Use of a telenursing triage service by Victorian parents attending the emergency department for their child's lower urgency condition

The effectiveness of tele-triage during the COVID-19 pandemic: A systematic review and narrative synthesis

BACKGROUND

Telehealth services were used by healthcare centers during the COVID-19 pandemic in order to identify and manage patients at the forefront of the healthcare system. As one of these technologies, tele-triage refers to the assessment of a patient's health status through telephone or another means of communication and recommending treatment or providing appropriate referrals in emergency rooms and primary care offices. This study aimed to perform a systematic review of the evidence on the effectiveness of tele-triage, as one of these technologies, during the COVID-19 pandemic.

METHODS

Medline (via PubMed), Scopus, and Web of Science databases were searched for relevant English articles published since the pandemic's onset until December 30, 2021. Studies investigating the tele-triage's effect on patient safety, clinical outcomes, and patient satisfaction were included. Data on study characteristics, intervention characteristics, and their effects on study outcomes were extracted separately by two authors. A narrative synthesis of the included studies was ultimately performed.

RESULTS

Out of the 6312 retrieved studies, 14 met the inclusion criteria. The tele-triage intervention was offered by an algorithm-based system in eight studies (57.14%) and by healthcare providers in six other studies (42.86%) to determine the patient's level of care. According to the results, tele-triage interventions during COVID-19 can reduce unnecessary emergency room visits (by 1.2-22.2%), improve clinical outcomes after intervention (such as would closure in diabetic feet), reduce mortality and injuries, and ensure patient satisfaction with tele-triage (53-98%).

CONCLUSIONS

This study found that tele-triage interventions reduced unnecessary visits, improved clinical outcomes, reduced mortality, and injuries, increased patient satisfaction, reduced healthcare provider workload, improved access to primary care consultation, and increased patient safety and satisfaction. Therefore, tele-triage systems are not only suitable for providing acute and emergency care remotely but they are also recommended as an alternative tool to monitor and diagnose COVID-19.

Safety in Teletriage by Nurses and Physicians in the United States and Israel: Narrative Review and Qualitative Study

BACKGROUND

The safety of telemedicine in general and telephone triage (teletriage) safety in particular have been a focus of concern since the 1970s. Today, telehealth, now subsuming teletriage, has a basic structure and process intended to promote safety. However, inadequate telehealth systems may also compromise patient safety. The COVID-19 pandemic accelerated rapid but uneven telehealth growth, both technologically and professionally. Within 5-10 years, the field will likely be more technologically advanced; however, these advances may still outpace professional standards. The need for an evidence-based system is crucial and urgent.

OBJECTIVE

Our aim was to explore ways that developed teletriage systems produce safe outcomes by examining key system components and questioning long-held assumptions.

METHODS

We examined safety by performing a narrative review of the literature using key terms concerning patient safety in teletriage. In addition, we conducted system analysis of 2 typical formal systems, physician led and nurse led, in Israel and the United States, respectively, and evaluated those systems' respective approaches to safety. Additionally, we conducted in-depth interviews with representative physicians and 1 nurse using a qualitative approach.

RESULTS

The review of literature indicated that research on various aspects of telehealth and teletriage safety is still sparse and of variable quality, producing conflicting and inconsistent results. Researchers, possibly unfamiliar with this complicated field, use an array of poorly defined terms and appear to design studies based on unfounded assumptions. The interviews with health care professionals demonstrated several challenges encountered during teletriage, mainly making diagnosis from a distance, treating unfamiliar patients, a stressful atmosphere, working alone, and technological difficulties. However, they reported using several measures that help them make accurate diagnoses and reasonable decisions, thus keeping patient safety, such as using their expertise and intuition, using structured protocols, and considering nonmedical factors and patient preferences (shared decision-making).

CONCLUSIONS

Remote encounters about acute, worrisome symptoms are time sensitive, requiring decision-making under conditions of uncertainty and urgency. Patient safety and safe professional practice are extremely important in the field of teletriage, which has a high potential for error. This underregulated subspecialty lacks adequate development and substantive research on system safety. Research may commingle terminology and widely different, ill-defined groups of decision makers with wide variation in decision-making skills, clinical training, experience, and job qualifications, thereby confounding results. The rapid pace of telehealth's technological growth creates urgency in identifying safe systems to guide developers and clinicians about needed improvements.

Telephone Triage for Emergency Patients Reduces Unnecessary Ambulance Use: A Propensity Score Analysis With Population-Based Data in Osaka City, Japan

Background

Telephone triage service in emergency care has been introduced around the world, but the impact of this service on the emergency medical service (EMS) system has not been fully revealed. The aim of this study was to evaluate the effect of telephone triage service for emergency patients on decreasing unnecessary ambulance use by analysis with propensity score (PS) matching.

Methods

This study was a retrospective observational study, and the study period was the 4 years from January 2016 to December 2019. We included cases for which ambulances were dispatched from the Osaka Municipal Fire Department (OMFD). The primary outcome of this study was unnecessary ambulance use. We calculated a PS by fitting a logistic regression model to adjust for 10 variables that existed before use of the telephone triage service. To ensure the robustness of this analysis, we used not only PS matching but also a multivariable logistic regression model and regression model with PS as a covariate.

Results

This study included 868,548 cases, of which 8,828 (1.0%) used telephone triage services and 859,720 (99.0%) did not use this service. Use of the telephone triage service was inversely associated with the occurrence of unnecessary ambulance use in multivariate logistic regression model (adjusted OR 0.453, 95% CI 0.405–0.506) and multivariate logistic regression model with PS as a covariate (adjusted OR 0.514, 95% CI 0.460–0.574). In the PS matching model, we also revealed same results (crude OR 0.487, 95% CI 0.425–0.588).

Conclusions

In this study, we were able to statistically evaluate the effectiveness of telephone triage service already in use by the public using the statistical method with PS. As a result, it was revealed that the use of a telephone triage service was associated with a lower proportion of unnecessary ambulance use in a metropolitan area of Japan.

Service use, clinical outcomes and user experience associated with urgent care services that use telephone-based digital triage: a systematic review

OBJECTIVE

To evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Medline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings.

RESULTS

Thirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients' adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions.

CONCLUSIONS

Further research is needed into patient level service use, including patients' adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery.

PROSPERO REGISTRATION NUMBER

CRD42020178500.

Comparing emergency department presentations among children with cerebral palsy with general childhood presentations: a data linkage study

AIM

The aims of this study were to estimate the proportion of emergency department presentations attributable to children with cerebral palsy (CP), investigate the frequency of emergency department presentations in a CP cohort, and compare emergency department presentations among children with CP with those of other children.

METHOD

This was a retrospective cohort study. The Victorian Cerebral Palsy Register was linked to the Victorian Emergency Minimum Dataset. Data on emergency department presentations for the CP cohort occurring between 2007 and 2014 and population control data were obtained.

RESULTS

The CP cohort (n=1748) had 7015 emergency department presentations during the 7-year period, accounting for 0.4% of the 1.69 million age-specific presentations during that time. The number of annual presentations per 1000 children rose with increasing CP severity. Compared with presentations among the general population, higher proportions of presentations among the CP cohort were preceded by ambulance arrivals (27% vs 8%), triaged as urgent (66% vs 32%), and required hospital admission (38% vs 12%).

INTERPRETATION

The marked differences in presentations between the CP cohort and the general population in the proportions that were urgent and required ambulance arrivals and hospital admissions was an important finding. Strategies to ensure appropriate use of services, including encouragement to seek earlier assistance from primary care providers, may prevent problems escalating to the need for urgent care.

WHAT THIS PAPER ADDS

Children with cerebral palsy (CP) account for 0.4% of childhood emergency department presentations. More emergency department presentations among children with CP require ambulance arrival. More CP emergency department presentations are urgent and require hospital admission. Traditional emergency department triage scales seem less accurate for this group.