Reliability and validity of an original nurse telephone triage tool for out-of-hours primary care calls: the SALOMON algorithm

Safety of patient self-triage: real-life prospective evaluation of a symptom-checker in adult patients visiting an interdisciplinary emergency care center

BACKGROUND

Symptom-checkers have become important tools for self-triage, assisting patients to determine the urgency of medical care. To be safe and effective, these tools must be validated, particularly to avoid potential hazardous undertriage without leading to inefficient overtriage. Only limited safety data from studies including small sample sizes have been available so far.

OBJECTIVE

The objective of our study was to prospectively investigate the safety of patients' self-triage in a large patient sample. We used SMASS pathfinder, a symptom-checker based on a computerized transparent neural network.

METHODS

We recruited 2543 patients into this single centre, prospective clinical trial conducted at the cantonal hospital of Baden, Switzerland. Patients with an Emergency Severity Index of 1-2 were treated by the team of the emergency department, while those with an index of 3-5 were seen at the walk-in clinic by general physicians. We compared the triage recommendation obtained by the patients' self-triage with the assessment of the clinical urgency made by three successive interdisciplinary panels of physicians (Panel A, B, C). Using a Clopper-Pearson confidence interval, we assumed that in order to confirm the symptom-checkers safety, the upper confidence bound for the probability of a potentially hazardous undertriage should lie below 1%. A potentially hazardous undertriage was defined as a triage in which either all (consensus criterion) or the majority (majority criterion) of the experts of the last panel (Panel C) rated the triage of the symptom-checker to be "rather likely" or "likely" life-threatening or harmful.

RESULTS

Of the 2543 patients, 1227 (48.3%) were female and 1316 (51.7%) male. None of the patients reached the pre-specified consensus criterion for a potentially hazardous undertriage. This resulted in an upper 95% confidence bound of 0.1184%. 4 cases met the majority criterion. This resulted in an upper 95% confidence bound for the probability of a potentially hazardous undertriage of 0.3616%. The two-sided 95% Clopper-Pearson confidence interval for the probability of overtriage (450 cases, 17.7%) was 16.23% to 19.24%, which is considerably lower than figures reported in the literature.

CONCLUSIONS

The symptom-checker proved to be a safe triage tool, avoiding potentially hazardous undertriage in a real-life clinical setting of emergency consultations at a WIC/ED, whithout causing undesirable overtriage. Our data suggest the symptom-checker may be safely used in clinical routine.

CLINICALTRIAL

ClinicalTrials.gov identifier NCT04055298.

A Bibliometric Analysis of Telephone Triage Research to 2021 Using VOSviewer

Telephone triage services are becoming increasingly commonplace in modern healthcare. Despite this widespread adoption, health researchers and practitioners seeking to understand evidence-based best practice face several challenges. Firstly, the few systematic reviews available yield small sample sizes, suggesting a small amount of research. Secondly, the rapid pace of development of telephone triage technologies means that there may be temporal validity issues with the available research, given some of this research is relatively old. Thirdly, researchers use different terminologies to describe telephone triage, meaning evidence may be more difficult to find than if consistent terminology was used. This bibliometric analysis therefore is aimed at providing a macroscopic overview of telephone triage, to understand the scale and scope of the available evidence (i.e., where, when, and by whom research is conducted), for interested researchers and practitioners. Additionally, it is aimed at quantifying the prevalence of terms used to describe telephone triage, to recommend consistent terminology for future use, and to improve accessibility of research. To address these aims, literature searches using three different key terms: "telephone triage," "remote triage," and "teletriage" were conducted in Scopus and PubMed. Corresponding bibliometric data was visualised and analysed using VOSviewer. This bibliometric review identified 784 papers since the term "telephone triage" first appears in 1980, confirming a paucity of literature in the field. An overview of telephone triage research up to 2021 is provided, which should serve as a useful foundation for future research and application of evidence-based practice. Gaps in telephone triage research are identified, and the use of consistent terminology is encouraged, with the aim of supporting telephone triage researchers in determining research priorities and improving the impact of future studies.

Patients' self-triage for unscheduled urgent care: a preliminary study on the accuracy and factors affecting the performance of a Belgian self-triage platform

Background

Management of unscheduled urgent care is a complex concern for many healthcare providers. Facing the challenge of appropriately dispatching unscheduled care, primary and emergency physicians have collaboratively implemented innovative strategies such as telephone triage. Currently, new original solutions tend to emerge with the development of new technologies. We created an interactive patient self-triage platform, ODISSEE, and aimed to explore its accuracy and potential factors affecting its performance using clinical case scenarios.

Methods

The ODISSEE platform was developed based on previously validated triage protocols for out-of-hours primary care. ODISSEE is composed of 18 icons leading to algorithmic questions that finally provide an advised orientation (emergency or primary care services). To investigate ODISSEE performance, we used 100 clinical case scenarios, each associated with a preestablished orientation determined by a group of experts. Fifteen volunteers were asked to self-triage with 50 randomly selected scenarios using ODISSEE on a digital tablet. Their triage results were compared with the experts’ references.

Results

The 15 participants performed a total of 750 self-triages, which matched the experts references regarding the level of care in 85.6% of the cases. The orientation was incorrect in 14.4%, with an undertriage rate of 1.9% and an overtriage rate of 12.5%. The tool’s specificity and sensitivity to advise participants on the appropriate level of care were 69% (95% CI: 64—74) and 97% (95% CI: 95—98) respectively. When combined with advice on the level of urgency, the tool only found the correct orientation in 68.4% with 9.2% of undertriages and 22.4% of overtriages. Some participant characteristics and the types of medical conditions demonstrated a significant association with the tool performance.

Conclusion

Self-triage apps, such as the ODISSEE platform, could represent an innovative method to allow patients to self-triage to the most appropriate level of care. This study based on clinical vignettes highlights some positive arguments regarding ODISSEE safety, but further research is needed to assess the generalizability of such tools to the population without equity issues.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08571-5.

Differences in emergency nurse triage between a simulated setting and the real world, post hoc analysis of a cluster randomised trial

OBJECTIVES

In the TRIAGE trial, a cluster randomised trial about diverting emergency department (ED) patients to a general practice cooperative (GPC) using a new extension to the Manchester Triage System, the difference in the proportion of patients assigned to the GPC was striking: 13.3% in the intervention group (patients were encouraged to comply to an ED or GPC assignment, real-world setting) and 24.7% in the control group (the assignment was not communicated, all remained at the ED, simulated setting). In this secondary analysis, we assess the differences in the use of the triage tool between intervention and control group and differences in costs and hospitalisations for patients assigned to the GPC.

SETTING

ED of a general hospital and the adjacent GPC.

PARTICIPANTS

8038 patients (6294 intervention and 1744 control).Primary and secondary outcome measures proportion of patients with triage parameters (reason for encounter, discriminator and urgency category) leading to an assignment to the ED, proportion of patients for which the computer-generated GPC assignment was overruled, motivations for choosing certain parameters, costs (invoices) and hospitalisations.

RESULTS

An additional 3.1% (p<0.01) of the patients in the intervention group were classified as urgent. Discriminators leading to the ED were registered for an additional 16.2% (p<0.01), mainly because of a perceived need for imaging. Nurses equally chose flow charts leading to the ED (p=0.41) and equally overruled the protocol (p=0.91). In the intervention group, the mean cost for patients assigned to the GPC was €23 (p<0.01) lower and less patients with an assignment to the GPC were hospitalised (1.0% vs 1.6%, p<0.01).

CONCLUSION

Nurses used a triage tool more risk averse when it was used to divert patients to primary care as compared with a theoretical assignment to primary care. Outcomes from a simulated setting should not be extrapolated to real patients.

TRIAL REGISTRATION NUMBER

NCT03793972.