Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study

A Symptom-Checker for Adult Patients Visiting an Interdisciplinary Emergency Care Center and the Safety of Patient Self-Triage: Real-Life Prospective Evaluation

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 potentially 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 (Swiss Medical Assessment System; in4medicine, Inc) pathfinder, a symptom-checker based on a computerized transparent neural network.

METHODS

We recruited 2543 patients into this single-center, 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 clinical urgency made by 3 successive interdisciplinary panels of physicians (panels A, B, and C). Using the Clopper-Pearson CI, we assumed that 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 (48.25%) were female and 1316 (51.75%) male. None of the patients reached the prespecified consensus criterion for a potentially hazardous undertriage. This resulted in an upper 95% confidence bound of 0.1184%. Further, 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 2-sided 95% Clopper-Pearson CI for the probability of overtriage (n=450 cases,17.69%) was 16.23% to 19.24%, which is considerably lower than the 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 walk-in clinic or emergency department without causing undesirable overtriage. Our data suggest the symptom-checker may be safely used in clinical routine.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04055298; https://clinicaltrials.gov/study/NCT04055298.

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.

[Initial assessment of ENT emergencies-a feasibility study]

In Germany, an increased volume of patient cases in the emergency department has been observed for several years, many of which do not represent hospital emergencies. To improve the triage and management of patient flows, the Structured Initial Medical Assessment (Strukturierte medizinische Ersteinschätzung in Deutschland, SmED) triage system was developed. This certified medical product is intended to assess both the urgency of everyday complaints and their adequate medical care in a targeted, faster, and safer manner. It supports medical professionals in triage by suggesting courses of action, whereby the ultimate responsibility remains with the professionals themselves. For otorhinolaryngology, a content review was carried out with regard to plausibility and patient safety in the head and neck region on the basis of nine specific emergencies. The cases were simulated by nine otorhinolaryngologists and triaged on the basis of the SmED by medical staff and medical students by assigning a care level and timepoint (urgency). The majority of cases were correctly assigned. The SmED initial assessment system is a good tool for assessing urgent clinical pictures in ear, nose, and throat (ENT) medicine. The long-term goal of the initial assessment is to relieve the capacities of outpatient departments. In order to achieve this and to shorten patient waiting times, it would be necessary to refer patients quickly to otorhinolaryngology. It is therefore necessary to ensure that patients are referred to an ENT on-call service via the online tool.

Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care

BACKGROUND

Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.

OBJECTIVE

To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.

METHODS

Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.

RESULTS

95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.

CONCLUSIONS

We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

Factors associated with undertriage in patients classified by the need to visit a hospital by telephone triage: a retrospective cohort study

BACKGROUND

Prehospital telephone triage stratifies patients into five categories, "need immediate hospital visit by ambulance," "need to visit a hospital within 1 hour," "need to visit a hospital within 6 hours," "need to visit a hospital within 24 hours," and "do not need a hospital visit" in Japan. However, studies on whether present and past histories cause undertriage are limited in patients triaged as need an early hospital visit. We investigated factors associated with undertriage by comparing patient assessed to be appropriately triaged with those assessed undertriaged.

METHODS

We included all patients classified by telephone triage as need to visit a hospital within 1 h and 6 h who used a single after-hours house call (AHHC) medical service in Tokyo, Japan, between November 1, 2019, and November 31, 2020. After home consultation, AHHC doctors classified patients as grade 1 (treatable with over-the-counter medications), 2 (requires hospital or clinic visit), or 3 (requires ambulance transportation). Patients classified as grade 2 and 3 were defined as appropriately triaged and undertriaged, respectively.

RESULTS

We identified 10,742 eligible patients triaged as need to visit a hospital within 1 h and 6 h, including 10,479 (97.6%) appropriately triaged and 263 (2.4%) undertriaged patients. Multivariable logistic regression analyses revealed patients aged 16-64, 65-74, and ≥ 75 years (adjusted odds ratio [OR], 2.40 [95% confidence interval {CI} 1.71-3.36], 8.57 [95% CI 4.83-15.2], and 14.9 [95% CI 9.65-23.0], respectively; reference patients aged < 15 years); those with diabetes mellitus (2.31 [95% CI 1.25-4.26]); those with dementia (2.32 [95% CI 1.05-5.10]); and those with a history of cerebral infarction (1.98 [95% CI 1.01-3.87]) as more likely to be undertriaged.

CONCLUSIONS

We found that older adults and patients with diabetes mellitus, dementia, or a history of cerebral infarction were at risk of undertriage in patients triaged as need to visit a hospital within 1 h and 6 h, but further studies are needed to validate these findings.

Oncology Nursing Telephone Triage Workshop: Impact on Nurses' Knowledge, Confidence, and Skill

BACKGROUND

Outpatient oncology nurses are responsible for symptom assessment/management and care coordination during telephone triage. Nursing telephone triage interventions can improve patient outcomes and clinical efficiency. Therefore, the lack of education and training in telephone triage can greatly impact patient care.

OBJECTIVE

Using a prospective pretest/posttest design, we sought to determine if a telephone triage educational workshop would improve oncology nurses' knowledge, confidence, and skill over 12 weeks.

INTERVENTION/METHODS

The educational intervention incorporated an online didactic lecture, group case scenario, and feedback on a virtual triage simulation. Evaluation was conducted before and after the intervention through an online, 13-item survey (knowledge and confidence) and simulation utilizing a 56-item checklist (skills).

RESULTS

Thirteen oncology nurses were enrolled; 54% did not have telephone triage experience before this job. A total of 12 participants completed the workshop. From pretest to posttest, there was a median 1.0 out of 5.0 (interquartile range, 2.8) improvement in confidence (P = .008) and a 26.3% (interquartile range, 15.2) improvement in skills (P = .002). There was no difference in knowledge scores from pretest to posttest (P = .11).

CONCLUSIONS

This workshop was associated with an improvement in oncology nurse confidence and skill, using telephone triage models. It benefits an existing process within the outpatient center and it highlights a new educational strategy that may optimize nursing practice and improve patient care and experience.

IMPLICATIONS FOR PRACTICE

This workshop contributes to existing evidence of telephone triage models and nursing education. The findings can guide future research, nursing orientation, and educational activities within the field of nursing and telehealth.

Quality indicators in telephone nursing - An integrative review

Aim

The aim of this study was to identify factors that indicate quality in telephone nursing.

Design

An integrative literature review.

Method

A literature search was performed in October 2018, in the PubMed, CINAHL, Cochrane Library, Academic Search, PsycINFO, Scopus and Web of Science databases. A total of 30 included were included and data that corresponded to the study's aim were extracted and categorized along the three areas of quality as described by Donabedian (Milbank Quarterly, 83, 691), namely structure, process and outcome.

Results

The analysis revealed ten factors indicating quality in telephone nursing (TN): availability and simplicity of the service, sustainable working conditions, specialist education and TN experience, healthcare resources and organization, good communication, person‐centredness, competence, correct and safe care, efficiency and satisfaction. TN services need to target all ten factors to ensure that the care given is of high quality and able to meet today's requirements for the service.

Exploring the role of nurses in after-hours telephone services in regional areas; A scoping review

INTRODUCTION

The management of patients who need chronic and complex care is a focus of attention internationally, brought about by an increase in chronic conditions, requiring significantly more care over longer periods of time. The increase in chronic conditions has placed pressure on health services, financially and physically, bringing about changes in the way care is delivered, with hospital avoidance and home-based care encouraged. In this environment, nurses play an important role in co-ordinating care across services. This review formed one part of a funded project that explored the nurse navigator role within a proposed 24-hour telephone-call service in one regional area that has a diverse population in terms of cultural identity and geographical location in relation to service access.

AIM

The review reports on the extant literature on the nurse's role in the provision of afterhours telephone services for patients with chronic and complex conditions. The specific aim was to explore the effectiveness of services for patients in geographically isolated locations.

METHODS

The methodological approach to the review followed the Preferred Reporting System for Meta-Analyses (PRISMA) guidelines. A thematic analysis was used to identify themes with chronic care models underpinning analysis.

RESULTS

Three themes were identified; nurse-led decision making; consumer profile; and program outcomes. Each theme was divided into two sub-themes. The two sub-themes for decision making were: the experience of the staff who provided the service and the tool or protocol used. The two sub-themes for consumers profile were; the geographic/demographic identity of the consumers, and consumer satisfaction. The final theme of outcomes describes how the effectiveness of the service is measured, broken into two sub-themes: the economic/workforce outcomes and the consumer outcomes.

DISCUSSION

The provision of an after-hours telephone service, in whatever model used should align with a Chronic Care Model. In this way, after-hours telephone services provided by experienced nurses, supported by ongoing professional development and relevant protocols, form part of the ongoing improvement for chronic and complex care management as a health priority.

Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasi-experimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls

Background

To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities.

Methods

Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage.

Results

The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s).

Conclusions

Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

Performance of a new guideline for telephone triage in out-of-hours services in Belgium: A pilot study using simulated patients

BACKGROUND

Patients in Belgium needing out-of-hours care have two options: the emergency department or the general practitioner on call often organised in a general practitioner cooperative. Currently, there is no triage system in Belgium so patients do not know where to go.

METHODS

Our primary objective was to examine the ability of a newly developed telephone guideline, called 1733, to adequately estimate the urgency of health problems presented by simulated patients. Ten clinical vignettes were presented to 12 operators in a simulated phone call. The operators had to assign a protocol, urgency level and resource to dispatch (ambulance, general practitioner house visit, etc.) to each case.

RESULTS

A total of 120 phone calls were analysed. The operators chose the right protocol in 69% and the correct urgency level in 35% of the cases. The proportion of under- and over-triage was 26% and 39%, respectively. There was important variation in between the operators. The sensitivity for detecting highly urgent cases was 0.42, the specificity 0.92.

CONCLUSION

Using the new Belgian 1733 guideline for telephone triage, operators mostly chose the appropriate protocol but only chose the correct urgency in one out of three cases. In this phase of development, the studied telephone guideline is not ready for implementation.

Communication quality in telephone triage conducted by general practitioners, nurses or physicians: a quasi-experimental study using the AQTT to assess audio-recorded telephone calls to out-of-hours primary care in Denmark

OBJECTIVES

To compare the quality of communication in out-of-hours (OOH) telephone triage conducted by general practitioners (GPs), nurses using a computerised decision support system and physicians with different medical specialities, and to explore the association between communication quality and efficiency, length of call and the accuracy of telephone triage.

DESIGN

Natural quasi-experimental cross-sectional study.

SETTING

Two Danish OOH services using different telephone triage models: a GP cooperative and the medical helpline 1813.

PARTICIPANTS

1294 audio-recorded randomly selected OOH telephone triage calls from 2016 conducted by GPs (n=423), nurses using CDSS (n=430) and physicians with different medical specialities (n=441).

MAIN OUTCOME MEASURES

Twenty-four physicians assessed the calls. The panel used a validated assessment tool (Assessment of Quality in Telephone Triage, AQTT) to measure nine aspects of communication, overall perceived communication quality, efficiency and length of call.

RESULTS

The risk of poor quality was significantly higher in calls triaged by GPs compared with calls triaged by nurses regarding 'allowing the caller to describe the situation' (GP: 13.5% nurse: 9.8%), 'mastering questioning techniques' (GP: 27.4% nurse: 21.1%), 'summarising' (GP: 33.0% nurse: 21.0%) and 'paying attention to caller's experience' (GP: 25.7% nurse: 17.0%). The risk of poor quality was significantly higher in calls triaged by physicians compared with calls triaged by GPs in five out of nine items. GP calls were significantly shorter (2 min 57 s) than nurse calls (4 min 44 s) and physician calls (4 min 1 s). Undertriaged calls were rated lower than optimally triaged calls for overall quality of communication (p<0.001) and all specific items.

CONCLUSIONS

Compared with telephone triage by GPs, the communication quality was higher in calls triaged by nurses and lower in calls triaged by physicians with different medical specialities. However, calls triaged by nurses and physicians were longer and perceived less efficient. Quality of communication was associated with accurate triage.

Sachstandsbericht: Strukturierte medizinische Ersteinschätzung in Deutschland (SmED)

Ab 01.01.2020 müssen die Kassenärztlichen Vereinigungen eine telefonische Ersteinschätzung im 24/7-Betrieb anbieten. Ziel ist die Ersteinschätzung der Dringlichkeit akuter Beschwerden und eine Vermittlung an die angemessene Versorgungsstufe. Sehr schwer kranke Patienten müssen unmittelbar der Notfallversorgung, weniger oder nicht dringliche Anliegen alternativen Versorgungsangeboten zugeführt werden. Diese anspruchsvolle Aufgabe werden Fachpersonen übernehmen, die durch geeignete Software unterstützt werden. Im Ausland existieren hierfür Vorbilder. Das Zentralinstitut für die kassenärztliche Versorgung (Zi) überträgt gemeinsam mit der Health Care Quality System GmbH (HCQS) das in Teilen der Schweiz bereits angewendete Swiss Medical Assessment System (SMASS) für eine Anwendung in Deutschland. Das System soll unter dem Namen Strukturierte medizinische Ersteinschätzung in Deutschland (SmED) im Jahr 2019 in den Arztrufzentralen unter der Nummer 116117 eingeführt werden. Auch eine Anwendung für den sogenannten „gemeinsamen Tresen“ von Bereitschaftsdienstpraxen und Krankenhausnotaufnahmen wird entwickelt. Beide Anwendungen werden in dem vom Innovationsfonds geförderten DEMAND-Projekt evaluiert. Die Entwicklung von SmED erfolgt unter Einbeziehung von Vertretern des Marburger Bundes sowie der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) und Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI). Eine technische Integration mit der 112 ist in Arbeit.

Factors affecting medical file documentation during telephone triage at an emergency call centre: a cross-sectional study of out-of-hours home visits by general practitioners in France

Background

In France, general practitioners (GPs) perform out-of-hours home visits (OOH-HVs) after physician-led telephone triage at the emergency call centre. The quality of a systematic physician-led triage has not been determined in France and may affect the efficiency of the OOH-HV process. The objectives of this study were first, to evaluate the quality of reporting in the electronic patient’s file after such triage and second, to analyse the factors associated with altered reporting.

Methods

Cross-sectional study in a French urban emergency call centre (district of Paris area) from January to December 2015. For a random selection of 30 days, data were collected from electronic medical files that ended with an OOH-HV decision. Missing key quality criteria (medical interrogation, diagnostic hypothesis or ruled-out severity criteria) were analysed by univariate then multivariate logistic regression, adjusted on patient, temporal and organizational data.

Results

Among 10,284 OOH-HVs performed in 2015, 748 medical files were selected. Reasons for the encounter were digestive tract symptoms (22%), fever (19%), ear nose and throat symptoms, and cardiovascular and respiratory problems (6% each). Medical interrogation was not reported in 2% of files (n = 16/748) and a diagnostic hypothesis in 58% (n = 432/748); ruled-out severity criteria were not reported in 60% (n = 449/748). On multivariate analysis, altered reporting was related to the work overload of triage assistants (number of incoming calls, call duration, telephone occupation rate; p < 0.03).

Conclusion

In the electronic files of patients requiring an OOH-HV by a GP in a French urban area, quality in medical reporting appeared to depend on organizational factors only, especially the triage assistants-related work factors. Corrective measures are needed to ensure good quality of triage and care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4350-4) contains supplementary material, which is available to authorized users.

Impact of caller's degree-of-worry on triage response in out-of-hours telephone consultations: a randomized controlled trial

BACKGROUND

Telephone triage entails assessment of urgency and direction of flow in out-of-hours (OOH) services, while visual cues are inherently lacking. Triage tools are recommended but current tools fail to provide systematic assessment of the caller's perspective. Research demonstrated that callers can scale their degree-of-worry (DOW) in a telephone contact with OOH services, but its impact on triage response is undetermined. The aim of this study was to investigate the association between call-handlers' awareness of the caller's DOW and the telephone triage response.

METHODS

A randomized controlled trial at a Danish OOH service using telephone triage with quantitative analyses and qualitative process evaluation. Prior to contact with a call-handler, callers were asked to rate their DOW on a five-point scale. Calls were randomized to show or not show DOW on the call-handlers' screens. Triage response (telephone consultation or face-to-face consultation) was analysed using Chi-square tests. Process evaluation incorporated a quantitative and qualitative assessment of intervention implementation and fidelity.

RESULTS

Of 11,413 calls, 5705 were allocated to the intervention and 5708 to the control group. No difference in number of face-to-face consultations was detected between the two groups (OR 1.05, 95% CI 0.98 to 1.14, p = 0.17). The process evaluation showed that call-handlers did not use the DOW systematically and were reluctant to use DOW.

CONCLUSION

Awareness of DOW did not affect the triage response, but this finding could reflect a weak implementation strategy. Future studies should emphasise the implementation strategy to determine the effect of DOW on triage response.

TRIAL REGISTRATION

Registration number, Clinicaltrials.gov NCT02979457 .

Physicians' experiences, attitudes and challenges in a Pediatric Telemedicine Service

BACKGROUND

Telemedicine in general, and telephone triage, in particular, is considered a high-stress clinical activity and involves decision making under conditions of uncertainty and urgency.

AIM

We wanted to explore the experiences, attitudes, and challenges of the physicians in a Pediatric Telemedicine Service operated in Israel, and to explore whether the doctors are using non-medical factors (not related to the medical problem), when making the clinical decisions in this setting.

METHODS

We used a qualitative methodology in order to obtain rich data that would reflect the participants' subjective experiences. Fifteen physicians who worked during the last 5 years in the "Pediatrician Online of Clalit" service were interviewed. Data were analyzed thematically.

FINDINGS

Seven main themes concerning the physicians' challenges during their work at this service were revealed, including difficulties diagnosing from a distance, treating unfamiliar patients, working alone, urgency and load of calls, technological obstacles, and a "moral conflict" between the desire to meet parents' expectations and maintain standards of care. The physicians stated that non-medical factors also affect their decisions.

CONCLUSIONS

In telemedicine setting, physicians face various difficulties and challenges, requiring special expertise, qualities and skills. Special measures are needed to obtain proper diagnosis and decisions.

Telephone counselling by nurses in Norwegian primary care out-of-hours services: a cross-sectional study

Background

The primary care out-of-hours (OOH) services in Norway are characterized by high contact rates by telephone. The telephone contacts are handled by local emergency medical communication centres (LEMCs), mainly staffed by registered nurses. When assessment by a medical doctor is not required, the nurse often handles the contact solely by nurse telephone counselling. Little is known about this group of contacts. Thus, the aim of this study was to investigate characteristics of encounters with the OOH services that are handled solely by nurse telephone counselling.

Methods

Nurses recorded ICPC-2 reason for encounter (RFE) codes and patient characteristics of all patients who contacted six primary care OOH services in Norway during 2014. Descriptive statistics and frequency analyses were applied.

Results

Of all telephone contacts (n = 61,441), 23% were handled solely by nurse counselling. Fever was the RFE most frequently handled (7.3% of all nurse advice), followed by abdominal pain, cough, ear pain and general symptoms. Among the youngest patients, 32% of the total telephone contacts were resolved by nurse advice compared with 17% in the oldest age group. At night, 31% of the total telephone contacts were resolved solely by nurse advice compared with 21% during the day shift and 23% in the evening. The share of nurse advice was higher on weekdays compared to weekends (mean share 25% versus 20% respectively).

Conclusion

This study shows that nurses make a significant contribution to patient management in the Norwegian OOH services. The findings indicate which conditions nurses should be able to handle by telephone, which has implications for training and routines in the LEMCs. There is the potential for more nurse involvement in several of the RFEs with a currently low share of nurse counselling.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0651-z) contains supplementary material, which is available to authorized users.

Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study

OBJECTIVES

To gain insights into the ability of general practitioners (GPs) and nurse practitioners (NPs) to meet patient demands in out-of-hours primary care by comparing the outcomes of teams with different ratios of practitioners.

DESIGN

Quasi-experimental study.

SETTING

A GP cooperative (GPC) in the Netherlands.

INTERVENTION

Team 2 (1 NP, 3 GPs) and team 3 (2 NPs, 2 GPs) were compared with team 1 (4 GPs). Each team covered 35 weekend days.

PARTICIPANTS

All 9503 patients who were scheduled for a consultation at the GPC through a nurse triage system.

OUTCOME MEASURES

The primary outcome was the total number of consultations per provider for weekend cover between 10:00 and 18:00 hours. Secondary outcomes concerned the numbers of patients outside the NPs' scope of practice, patient safety, resource use, direct healthcare costs and GPs' performance.

RESULTS

The mean number of consultations per shift was lower in teams with NPs (team 1: 93.9, team 3: 87.1; p<0.001). The mean proportion of patients outside NPs' scope of practice per hour was 9.0% (SD 6.7), and the highest value in any hour was 40%. The proportion of patients who did not receive treatment within the targeted time period was higher in teams with NPs (team 2, 5.2%; team 3, 8.3%) compared with GPs only (team 1 3.5%) (p<0.01). Team 3 referred more patients to the emergency department (14.7%) compared with team 1 (12.0%; p=0.028). In teams with NPs, GPs more often treated urgent patients (team 1: 13.2%, team 2: 16.3%, team 3: 21.4%; p<0.01) and patients with digestive complaints (team 1: 11.1%, team 2: 11.8%, team 3: 16.7%; p<0.01).

CONCLUSIONS

Primary healthcare teams with a ratio of up to two GPs and two NPs provided sufficient capacity to provide care to all patients during weekend cover. Areas of concern are the number of consultations, delay in patient care and referrals to the emergency department.

TRIAL REGISTRATION

NCT02407847.

Training interventions for improving telephone consultation skills in clinicians

BACKGROUND

Since 1879, the year of the first documented medical telephone consultation, the ability to consult by telephone has become an integral part of modern patient-centred healthcare systems. Nowadays, upwards of a quarter of all care consultations are conducted by telephone. Studies have quantified the impact of medical telephone consultation on clinicians' workload and detected the need for quality improvement. While doctors routinely receive training in communication and consultation skills, this does not necessarily include the specificities of telephone communication and consultation. Several studies assessed the short-term effect of interventions aimed at improving clinicians' telephone consultation skills, but there is no systematic review reporting patient-oriented outcomes or outcomes of interest to clinicians.

OBJECTIVES

To assess the effects of training interventions for clinicians' telephone consultation skills and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other electronic databases and two trial registers up to 19 May 2016, and we handsearched references, checked citations and contacted study authors to identify additional studies and data.

SELECTION CRITERIA

We considered randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted time series studies evaluating training interventions compared with any control intervention, including no intervention, for improving clinicians' telephone consultation skills with patients and their impact on patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed the risk of bias of eligible studies using standard Cochrane and EPOC guidance and the certainty of evidence using GRADE. We contacted study authors where additional information was needed. We used standard methodological procedures expected by Cochrane for data analysis.

MAIN RESULTS

We identified one very small controlled before-after study performed in 1989: this study used a validated tool to assess the effects of a training intervention on paediatric residents' history-taking and case management skills. It reported no difference compared to no intervention, but authors did not report any quantitative analyses and could not supply additional data. We rated this study as being at high risk of bias. Based on GRADE, we assessed the certainty of the evidence as very low, and consequently it is uncertain whether this intervention improves clinicians' telephone skills.We did not find any study assessing the effect of training interventions for improving clinicians' telephone communication skills on patient primary outcomes (health outcomes measured by validated tools or biomedical markers or patient behaviours, patient morbidity or mortality, patient satisfaction, urgency assessment accuracy or adverse events).

AUTHORS' CONCLUSIONS

Telephone consultation skills are part of a wider set of remote consulting skills whose importance is growing as more and more medical care is delivered from a distance with the support of information technology. Nevertheless, no evidence specifically coming from telephone consultation studies is available, and the training of clinicians at the moment has to be guided by studies and models based on face-to-face communication, which do not consider the differences between these two communicative dimensions. There is an urgent need for more research assessing the effect of different training interventions on clinicians' telephone consultation skills and their effect on patient outcomes.

Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

BACKGROUND

The UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting.

METHODS AND FINDINGS

We undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales' National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions. Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods.

CONCLUSIONS

This study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.

Effect of a national urgent care telephone triage service on population perceptions of urgent care provision: controlled before and after study

OBJECTIVE

To measure the effect of an urgent care telephone service NHS 111 on population perceptions of urgent care.

DESIGN

Controlled before and after population survey, using quota sampling to identify 2000 respondents reflective of the age/sex profile of the general population.

SETTING

England. 4 areas where NHS 111 was introduced, and 3 control areas where NHS 111 had yet to be introduced.

PARTICIPANTS

28 071 members of the general population, including 2237 recent users of urgent care.

INTERVENTION

NHS 111 offers advice to members of the general population seeking urgent care, recommending the best service to use or self-management. Policymakers introduced NHS 111 to improve access to urgent care.

OUTCOMES MEASURES

The primary outcome was change in satisfaction with recent urgent care use 9 months after the launch of NHS 111. Secondary outcomes were change in satisfaction with urgent care generally and with the national health service.

RESULTS

The overall response rate was 28% (28 071/100 408). 8% (2237/28 071) had used urgent care in the previous 3 months. Of the 652 recent users of urgent care in the NHS 111 intervention areas, 9% (60/652) reported calling NHS 111 in the 'after' period. There was no evidence that the introduction of NHS 111 was associated with a changed perception of recent urgent care. For example, the percentage rating their experience as excellent remained at 43% (OR 0.97, 95% CI 0.69 to 1.37). Similarly, there was no change in population perceptions of urgent care generally (1.06, 95% CI 0.95 to 1.17) or the NHS (0.94, 95% CI 0.85 to 1.05) following the introduction of NHS 111.

CONCLUSIONS

A new telephone triage service did not improve perceptions of urgent care or the health service. This could be explained by the small amount of NHS 111 activity in a large emergency and urgent care system.

Telephone triage by GPs in out-of-hours primary care in Denmark: a prospective observational study of efficiency and relevance

BACKGROUND

In the UK, telephone triage in out-of-hours primary care is mostly managed by nurses, whereas GPs perform triage in Denmark.

AIM

To describe telephone contacts triaged to face-to-face contacts, GP-assessed relevance, and factors associated with triage to face-to-face contact.

DESIGN AND SETTING

A prospective observational study in Danish out-of-hours primary care, conducted from June 2010 to May 2011.

METHOD

Information on patients was collected from the electronic patient administration system and GPs completed electronic questionnaires about the contacts. The GPs conducting the face-to-face contacts assessed relevance of the triage to face-to-face contacts. The authors performed binomial regression analyses, calculating relative risk (RR) and 95% confidence intervals.

RESULTS

In total, 59.2% of calls ended with a telephone consultation. Factors associated with triage to a face-to-face contact were: patient age >40 years (40-64: RR = 1.13; >64: RR = 1.34), persisting problem for 12-24 hours (RR = 1.15), severe problem (RR = 2.60), potentially severe problem (RR = 5.81), and non-severe problem (RR = 2.23). Face-to-face contacts were assessed as irrelevant for 12.7% of clinic consultations and 11.7% of home visits. A statistically significantly higher risk of irrelevant face-to-face contact was found for a persisting problem of >24 hours (RR = 1.25), contact on weekday nights (RR = 1.25), and contact <2 hours before the patient's own GP's opening time (RR = 1.80).

CONCLUSION

Around 12% of all face-to-face consultations in the study are assessed as irrelevant by GP colleagues, suggesting that GP triage is efficient. Knowledge of the factors influencing triage can provide better education for GPs, but future studies are needed to investigate other quality aspects of GP telephone triage.

Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners

BACKGROUND

Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent.

OBJECTIVES

To identify views of GPs to influence the use of the out-of-hours GP cooperatives.

METHODS

Cross-sectional survey study among a random sample of 800 GPs in the Netherlands.

RESULTS

Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a 'very important' reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective.

CONCLUSION

This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies. [Box: see text].

Telephone triage in general practices: A written case scenario study in the Netherlands

OBJECTIVE

General practices increasingly use telephone triage to manage patient flows. During triage, the urgency of the call and required type of care are determined. This study examined the organization and adequacy of telephone triage in general practices in the Netherlands.

DESIGN

Cross-sectional observational study using a web-based survey among practice assistants including questions on background characteristics and triage organization. Furthermore, practice assistants were asked to assess the required type of care of written case scenarios with varying health problems and levels of urgency. To determine the adequacy of the assessments, a comparison with a reference standard was made. In addition, the association between background characteristics and triage organization and the adequacy of triage was examined.

SETTING

Daytime general practices.

SUBJECTS

Practice assistants.

MAIN OUTCOME MEASURES

Over- and under-estimation, sensitivity, specificity.

RESULTS

The response rate was 41.1% (n = 973). The required care was assessed adequately in 63.6% of cases, was over-estimated in 19.3%, and under-estimated in 17.1%. The sensitivity of identifying patients with a highly urgent problem was 76.7% and the specificity was 94.0%. The adequacy of the assessments of the required care was higher for more experienced assistants and assistants with fixed daily work meetings with the GP. Triage training, use of a triage tool, and authorization of advice were not associated with adequacy of triage.

CONCLUSION

Triage by practice assistants in general practices is efficient (high specificity), but potentially unsafe in highly urgent cases (suboptimal sensitivity). It is important to train practice assistants in identifying highly urgent cases.

KEY POINTS

General practices increasingly use telephone triage to manage patient flows, but little is known about the organization and adequacy of triage in daytime practices. Telephone triage by general practice assistants is efficient, but potentially unsafe in highly urgent cases. The adequacy of triage is higher for more experienced assistants and assistants with fixed daily work meetings with the general practitioner.

The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial)

BACKGROUND

Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice.

OBJECTIVES

In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice.

DESIGN

Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation.

SETTING

General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk).

PARTICIPANTS

Patients requesting same-day consultations.

INTERVENTIONS

Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation.

MAIN OUTCOME MEASURES

Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care.

RESULTS

Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it.

CONCLUSIONS

Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20687662.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

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.

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.

'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety

BACKGROUND

The role of time management in safe and efficient medicine is important but poorly incorporated into the taxonomies of error in primary care. This paper addresses the lack of time management, presenting a framework integrating five time scales termed 'Tempos' requiring parallel processing by GPs: the disease's tempo (unexpected rapid evolutions, slow reaction to treatment); the office's tempo (day-to-day agenda and interruptions); the patient's tempo (time to express symptoms, compliance, emotion); the system's tempo (time for appointments, exams, and feedback); and the time to access to knowledge. The art of medicine is to control all of these tempos in parallel and simultaneously.

METHOD

Two qualified physicians reviewed a sample of 1046 malpractice claims from one liability insurer to determine whether a medical injury had occurred and, if so, whether it was due to one or more tempo-related problems. 623 of these reports were analysed in greater detail to identify the prevalence and characteristics of claims and related time management errors.

RESULTS

The percentages of contributing factors were as follows: disease tempo, 37.9%; office tempo, 13.2%; patient tempo, 13.8%; out-of-office coordination tempo, 22.6%; and GP's access to knowledge tempo, 33.2%.

CONCLUSION

Although not conceptualised in most error taxonomies, the disease and patient tempos are cornerstones in risk management in primary care. Traditional taxonomies describe events from an analytical perspective of care at the system level and offer opportunities to improve organisation, process, and evidence-based medicine. The suggested classification describes events in terms of (unsafe) dynamic control of parallel constraints from the carer's perspective, namely the GP, and offers improvement on how to self manage and coordinate different contradictory tempos and day-to-day activities. Further work is needed to test the validity and usefulness of this approach.

Awareness and use of a new urgent care telephone service, NHS 111: cross-sectional population survey

OBJECTIVES

Telephone-accessed health care plays a significant part in the delivery of urgent care internationally. NHS 111 is a telephone service set up to improve and simplify access to non-emergency National Health Service health care in England. The first aim of this research was to describe population awareness and use of this new service, overall and within different sub-groups. In doing so, the second aim was to identify any inequity in awareness or use of telephone-accessed health care.

METHODS

We undertook a telephone survey to assess awareness and use of NHS 111 in four sites. Random digit dialing was undertaken to identify 2000 respondents in each site. The survey was undertaken in 2011, approximately 9-10 months after the launch of NHS 111 in each site. Eight thousand and ten members of the general population completed a questionnaire.

RESULTS

Fifty-nine percent of respondents had heard of NHS 111 and 9% reported ever using NHS 111. Respondents were less likely to have used NHS 111 if they were older (p ≤ 0.001), male (p ≤ 0.001), and did not have a disability/limiting long-term illness (p ≤ 0.001) or own their home (p = 0.039).

CONCLUSIONS

The use of the telephone as an important means of access to urgent care may be problematic if some groups in the population are less likely to use it. Policy makers and service providers may need to consider other ways of offering access to care or deliver targeted publicity campaigns to encourage the use of telephone-accessed health care amongst specific groups within a population.

Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support

Background

Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN^©.

Methods

We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety.

Results

Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68).

Conclusions

CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved 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.

Employees' views on home-based, after-hours telephone triage by Dutch GP cooperatives

BACKGROUND

Dutch out-of-hours (OOH) centers find it difficult to attract sufficient triage staff. They regard home-based triage as an option that might attract employees. Specially trained nurses are supposed to conduct triage by telephone from home for after-hours medical care. The central aim of this research is to investigate the views of employees of OOH centers in The Netherlands on home-based telephone triage in after-hours care.

METHODS

The study is a Q methodology study. Triage nurses, general practitioners (GPs) and managers of OOH centers ranked 36 opinion statements on home-based triage. We interviewed 10 participants to help develop and validate the statements for the Q sort, and 77 participants did the Q sort.

RESULTS

We identified four views on home-based telephone triage. Two generally favor home-based triage, one highlights some concerns and conditions, and one opposes it out of concern for quality. The four views perceive different sources of credibility for nurse triagists working from home.

CONCLUSION

Home-based telephone triage is a controversial issue among triage nurses, GPs and managers of OOH centers. By identifying consensus and dissension among GPs, triagists, managers and regulators, this study generates four perspectives on home-based triage. In addition, it reveals the conditions considered important for home-based triage.

Teleconsultation in children with abdominal pain: a comparison of physician triage recommendations and an established paediatric telephone triage protocol

Background

Quality assessment and continuous quality feedback to the staff is crucial for safety and efficiency of teleconsultation and triage. This study evaluates whether it is feasible to use an already existing telephone triage protocol to assess the appropriateness of point-of-care and time-to-treat recommendations after teleconsultations.

Methods

Based on electronic patient records, we retrospectively compared the point-of-care and time-to-treat recommendations of the paediatric telephone triage protocol with the actual recommendations of trained physicians for children with abdominal pain, following a teleconsultation.

Results

In 59 of 96 cases (61%) these recommendations were congruent with the paediatric telephone protocol. Discrepancies were either of organizational nature, due to factors such as local referral policies or gatekeeping insurance models, or of medical origin, such as milder than usual symptoms or clear diagnosis of a minor ailment.

Conclusions

A paediatric telephone triage protocol may be applicable in healthcare systems other than the one in which it has been developed, if triage rules are adapted to match the organisational aspects of the local healthcare system.

The effectiveness and cost-effectiveness of telephone triage of patients requesting same day consultations in general practice: study protocol for a cluster randomised controlled trial comparing nurse-led and GP-led management systems (ESTEEM)

BACKGROUND

Recent years have seen an increase in primary care workload, especially following the introduction of a new General Medical Services contract in 2004. Telephone triage and telephone consultation with patients seeking health care represent initiatives aimed at improving access to care. Some evidence suggests that such approaches may be feasible but conclusions regarding GP workload, cost, and patients' experience of care, safety, and health status are equivocal. The ESTEEM trial aims to assess the clinical- and cost-effectiveness of nurse-led computer-supported telephone triage and GP-led telephone triage, compared to usual care, for patients requesting same-day consultations in general practice.

METHODS/DESIGN

ESTEEM is a pragmatic, multi-centre cluster randomised clinical trial with patients randomised at practice level to usual care, computer decision-supported nurse triage, or GP-led triage. Following triage of 350-550 patients per practice we anticipate estimating and comparing total primary care workload (volume and time), the economic cost to the NHS, and patient experience of care, safety, and health status in the 4-week period following the index same-day consultation request across the three trial conditions.We will recruit all patients seeking a non-emergency same-day appointment in primary care. Patients aged 12.0-15.9 years and temporary residents will be excluded from the study.The primary outcome is the number of healthcare contacts taking place in the 4-week period following (and including) the index same-day consultation request. A range of secondary outcomes will be examined including patient flow, primary care NHS resource use, patients' experience of care, safety, and health status.The estimated sample size required is 3,751 patients (11,253 total) in each of the three trial conditions, to detect a mean difference of 0.36 consultations per patient in the four week follow-up period between either intervention group and usual care 90% power, 5% alpha, and an estimated intracluster correlation coefficient ICC of 0.05. The primary analysis will be based on the intention-to-treat principle and take the form of a random effects regression analysis taking account of the hierarchical nature of the study design. Statistical models will allow for adjustment for practice level minimisation variables and patient-level baseline covariates shown to differ at baseline.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN20687662.

Patient views of single number access to urgent care services

BACKGROUND

In October 2009, NHS County Durham and Darlington introduced a single point of access telephone number for people requiring out-of-hours health care. We evaluated users' views and experiences of the service.

METHODS

We used a validated questionnaire adapted for use in telephone interviews, with open-ended questions added to allow people to express their views. Interviews were carried out with 493 people who had used the urgent care line between April and July 2010 of 1626 telephone calls made, a response rate of 30.3%. SPSS 17.0 was used to analyse the quantitative data and Framework analysis the qualitative data.

RESULTS

We found that (i) regardless of age or gender people who used the call line were satisfied with the service they received, (ii) the call line advised most cases to go to an urgent care centre, (iii) people who received advice other than that expected were still satisfied with the service. Criticisms of the service related to confusion about accessing the service and which number callers should use.

CONCLUSIONS

We found very high levels of satisfaction across all groups for a single point of access telephone number for urgent care. Clear information about the service, in particular that it will involve telephone triage and that access to a doctor or nurse is not immediate, may also resolve some instances of dissatisfaction. It appears that the service is effective in directing people to places where they can be dealt with appropriately.

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.

Nurse telephone triage: good quality associated with appropriate decisions

BACKGROUND

Triage at out-of-hours GP cooperatives (GPCs) is aimed at determining medical urgency and guiding decisions. Both medical knowledge and communication skills are required for this complex task.

OBJECTIVE

To explore the impact of quality of consultation and estimated urgency on the appropriateness of decisions.

METHODS

We performed a secondary analysis of telephone triage consultations by nurses at 29 Dutch GPCs. Consultations were taped and assessed by trained observers, using a validated instrument. Measures concerned quality of consultation, nurse-estimated urgency (four levels) and appropriateness of decisions (urgency, follow-up advice and timing). Bivariate analyses and logistic multilevel regression analyses were used to explore the impact of quality of consultation (controlling for urgency) on appropriateness of decisions.

RESULTS

The sample included 6739 telephone contacts, most of which (90%) were non-urgent. The majority of decisions were appropriate (91% for urgency, 96% for follow-up advice and 95% for timing). In bivariate analyses, appropriateness of decisions was positively related to higher quality of consultation. Estimated urgency was negatively associated with quality of consultation. Logistic multilevel analysis showed that higher quality of consultation was related to a more appropriate estimation of urgency [odds ratio (OR) = 1.82; 95% confidence interval (CI): 1.69-1.95], follow-up advice (OR = 2.69; 95% CI: 2.41-3.01) and timing of decisions (OR = 2.41; 95% CI: 2.20-2.63).

CONCLUSIONS

High quality of consultation has a positive, but small, impact on the appropriateness of decisions. Quality of consultation needs to be targeted in training and support of triage nurses, especially when it concerns highly urgent contacts.

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

OBJECTIVE

Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.

METHODS

A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem).

RESULTS

Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5-97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7-90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7-49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6).

CONCLUSIONS

There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.

Validity of telephone and physical triage in emergency care: the Netherlands Triage System

BACKGROUND

Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers.

OBJECTIVE

Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs).

METHODS

Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend.

RESULTS

We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice.

CONCLUSIONS

Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible.

Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios

Background

The use of nurses for telephone-based triage in out-of-hours services is increasing in several countries. No investigations have been carried out in Norway into the quality of decisions made by nurses regarding our priority degree system. There are three levels: acute, urgent and non-urgent.

Methods

Nurses working in seven casualty clinics in out-of-hours districts in Norway (The Watchtowers) were all invited to participate in a study to assess priority grade on 20 written medical scenarios validated by an expert group. 83 nurses (response rate 76%) participated in the study. A one-out-of-five sample of the nurses assessed the same written cases after 3 months (n=18, response rate 90%) as a test–retest assessment.

Results

Among the acute, urgent and non-urgent scenarios, 82%, 74% and 81% were correctly classified according to national guidelines. There were significant differences in the proportion of correct classifications among the casualty clinics, but neither employment percentage nor profession or work experience affected the triage decision. The mean intraobserver variability measured by the Cohen kappa was 0.61 (CI 0.52 to 0.70), and there were significant differences in kappa with employment percentage. Casualty clinics and work experience did not affect intrarater agreement.

Conclusion

Correct classification of acute and non-urgent cases among nurses was quite high. Work experience and employment percentage did not affect triage decision. The intrarater agreement was good and about the same as in previous studies performed in other countries. Kappa increased significantly with increasing employment percentage.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median child's age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or caller's part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.

How serious are the symptoms of callers to a telephone triage call centre?

Adverse events such as deaths following telephone triage calls are rare, suggesting that the process is basically safe. However, if calls tend to concern mostly minor illnesses, then adverse events following calls would be uncommon even if the triage process itself was flawed. We investigated hospitalization rates following triage calls and compared them to hospitalization following two other types of medical access, emergency department (ED) visits and office visits. For the Ask Mayo Clinic telephone triage centre, hospitalization rates for adult calls concerning chest pain and abdominal pain were each 13%. Based on national survey data, hospitalization for adult ED visits concerning the same symptoms were 33% (chest pain) and 19% (abdominal pain). Office visits had hospitalization rates significantly lower than triage calls in all age groups, while ED visits had higher hospitalization rates than triage calls in all age groups. There are both qualitative and quantitative similarities between triage calls and ED visits and, using hospitalization as an indicator, some subgroups of triage calls are nearly as serious as ED visits.