Primary care: nurse-led telephone triage and advice out-of-hours

In this article the authors report on the evaluation of an out-of-hours telephone triage and advice service in general practice. A computer-based decision support tool was used to guide nurses in the assessment of patients and outcome for calls. Data from the computer system were analysed for all calls over a six-month period. The researchers found that the nurses were able to handle just over half the calls received by giving advice alone. Overall, the service appeared to be remarkably consistent in the decisions taken by nurses, and training and organisational issues to be considered in the future development of the service were identified.

Telephone helplines. Direct enquiries

A survey of potential users of NHS Direct showed the idea was popular, particularly with parents of children under five, people with long-term illness and carers. Respondents envisaged the main function of the service as providing advice on minor ailments. Most respondents were willing to pay for a local call to ring the service.

Telephone triage--how good are the decisions? (Part 2)

This is the second part of a review of the literature about telephone triage and explores the accuracy and reliability of telephone assessment and advice. The authors identify the need to formalise processes of telephone advice and assessment.

Working out of hours: the experiences and training needs of general practitioner registrars

Out-of-hours work has been identified as a major concern for registrars, and as contributing to the steady decline both in the number of applicants to vocational training schemes and in those practising as principals on completion of their training. Until now, little has been known about registrars' views about their experience of working out of hours and how this might be improved. The present study describes general practitioner (GP) registrars' current patterns of out-of-hours working and their perceptions about training needs.

Emergency department senior house officers' consultation difficulties: implications for training

STUDY OBJECTIVE

We investigated the types of patient presentations that cause senior house officers (SHOs) most difficulty during their tenure in emergency departments and report the extent to which such difficulties are related to SHOs' communication problems, stress, or perceived lack of skills or knowledge.

METHODS

We conducted a questionnaire survey of 171 newly appointed SHOs employed in 27 EDs in the South Thames region of England. Subjects were asked to describe the presentation that gave them greatest difficulty during three subsequent shifts at the end of the first and fourth months of their ED appointment.

RESULTS

A total of 132 (77%) and 110 (64%) respondents returned questionnaires at the end of the first and fourth months, respectively; 61% (105) responded to both questionnaires. The respondents described 537 of a possible total of 726 cases (74%). Communication problems caused difficulty in 406 (76%) cases, SHOs' experience of stress in 352 (66%) cases, and a perceived lack of knowledge or skills in 281 (52%) cases. Communication problems and the experience of stress occurred in 141 (26%) cases. Patients presenting with mental or behavioral disorders and symptoms most frequently gave rise to communication problems, perceived lack of skills, and the experience of stress. The difficulties described at the two time periods were very similar indicating that experience alone had little effect on these problems.

CONCLUSION

ED SHOs may benefit from communication skills training, the opportunity to review difficult case presentations, and the alleviation of organizational stress factors.

Telephone services. Wired for sound

There is some evidence that the British public would like to see an expansion of telephone advice lines. Exact demand is difficult to predict, but some research suggests that 500-1,000 nurses will be needed to staff a national service. The government's timetable for establishing a national service by 2000 is unrealistic.

Primary care in the A & E department: meeting the challenge--a workshop series for A & E nurses

Accident and emergency (A & E) departments lie at the interface between primary and secondary care. Patients who attend the accident and emergency department with primary care needs have traditionally been seen as 'inappropriate' and labelled in pejorative terms. Over the past few years, however, new models of care have emerged through research and practice development for meeting the needs of this group of patients in A & E. For effective service development there is a need to challenge and change the traditional A & E culture. This paper describes an educational approach towards changing clinical practice, by disseminating research and practice development initiatives through a workshop series. It aimed to disseminate research in a relevant manner to practitioners and to develop the primary care orientation of a number of A & E departments in England and Scotland. The workshop series sought to influence clinical practice by sharing the experience of researchers and practitioners in a supportive learning environment. The use of this approach offered a means of bridging the gap between research and practice development. The paper outlines the rationale for the workshop series, its structure, aims and objectives, and the reported progress in relation to change management and service provision identified by the participants. The workshop series proved to be an effective means of disseminating experience of research, practice development and change management.

Using out-of-hours services: general practice or A&E?

BACKGROUND

General medical and accident and emergency (A&E) services are the two major providers of open access out-of-hours care, and there are widespread concerns about rising and non-urgent demand presented to both.

METHODS

This paper examines the differential use of these services out of hours, in an audit and research study two A&E departments and 21 practices in South London. It focuses on aspects of demand, including time of contact, age-related usage and nature of presenting complaints. Through interviews with a subsample of 82 patients who attended A&E, it also provides a more qualitative focus on differential decision making.

RESULTS

Findings show that there are differences in the way A&E and general medical services are used in terms of age-related demand and aspects of presenting complaints. Significantly more families with children aged under 10 contacted a GP, and whilst more digestive, respiratory and viral/non-specific complaints were presented to GPs, musculoskeletal problems constituted the largest category of complaints presented at the A&E departments. However, some usage relating to perceived and actual availability of services appeared to be interchangeable in terms of site-of-help seeking.

CONCLUSION

There is a need for a collaborative multi-method approach to respond to and influence demand.

Patterns of childhood solid tumor incidence in northern Israel, 1973-1990

A retrospective analysis of 515 pediatric cancer cases diagnosed over 18 years, 1973-1990, showed an annual incidence of pediatric solid tumors in northern Israel of 77.1 per million, somewhat lower than previously reported. Lymphomas predominated over central nervous system (CNS) neoplasms, suggesting an Afro-Asian rather than a Western pattern. Jewish and non-Jewish children were at approximately equal risk (1:07:1.0) for the nonleukemic cancer. However, there was a notably higher frequency in males than females (1:42:1.0) and in Ashkenasi Jews as compared to either Sephardi Jews (1.25:1.00) or non-Jews (1.23:1.0). Ethnic, age, and sex predispositions for particular types of malignancy were also noted. Non-Jews tended to have lymphomas or retinoblastomas and Sephardi Jews were predisposed to soft tissue sarcomas. Ashkenasi Jews tended to manifest CNS tumors, retinoblastoma, and osteosarcoma. Children under 5 years showed Burkitt's lymphoma and neuroblastoma, whereas the older group tended to have Hodgkin's lymphoma. Boys were more vulnerable to non-Hodgkin's lymphoma, medulloblastoma, neuroblastoma, and rhabdomyosarcoma, and girls were subject to higher incidences of bone, gonadal, germ cell, and epithelial tumors, as well as to astrocytoma. The implications for genetic or environmental contributions to several cancers are considered in conjunction with ethnic or gender predisposition to those cancers.

Patients with chronic fatigue syndrome and accurate feeling-of-knowing judgments

Many Chronic Fatigue Syndrome (CFS) patients complain of memory impairments which have been difficult to document empirically. Subjective complaints of memory impairment may be due to a deficit in metamemory judgment. CFS patients and matched controls were tested with a computerized Trivia Information Quiz that required them to rate their confidence about correctly recognizing an answer in a multiple choice format that they had been unable to remember in a fact-recall format. Even though CFS patients reported significantly greater amounts of fatigue, cognitive, and physical symptoms, the accuracy of their confidence levels and recognition responses were similar to controls. This finding suggests that a metamemory deficit is not the cause of the memory problems reported by CFS patients.

Randomized trial of low molecular weight heparin (dalteparin) in prevention of left ventricular thrombus formation and arterial embolism after acute anterior myocardial infarction: the Fragmin in Acute Myocardial Infarction (FRAMI) Study

OBJECTIVES

The present trial investigated the efficacy and safety of dalteparin in the prevention of arterial thromboembolism after an acute anterior myocardial infarction (MI).

BACKGROUND

Left ventricular (LV) thrombus formation is associated with increased risk of arterial embolism in patients with an acute MI. Thrombolytic and antiplatelet therapy do not prevent thrombus formation.

METHODS

A total of 776 patients were enrolled in a multicenter, randomized, double-blind, placebo-controlled trial of subcutaneous dalteparin (150 IU/kg body weight every 12 h during the hospital period). Thrombolytic therapy and aspirin were administered in 91.5% and 97.6% of patients, respectively. The primary study end point was the composite of thrombus formation diagnosed by echocardiography and arterial embolism on day 9 +/- 2.

RESULTS

Of 517 patients with echocardiographic recordings available for end point analysis, thrombus formation or embolism, or both, was found in 59 (21.9%) of 270 patients (59 with thrombus, none with embolism) in the placebo group and 35 (14.2%) of 247 patients (34 with thrombus, 1 with embolism) in the dalteparin group (p = 0.03). The risk reduction of thrombus formation associated with dalteparin treatment was 0.63 (95% confidence interval 0.43 to 0.92, p = 0.02). Analyses of all randomized patients (388 in each group) revealed no significant difference between the placebo and dalteparin groups with respect to arterial embolism (6 vs. 5 patients), reinfarction (8 vs. 6 patients) and mortality rates (23 vs. 23 patients, p = NS for all). Dalteparin was associated with an increased risk of hemorrhage: major in 11 dalteparin group patients (2.9%) verus 1 placebo group patient (0.3%, p = 0.006); minor in 52 dalteparin group patients (14.8%) versus 8 placebo group patients (1.8%, p < 0.001).

CONCLUSIONS

Dalteparin treatment significantly reduces LV thrombus formation in acute anterior MI but is associated with increased hemorrhagic risk.

Wound dressings

Wound healing is a complex rebuilding process that may be easily disrupted if dressings and topical applications are chosen unwisely. There is now a consensus of opinion on the attributes of an ideal dressing. There are many dressings available, each possessing certain of these attributes. There is a shortage of clinical trials in this area.

Satisfaction with telephone advice from an accident and emergency department: identifying areas for service improvement

OBJECTIVES

Members of the public often telephone general practice, accident and emergency departments, and other health services for advice. However, satisfaction related to telephone consultation has received relatively little attention. This study aimed to describe the views of callers to an accident and emergency department who expressed any element of dissatisfaction about their telephone consultation. This was part of a larger study intended to help identify areas for service improvement.

METHODS

A telephone consultation record form was used to document details of advice calls made to the accident and emergency department over a three month period. Callers who provided a telephone number were followed up within 72 hours. The interviews were tape recorded, transcribed, and explored using content analysis for emerging themes related to dissatisfaction.

RESULTS

203 callers were contacted within 72 hours of their call, of which 197 (97%) agreed to participate. 11 (5.6%) expressed global dissatisfaction, and a further 34 (17%) callers expressed at least one element of dissatisfaction at some point during the interview. Sources of dissatisfaction fell into four broad categories, each of which included more specific aspects of dissatisfaction: 36 (80%) callers were dissatisfied with advice issues, 31 (69%) with process aspects, such as the interpersonal skills of the staff member who took the call, 23 (51%) due to lack of acknowledgement of physical or emotional needs, and 11 (24%) due to access problems.

CONCLUSIONS

This study supports the findings of other work and identifies three issues for particular consideration in improving the practice of telephone consultation: (a) training of health professionals at both undergraduate and specialist levels should cover telephone communication skills, (b) specific attention needs to be given to ensuring that the information and advice given over the phone is reliable and consistent, and (c) organisational change is required, including the introduction of departmental policies for telephone advice which should become the subject of regular audit.

Telephone assessment and advice: a training programme

Nurses have become increasingly involved in providing telephone assessment and advice, and telephone triage is emerging as an important part of the everyday role that nurses can play in A&E, general practice and other community settings. This article describes a project to prepare staff to fulfil this role.

Characteristics of self referred patients attending minor injury units

OBJECTIVE

To examine the characteristics, expectations, and use of health services of patients who self refer to minor injury units (MIUs).

DESIGN

Preconsultation questionnaire administered to self referred patients attending with new problems.

SETTING

Two MIUs in south Kent.

MAIN RESULTS

Of 312 self referred patients, 265 (84.9%) presented with minor injuries and 47 (15.1%) with illnesses. In most cases the illness/injury was of recent origin: 119 (38.1%) said it was of less than six hours' duration and 115 (27.6%) between 6 and 24 hours' duration. Most (214; 68.6%) came from home, and for 268 (85.9%) it took 10 min or less to get to the MIU. 79 patients (25.3%) had used the MIU on on e to two occasions in the previous year, and 21 (6.7%) had used it on three or more occasions. In the same period, 44 (14.1%) had attended on accident and emergency (A&E) department on one to two occasions, and 17 (5.4%) has used A&E on three or more occasions, while 108 (34.6%) had been to a general practitioner on one to two occasions, and 144 (46.1%) on three or more occasions. If there had been no MIU available, 151 patients (48.4%) said they would have attended an A&E department, and 91 (29.4%) said they would have attended their general practitioner. The remainder would have self treated or were unsure.

CONCLUSIONS

While the availability of an intermediate tier of care appears to result in greater overall workload for the health service, this must be balanced against the clinical and social costs involved in different patterns of service provision. The cost-effectiveness of these services need further study.

Primary care consultation skills training: implementing a new training programme for senior house officers in an accident and emergency department

Senior house officers (SHOs) in Accident and Emergency (A&E) departments see many patients who present with primary care problems. Until now, most SHOs have lacked postgraduate training in primary care skills to enable them to meet these patients' needs effectively. This paper describes an innovative training programme that has been developing at King's College Hospital, London. It identifies a new opportunity for general practitioners to contribute to the postgraduate medical education of hospital junior medical staff. The training programme was designed to give A&E SHOs protected time in which to reflect on strengths and weaknesses in relation to primary care consultations and learn from their experiences. Its aim was to improve the assessment and management of patients, and to encourage a problem solving approach within the A&E setting. The programme, established in 1992, was developed through collaboration between the departments of A&E Medicine and General Practice and Primary Care. Evaluation has been a central theme in its development, and has been used to ensure that the training meets the needs of each individual set of SHOs and of the department. It has been used in establishing agreement about the training's value and benefits. The authors discuss some of the methodological difficulties encountered in evaluating this type of educational initiative.

Visualization of flumes from pharmaceutical delivery devices

For the treatment of some diseases, drugs are delivered suspended in sprays that are administered either intranasally or by inhalation. The characteristics of these sprays or flumes have an influence on the effectiveness of the drug and some of these characteristics are best understood if the emerging flumes can be visualized. At GlaxoWellcome we have developed a multi-exposure photographic system whereby individual flumes can be recorded at pre-set intervals over their entire time period, typically 250 ms. It may also be desirable to visualize the flume within the nasal passage and this may be achieved by the use of a glass model nose. In this paper I will summarize pre-existing photographic methods and describe in detail the new technique.

Senior house officers' work related stressors, psychological distress, and confidence in performing clinical tasks in accident and emergency: a questionnaire study

OBJECTIVE

To investigate the relation between accident and emergency senior house officers' psychological distress and confidence in performing clinical tasks and to describe work related stressors.

DESIGN

Questionnaire survey with data collected at four points during senior house officers' six month attachment to accident and emergency departments.

SUBJECTS

171 newly appointed accident and emergency senior house officers from 27 hospitals in the South Thames region.

MAIN OUTCOME MEASURES

Psychological distress measured with a 25 item questionnaire; confidence in performing a range of 35 clinical and practical activities (visual analogue scales); reported consultation stress factors, other work related stressors, and personal stressors.

RESULTS

Overall confidence scores in carrying out a range of clinical and practical activities increased significantly between the end of the first and the end of the fourth month (Z = -6.05, P < 0.001). Senior house officers with higher psychological distress scores at the end of their first and fourth month had significantly lower confidence scores (Z = -3.20, P < 0.001; Z = -1.90, P < 0.05). Senior house officers with lower increases in confidence between the first and fourth month had significantly higher distress than those with greater increases (Z = -2.62, P < 0.001). Factors identified as causing stress during consultations included difficulties with communication, certain clinical presentations, and department organisational factors (particularly the intensity of workload).

CONCLUSIONS

Psychological distress is linked to confidence in senior house officers. This supports the need to monitor and build confidence in senior house officers and to address work related stressors. Additional communication skills training needs to be considered.

A study of out-of-hours telephone advice from an A&E department

A prospective analysis of telephone calls to an accident and emergency (A&E) department during weekday evenings/nights and weekends was undertaken over a 3-month period. A telephone consultation record (TCR) proforma was developed to record information about each call for advice. The volume of calls, characteristics of callers and patients, nature of presented problems, and advice given were analysed. An average of 9.3 calls were documented during each weekend 24-hour period, and 3.3 calls during each weekday evening/night. Junior nurses took 93% of calls. Advice was sought for a broad range of problems, of which only 11% were musculoskeletal conditions or injuries. Twenty-six per cent of patients were advised to attend A&E, 35% were given self-care advice, and the remainder were advised to contact or see their GP. There is considerable potential to develop a nurse-provided telephone advice service, but the need for staff training and guidelines has to be addressed.