work, mainly in consultation with patients.

Does NHS Direct deserve its recent criticism?

In recent weeks, NHS Direct has been the subject of critical media coverage (e.g. Financial Times, 2000), following the publication of an investigation by the Consumers' Association (Williams, 2000). Launched on a wave of publicity in 1998, NHS Direct was seen as a strategic plank in the Labour Government's plans for a modern and dependable health service (Department of Health (DoH), 1997).

An audit of out-of-hours advice services provided by hospice staff

For those giving and receiving health care there will always be problems and queries which occur outside of normal office hours. Palliative care is no exception. It was found that Queenscourt Hospice in Southport was being used as an accessible point of contact for specialist palliative care advice by patients, relatives and health professionals. In response, an audit was undertaken to monitor the frequency and substance of the many drop-in visits and telephone calls to the hospice. The results showed that almost half of the calls/visits received are outside office hours. This article describes the nature of the calls and the advice offered by the staff taking the call. As the majority of the 'out-of-hours' calls/visits were taken by nursing staff, it was necessary for them to draw on their specialist palliative care knowledge and communication skills to make an assessment of how best to deal with each situation. As a result of the audit, several organizational and educational initiatives have been developed to further improve the service offered.

Help--we need a helpline! A public health audit case study

Multi-disciplinary public health audit involving whole departments is often perceived as difficult to carry out in areas other than the annual report of the Director of Public Health. This paper describes the audit of an emergency telephone helpline set up during a meningococcal disease outbreak and provides standards that could be applied to any emergency helpline set up in response to issues of public health concern.