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

The effects of intervention on quality of telephone triage at an emergency unit in Finland: Nurses' perspective

AIMS AND OBJECTIVES

The aim of this study was to investigate the effects of a nurse training intervention on the assessment of patients' care needs in telephone triage at an emergency unit. The objective of this study was to generate information about nurse training that can be utilized when developing telephone triage and health care education.

BACKGROUND

With the growing number of patients coming into emergency departments and a lack of resources in healthcare, it would be valuable to determine an effective training intervention in telephone triage, particularly when assessing the training needs of nurses.

DESIGN

The study was quasi-experimental, with a pre- and post-test design.

METHODS

The data were collected from the nurses at the emergency department and joint emergency service of the Central Hospital in Northern Finland (baseline n = 28, post-test n = 26). The descriptive statistic, Fisher's χ(2) test and McNemar's test were used to analyse the data.

RESULTS

The intervention improved nurses' skills to evaluate patients' needs and health condition via the telephone triage. There was a statistically significant difference in the resources, knowledge, skills and attitudes of the nurses between the baseline and post-test measurements.

CONCLUSIONS

The nurse training intervention improved the quality of telephone triage.

RELEVANCE TO CLINICAL PRACTICE

Nurses should receive continuous training in telephone triage in order to maintain and reinforce their professional competence. When planning the training, the age and relevant work experience of the nurses should be taken into consideration as well, since the results indicate that they lead to variation in the nurses' competence.

Agreement on urgency assessment between secretaries and general practitioners: an observational study in out-of-hours general practice service in Belgium

BACKGROUND

In some European countries telephone triage (TT) during out-of-hours primary care showed to be safe and effective. Other countries, such as Belgium, may not have trained auxiliary personnel while their national health services want to establish TT.

OBJECTIVES

To compare urgency levels assessed by secretaries and general practitioners in one general practice cooperative in Belgium.

METHODS

Percentage of correct-, under-, and over-triage were calculated in total and per reason for encounter. Inter-rater agreement was investigated.

RESULTS

The secretaries correctly triaged (same urgency level) 77% of the telephone calls, under-triaged 10% and over-triaged 13%.'Shortness of breath', 'skin cuts', 'chest pain', 'feeling unwell' and 'syncope' were often under-triaged.

CONCLUSION

Before introducing TT, auxiliary staff should be trained and protocols should be used.

Gaps in governance: protective mechanisms used by nurse leaders when policy and practice are misaligned

BACKGROUND

Due to large geographical distances, the telephone is central to enabling rural Australian communities to access care from their local health service. While there is a history of rural nurses providing care via the telephone, it has been a highly controversial practice that is not routinely documented and little is known about how the practice is governed. The lack of knowledge regarding governance extends to the role of Directors of Nursing as clinical leaders charged with the responsibility of ensuring practice safety, quality, regulation and risk management. The purpose of this study was to identify clinical governance processes related to managing telephone presentations, and to explore Directors of Nursing perceptions of processes and clinical practices related to the management of telephone presentations to health services in rural Victoria, Australia.

METHODS

Qualitative documentary analysis and semi structured interviews were used in the study to examine the content of health service policies and explore the perceptions of Directors of Nursing in eight rural health services regarding policy content and enactment when people telephone rural health services for care. Participants were purposively selected for their knowledge and leadership role in governance processes and clinical practice. Data from the interviews were analysed using framework analysis. The process of analysis resulted in the identification of five themes.

RESULTS

The majority of policies reviewed provided little guidance for managing telephone presentations. The Directors of Nursing perceived policy content and enactment to be largely inadequate. When organisational structures failed to provide appropriate governance for the context, the Directors of Nursing engaged in protective mechanisms to support rural nurses who manage telephone presentations.

CONCLUSIONS

Rural Directors of Nursing employed intuitive behaviours to protect rural nurses practicing within a clinical governance context that is inadequate for the complexities of the environment. Protective mechanisms provided indicators of clinical leadership and governance effectiveness, which may assist rural nurse leaders to strengthen quality and safe care by unlocking the potential of intuitive behaviours. Kanter's theory of structural power provides a way of conceptualising these protective mechanisms, illustrating how rural nurse leaders enact power.

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.

A cross-sectional study of the quality of telephone triage in a primary care out-of-hours service

We evaluated the quality of telephone triage and the appropriateness of the decisions resulting from it at a primary care out-of-hours service. Four simulated clinical cases were used in the Incognito Standardized Patient method: an adult with nosebleed, an adult with fever, a child with fever and a child with vomiting. There was a set of obligatory questions for each case, translated from those used in a previous study. Quality was assessed by the proportion of questions asked by the call-handlers during telephone triage versus those that should have been asked. A total of 22 out-of-hours doctors were involved in the study, working in two different locations in the Verona city area. Over a 4-month period each of the four simulated clinical cases was used five times in calls to the two centres involved. The proportion of obligatory questions asked compared to those expected to be asked was 27-36%. On three occasions out of the 40 simulations, all of which were considered to be manageable by telephone, the patient was advised to go to an outpatient clinic for a face-to-face evaluation. The average duration of the calls was 3 min 47 s. The quality of telephone triage in the regions studied was low and provided considerable room for improvement. This is relevant to patient safety and risk management of the service.

A comparison of calls subjected to a malpractice claim versus 'normal calls' within the Swedish healthcare direct: a case-control study

OBJECTIVES

The purpose of this study is to compare communication patterns in calls subjected to a malpractice claim with matched controls.

SETTING

In many countries, telephone advice nursing is patients' first contact with healthcare. Telenurses' assessment of callers' symptoms and needs are based on verbal communication only, and problems with over-triage and under-triage have been reported.

PARTICIPANTS

A total sample of all reported medical errors (n=33) during the period 2003-2010 within Swedish Healthcare Direct was retrieved. Corresponding calls were thereafter identified and collected as sound files from the manager in charge at the respective call centres. For technical reasons, calls from four of the cases were not possible to retrieve. For the present study, matched control calls (n=26) based on the patient's age, gender and main symptom presented by the caller were collected.

RESULTS

Male patients were in majority (n=16), and the most common reasons for calling were abdominal pain (n=10) and chest pain (n=5). There were statistically significant differences between the communication in the cases and controls: telenurses used fewer open-ended medical questions (p<0.001) in the cases compared to the control calls; callers provided telenurses with more medical information in the control calls compared to the cases (p=0.001); and telenurses used more facilitation and patient activation activities in the control calls (p=0.034), such as back-channel response (p=0.001), compared to the cases.

CONCLUSIONS

The present study shows that telenurses in malpractice claimed calls used more closed-ended questioning compared to those in control calls, who used more open-ended questioning and back-channel response, which provided them with richer medical descriptions and more information from the caller. Hence, these communicative techniques are important in addition to solid medical and nursing competence and sound decision aid systems.

Drug prescription by telephone consultation in Danish out-of-hours primary care: a population-based study of frequency and associations with clinical severity and diagnosis

Background

Danish general practitioners (GPs) answer all calls to the out-of-hours primary care service. About 60% of the calls are terminated on the telephone through provision of medical advice and prescription of medication. Nevertheless, little is known about the prescription patterns of telephone consultations, such as prescription frequency and indications for drug use. Our aim was to examine the characteristics of patients and GPs in telephone consultations resulting in drug prescription.

Methods

The study was based on a 12-month survey on reasons for encounter in the Danish out-of-hours primary care service. A total of 385 GPs (55.5% of all GPs from Central Denmark Region on duty during a year) participated in answering electronic pop-up questionnaires integrated in the electronic patient administration system. The questionnaires contained items on reasons for encounter (e.g. existing chronic disease or new health problem), diagnoses, and GP-assessed severity of the health problem. Data on time of contact, patient gender and age, and prescribed medication (Anatomic Therapeutic Chemical classifications) for telephone consultations were obtained from the patient administration system. Differences in characteristics of patients, general practitioners, and contacts were examined, and associations with prescribed medication were analysed using a multivariate analysis with prevalence ratios.

Results

Medication was prescribed in 19.9% of the included 4,173 telephone consultations; antibiotics and analgesics were prescribed most frequently (10.8% and 2.5%, respectively). GPs tended to assess contacts resulting in antibiotic prescription as more severe than other contacts. For high-severity contacts, there was a lower likelihood for prescription (prevalence ratio = 0.28 (0.16-0.47)). Children aged 0-4 years had lower probability of receiving a prescription compared with patients aged 18-40 years. The prescription rate was highest during the first four hours of the opening hours of the out-of-hours primary care service.

Conclusion

One in five of all telephone consultations involved drug prescription; antibiotics constituted half of these prescriptions. Drug prescription by telephone was less likely to be offered in cases involving ‘severe’ reason for encounter or children. This study calls for further studies of drug prescriptions issued via out-of-hours primary care telephone consultations.

On a European collaboration to identify organizational models, potential shortcomings and improvement options in out-of-hours primary health care

Abstract Background: Out-of-hours care (OOHC) provision is an increasingly challenging aspect in the delivery of primary health care services. Although many European countries have implemented organizational models for out-of-hours primary care, which has been traditionally delivered by general practitioners, health care providers throughout Europe are still looking to resolve current challenges in OOHC. It is within this context that the European Research Network for Out-of-Hours Primary Health Care (EurOOHnet) was established in 2010 to investigate the provision of out-of-hours care across European countries, which have diverse political and health care systems. In this paper, we report on the EurOOHnet work related to OOHC organizational models, potential shortcomings and improvement options in out-of-hours primary health care. Needs assessment: The EurOOHnet expert working party proposed that models for OOHC should be reviewed to evaluate the availability and accessibility of OOHC for patients while also seeking ways to make the delivery of care more satisfying for service providers.

OUTCOMES

To move towards resolution of OOHC challenges in primary care, as the first stage, the EurOOHnet expert working party identified the following key needs: clear and uniform definitions of the different OOHC models between different countries; adequate-ideally transnational-definitions of urgency levels and corresponding data; and educational programmes for nurses and doctors (e.g. in the use of a standardized triage system for OOHC). Finally, the need for a modern system of data transfer between different health care providers in regular care and providers in OOHC to prevent information loss was identified.

How do patients respond when confronted with telephone access barriers to care?

OBJECTIVE

To gain an in-depth understanding of patient barriers to accessing telephone care, subsequent responses to telephone access issues and recommendations for system improvement within a large integrated health-care system.

STUDY DESIGN

Cross-sectional qualitative focus group study.

METHODS

One focus group was conducted at each of 17 Veterans Affairs facilities with a total of 123 Veteran users of VA health care. All facilities followed a focus group discussion guide, and purposively sampled patients receiving care at their VA facility in primary and/or specialty care. Focus groups' recordings were sent to the authors' independent evaluation centre, transcribed verbatim and analysed using qualitative content analysis methodology.

RESULTS

Participants described many issues with the phone system that resulted in delays to care needs being addressed, including difficulty getting someone to answer the phone, out-dated phone directories, frequent disconnections and incorrect transfers. Participants most frequently responded to access issues by doing nothing or waiting to contact at a later time, or seeking unscheduled in-person care in the emergency department or primary care clinic. Participants offered recommendations for improving telephone care, including access to direct extensions, and upgrades to the telephone system.

CONCLUSIONS

Telephone access issues could result in increased patient harm and/or increased wait times for in-person primary care or emergency services. Periodic evaluation of telephone systems is necessary to ensure telephone systems adequately meet patient needs while using resources efficiently to optimize the delivery of high quality, safe health care.

Question design in nurse-led and GP-led telephone triage for same-day appointment requests: a comparative investigation

OBJECTIVE

To compare doctors' and nurses' communication with patients in primary care telephone triage consultations.

DESIGN

Qualitative comparative study of content and form of questions in 51 telephone triage encounters between practitioners (general practitioners (GPs)=29; nurses=22) and patients requesting a same-day appointment in primary care. Audio-recordings of nurse-led calls were synchronised with video recordings of nurse's use of computer decision support software (CDSS) during triage.

SETTING

2 GP practices in Devon and Warwickshire, UK.

PARTICIPANTS

4 GPs and 29 patients; and 4 nurses and 22 patients requesting a same-day face-to-face appointment with a GP.

MAIN OUTCOME MEASURE

Form and content of practitioner-initiated questions and patient responses during clinical assessment.

RESULTS

A total of 484 question-response sequences were coded (160 GP; 324 N). Despite average call lengths being similar (GP=4 min, 37 s, (SD=1 min, 26 s); N=4 min, 39 s, (SD=2 min, 22 s)), GPs and nurses differed in the average number (GP=5.51, (SD=4.66); N=14.72, (SD=6.42)), content and form of questions asked. A higher frequency of questioning in nurse-led triage was found to be due to nurses' use of CDSS to guide telephone triage. 89% of nurse questions were oriented to asking patients about their reported symptoms or to wider-information gathering, compared to 54% of GP questions. 43% of GP questions involved eliciting patient concerns or expectations, and obtaining details of medical history, compared to 11% of nurse questions. Nurses using CDSS frequently delivered questions designed as declarative statements requesting confirmation and which typically preferred a 'no problem' response. In contrast, GPs asked a higher proportion of interrogative questions designed to request information.

CONCLUSIONS

Nurses and GPs emphasise different aspects of the clinical assessment process during telephone triage. These different styles of triage have implications for the type of information available following nurse-led or doctor-led triage, and for how patients experience triage.

[Patient safety in general practice]

INTRODUCTION

So far, there has been a lack of systematic data regarding critical incidents and safety climate in Swiss primary care offices. Therefore, a survey was conducted amongst physicians and nurses ("MPA") working in Swiss German primary care offices leading to a subsequent project on the telephone triage.

METHODS

Using a standardised questionnaire, healthcare professionals in primary care offices have been surveyed to determine safety risks and safety climate in their offices. The questionnaire consisted of safety-climate items as well as descriptions of 23 safety incidents. These incidents were rated in terms of frequency (appearance in the office during the past 12 months) and severity (harm associated with the last occurrence in the office). In addition, physicians and nurses answered an open-ended question referring to patient safety risks they would wish to eliminate in their offices. In the subsequent project, interviews and group discussions have been conducted with physicians and nurses in order to perform a process analysis of the telephone triage and to develop a tool that may help primary care offices to strengthen telephone triage as a secure process.

RESULTS

630 physicians and nurses (50.2% physicians, 49.8% nurses) participated in the study. 30% of the physicians and 17% of the nurses observed at least one of the 23 incidents in their offices on a daily or weekly basis. Errors in documentation were reported most frequently. As regards severity, the triage by nurses at the initial patient contact, errors in diagnosis, failure to monitor patients after therapeutic treatment in the office, and errors regarding the medication process were shown to be the most relevant. Most frequently participants wanted to eliminate the following risks to patient safety in their offices: medication (28% of all mentions), medical procedures in the office (11%) and telephone triage (7%). Participation in team meetings and quality circles proved to be relevant predictors of the safety climate dimension "team-based error prevention". Differences between occupational groups were found regarding safety incidents as well as safety climate.

CONCLUSION

The results of this study show the telephone triage to be a relevant area of patient safety in primary care that has not been focused on so far. In order to enhance safety of the triage process a new project was initiated. The result of the project is a triage guide for primary care offices. This guide supports physicians and nurses in a joint and critical examination of office structures and processes related to telephone triage. The systematically observed differences between occupational groups indicate that the entire office team need to be involved when analysing safety risks and taking action to improve patient safety. Only in doing so, risks can be identified comprehensively. Moreover, measures can be taken that are relevant to and supported by all healthcare professionals working in a primary care office. This approach of involving the entire team forms the basis for the guide on telephone triage.

Changes of triage by GPs during the course of prehospital emergency situations in a Norwegian rural community

Background

Priority grade assessment according to urgency level of the patients (triage) is considered vital in emergency medicine casualties. Little is known of the experiences of pre-hospital emergency medicine triage performed by General Practitioners (GPs) in the community. In this study we bring such experiences from a Norwegian island community, with special emphasis on over- and undertriage.

Methods

In the island municipality of Austevoll, Western Norway, where the GPs and the ambulance services both take part in all medical emergency cases, all these cases were recorded during a 2-year period (2005–2007). We compared the triage of the patients at the stage of the telephone reception of the incident, and the subsequent revision of the triage at the first personal examination of the patient.

Results

236 emergency medical events were recorded, comprising 240 patients. Of these, 42% were downgraded between the stages (i.e. initially overtriaged), 11% were upgraded (i.e. initially undertriaged) and 47% remained in unchanged priority group. Of the diagnostic groups, acute abdominal cases had the highest probability of being upgraded between stages, while the aggregated diagnostic group of syncopes, seizures, intoxications and traumas had the highest probability of being downgraded. The principal reason for upgrading was lack of necessary information at the stage of call. In a minority of cases the upgrading was due to real patient deterioration between stages.

Conclusions

In pre-hospital triage of emergency patients, downgrading happens between notification of events and actual patient examination in a substantial proportion. Upgradings of cases are considerably fewer, but the potential serious implications of upgrading warrants individual scrutiny of such cases.

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis

BACKGROUND

This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety.

METHODS

We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes.

RESULTS

Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks.

CONCLUSIONS

Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Triage systems for pre-hospital emergency medical services - a systematic review

The emergency medical services (EMS) cover initiatives and services established to provide essential medical assistance in situations of acute illness. Triage-methods for systematic prioritizing of patients according to how urgent patients need care, including triage of requests of acute medical treatment, are adopted in hospitals as well as in the pre-hospital settings. This systematic review searched to identify available research on the effects of validated triage systems for use in the pre-hospital EMS on health outcomes, patient safety, patient satisfaction, user-friendliness, resource use, goal achievement, and the quality on the information exchange between the different settings of the EMS (for example the quality of documentation). The specific research questions were: 1) are pre-hospital triage systems effective, 2) is one triage system more effective than others, and 3) is it effective to use the same triage system in two or more settings of the EMS-chain? We conducted a systematic literature search in nine databases up to June 2012. We searched for systematic reviews (SRs), randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITSs). Two persons independently reviewed titles and abstracts, and the same persons read all possibly relevant full text articles and rated the methodological quality where relevant. The literature search identified 11011 unique references. A total of 120 publications were read in full text. None of the identified articles fulfilled our inclusion criteria, thus our question on the effects of pre-hospital triage systems, if one system is better than other systems, and the question on effects of using the same triage system in two or more settings of the EMS, remain unanswered. We conclude that there is an evidence gap regarding the effects of pre-hospital triage systems and the effects of using the same triage system in two or more settings of the EMS. The finding does not mean that pre-hospital triage systems are ineffective, but that we lack knowledge about potential effects. When introducing a new assessment tool in the EMS, it is timely to conduct well-planned studies aimed to assess the effect.

Patient satisfaction with out-of-hours GP cooperatives: a longitudinal study

OBJECTIVE

For over a decade, out-of-hours primary care in the Netherlands has been provided by general practitioner (GP) cooperatives. In the past years, quality improvements have been made and patients have become acquainted with the service. This may have increased patient satisfaction. The objective of this study was to examine changes in patient satisfaction with GP cooperatives over time.

DESIGN

Longitudinal observational study. A validated patient satisfaction questionnaire was distributed in 2003-2004 (T1) and 2007-2008 (T2). Items were rated on a scale from 0 to 10 (1 = very bad; 10 = excellent).

SETTING

Eight GP cooperatives in the Netherlands.

SUBJECTS

Stratified sample of 9600 patients. Response was 55% at T1 (n = 2634) and 51% at T2 (n = 2462).

MAIN OUTCOME MEASURES

Expectations met; satisfaction with triage nurses, GPs, and organization.

RESULTS

For most patients the care received at the GP cooperative met their expectations (T1: 86.1% and T2: 88.4%). Patients were satisfied with the triage nurses (overall grade T1: 7.73 and T2: 7.99), GPs (T1: 8.04 and T2: 8.25), and organization (overall grade T1: 7.60 and T2: 7.78). Satisfaction with triage nurses showed the largest increase over time. The quality and effectiveness of advice or treatment were given relatively low grades. Of all organizational aspects, the lowest grades were given for waiting times and information about the cooperative.

CONCLUSION

In general, patients were initially satisfied with GP cooperatives and satisfaction had even increased four years later. However, there is room for improvement in the content of the advice, waiting times, and information supply. More research is needed into satisfaction of specific patient groups.

Factors which influence the length of an out-of-hours telephone consultation in primary care: a retrospective database study

BACKGROUND

Given the increasing use of telephone consultation it is important to determine the factors which influence the length of a telephone consultation.

METHOD

Analysis of 128717 telephone consultations during January to December 2011 to a National Health Service (NHS) out-of-hours primary care service provider in Shropshire and Telford and Powys, England, involving 102 General Practitioners (GPs) and 36 Nurse Practitioners (NPs). Telephone consultation conclude with one of three outcomes - advice only, the patient is invited to a face-to-face consultation with a GP or NP at a nearby health centre (known as a base visit) or the patient is visited at home by a GP or NP (known as home visit). Call length was analysed by these outcomes.

RESULTS

The overall mean call length was 7.78 minutes (standard deviation (SD) 4.77). Calls for advice only were longest (mean 8.11 minutes, SD 5.17), followed by calls which concluded with a base visit (mean 7.36 minutes, SD 4.08) or a home visit (mean 7.16 minutes, SD 4.53). Two primary factors influenced call length. Calls by GPs were shorter (mean 7.15 minutes, SD 4.41) than those by NPs (mean 8.74 minutes, SD 5.31) and calls designated as a mental health call were longer (mean 11.16 minutes, SD 4.75) than all other calls (mean 7.73 minutes, SD 7.7).

CONCLUSIONS

Telephone consultation length in the out-of-hours setting is influenced primarily by whether the clinician is a GP or a NP and whether the call is designated as a mental health call or not. These findings suggest that appropriate attempts to reduce the length of the telephone consultations should focus on these two areas, although the longer consultation length associated with NPs is offset to some extent by their lower employment costs compared to GPs. Nonetheless the extent to which the length of a telephone consultation impacts on subsequent use of the health service and correlates with quality and safety remains unclear.