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

Factors associated with undertriage and overtriage in telephone triage in Danish out-of-hours primary care: a natural quasi-experimental cross-sectional study of randomly selected and high-risk calls

OBJECTIVES

We aim to explore undertriage and overtriage in a high-risk patient population and explore patient characteristics and call characteristics associated with undertriage and overtriage in both randomly selected and in high-risk telephone calls to out-of-hours primary care (OOH-PC).

DESIGN

Natural quasi-experimental cross-sectional study.

SETTING

Two Danish OOH-PC services using different telephone triage models: a general practitioner cooperative with GP-led triage and the medical helpline 1813 with computerised decision support system-guided nurse-led triage.

PARTICIPANTS

We included audio-recorded telephone triage calls from 2016: 806 random calls and 405 high-risk calls (defined as patients ≥30 years calling with abdominal pain).

MAIN OUTCOME MEASURES

Twenty-four experienced physicians used a validated assessment tool to assess the accuracy of triage. We calculated the relative risk (RR) for clinically relevant undertriage and overtriage for a range of patient characteristics and call characteristics.

RESULTS

We included 806 randomly selected calls (44 clinically relevant undertriaged and 54 clinically relevant overtriaged) and 405 high-risk calls (32 undertriaged and 24 overtriaged). In high-risk calls, nurse-led triage was associated with significantly less undertriage (RR: 0.47, 95% CI 0.23 to 0.97) and more overtriage (RR: 3.93, 95% CI 1.50 to 10.33) compared with GP-led triage. In high-risk calls, the risk of undertriage was significantly higher for calls during nighttime (RR: 2.1, 95% CI 1.05 to 4.07). Undertriage tended to be more likely for calls concerning patients ≥60 years compared with 30-59 years (11.3% vs 6.3%) in high-risk calls. However, this result was not significant.

CONCLUSION

Nurse-led triage was associated with less undertriage and more overtriage compared with GP-led triage in high-risk calls. This study may suggest that to minimise undertriage, the triage professionals should pay extra attention when a call occurs during nighttime or concerns elderly. However, this needs confirmation in future studies.

From direct attendance to telephone triage in an emergency primary healthcare service: an observational study

OBJECTIVES

To describe how an intervention to limit direct attendance in an emergency primary healthcare service affected the contacts to the clinic and the level of care given, and which factors were associated with a change from direct attendance to telephone contact.

DESIGN

Observational study.

SETTING

Seven Norwegian emergency primary healthcare services. The telephone triage operators are primarily registered nurses.

PARTICIPANTS

Registered patient contacts to the services during 2007-2019.

INTERVENTIONS

In 2013, one of the seven services made an intervention to limit direct attendances to the emergency primary healthcare clinic. Through an advertisement in a local newspaper, the public was encouraged to call in advance. Patients who still attended directly, were encouraged to call in advance next time.

MEASURES

We compared the proportions of direct attendance and telephone contact, and of consultation by a general practitioner and telephone consultation by an operator, before and after the intervention. We also compared the proportions of direct attendance regarding gender, age group, time of day and urgency level. Descriptive analyses and log binomial regression analyses were applied.

RESULTS

There were 1 105 019 contacts to the seven services during the study period. The average proportion of direct attendance decreased from 68.7% (95% CI 68.4% to 68.9%) to 23.4% (95% CI 23.2% to 23.6%) in the service that carried out the intervention. Telephone consultation by an operator increased from 11.7% (95% CI 11.5% to 11.8%) to 29.2% (95% CI 28.9% to 29.5%) and medical consultation by a general practitioner decreased from 78.3% (95% CI 78.1% to 78.5%) to 57.0% (95% CI 56.7% to 57.3%). The youngest and the oldest age group and women had the largest decrease in direct attendance, by -81%, -74% and -71%, respectively.

CONCLUSION

The intervention influenced how the public contacted the service. Information campaigns on how to contact healthcare services should be implemented on a regular basis.

Out-of-hours primary care for people with intellectual disabilities: interviews in general practice

BACKGROUND

Out-of-hours primary care for people with intellectual disabilities (ID) involves different groups of health care professionals, who are often not familiar to one another nor to the specific health care needs of this vulnerable population. It is not known to what extend these specific health care needs or organizational factors influence the delivery of out-of-hours primary care for people with ID.

OBJECTIVE

The objective of this study is to explore the experiences of health care professionals regarding the medical content and the organizational context of out-of-hours primary care for people with ID.

METHODS

Semi-structured interviews were conducted with daily care professionals, triage nurses and general practitioners (GPs) involved in out-of-hours primary care for people with ID in the Netherlands. Interviews were thematically analysed for medical content and organizational context.

RESULTS

The analysis resulted in four interconnected themes: (i) uncertainties in the triage assessment of ID patients; (ii) confusion about inter-professional responsibilities; (iii) impact on routines and workflow concerning ID patients and (iv) constraints in the decision-making process. All issues raised were related to the organizational context.

CONCLUSIONS

Health care professionals involved in out-of-hours primary care for people with ID indicate that the quality of this care is more influenced by the organizational context than by the medical content. We recommend out-of-hours GP services and care provider services for people with ID to set standards for roles and responsibilities in order to facilitate health care professionals in delivering accessible and high-quality care to this vulnerable population.

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.

Impact of a telephone triage service for non-critical emergencies in Switzerland: A cross-sectional study

INTRODUCTION

Telephone triage services (TTS) play an increasing role in the delivery of healthcare. The objective of this study was to characterize the adult users of a TTS for non-critical emergencies, describe the types of advice given and their subsequent observation, and assess the influence of TTS on the use of the healthcare system in a sanitary region of Switzerland.

METHODS

Data from a TTS based in the French part of Switzerland were analyzed. This service consists of a medical contact center for non-critical emergencies, with trained nurses available 24/7. A random selection of 2,034 adult calls was performed between July and December 2018. Research students contacted users 2 to 4 weeks after the initial call and assessed sociodemographic and clinical data, as well as the impact of the advice received on the use of the healthcare system.

RESULTS

A sample of 412 users was included in the analyses. The average age was 49.0 (SD 20.4) years; 68.5% were women and 72.8% of Swiss origin. The two main recommendations provided by nurses were to consult the emergency department (ED) (44.6%, n = 184) and to contact a physician on duty (33.2%, n = 137). The majority of users followed the advice given by the nurses (substantial agreement [k = 0.79] with consulting the ED and perfect agreement [k = 0.87] with contacting a physician on duty). We calculated that calling the TTS could decrease the intention to visit the ED by 28.1%.

CONCLUSION

TTS for non-critical emergencies have the potential to decrease the use of ED services.

The implementation of the nationwide out-of-hours phone number 1733 in Belgium: analysis of efficiency and safety

Background:

Belgium has a problem with inappropriate use of emergency services. The government installed the number 1733 for out-of-hours care. Through a dry run test, we learned that 30% of all calls were allocated to the protocol ‘unclear problem’. In only 11.9% of all cases, there was an unclear problem.

Methods:

The study aimed to determine whether the adjusted protocol ‘unwell for no clear reason’ led to a safer and more efficient referral and to evaluate the efficiency and safety of the primary care protocols (PCPs). The study ran in cross-sectional design involving patients, General Practitioner Cooperatives and telephone operators. A random sample of calls to 1733 and patient referrals were assessed on efficiency and safety.

Results:

During 6 months in 2018, 11 622 calls to 1733 were registered. Seven hundred fifty-six of them were allocated to ‘unwell for no clear reason’, and a random sample of 180 calls was audited. To evaluate the PCPs, 202 calls were audited. The efficiency and safety of the protocol ‘unwell for no clear reason’ improved, and safety levels for under- and over-triage were not exceeded. The GP’s judged that 9/10 of all patient encounters were correctly referred.

Conclusion:

This study demonstrated that the 1733-telephone triage system for out-of-hours care is successful if protocols, flow charts and emergency levels are well defined, monitored and operators are trained.

Limited reliability of experts' assessment of telephone triage in primary care patients with chest discomfort

OBJECTIVE

Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability.

STUDY DESIGN AND SETTING

This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation.

RESULTS

In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32).

CONCLUSIONS

Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.

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.

Benefit of a nurse-led telephone-based intervention prior to the first urogynecology outpatient visit: a randomized-controlled trial

Introduction and hypothesis

Triage has become a valid tool to reduce workload during the first consultation in a specialized clinic. A nurse-led telephone intervention prior to the first urogynecologic visit reduces visit duration and increases patients’ and physicians’ satisfaction.

Methods

All patients scheduled for their very first visit were recruited. They were randomized into an intervention group (prior contact by a specialized urogynecology nurse) and a control group (no contact). The intervention included a questionnaire about history and symptoms. Patients were prompted to complete a bladder diary. Primary outcome was duration of the consultation; secondary outcomes were patients’ and physicians’ satisfaction with the intervention.

Results

Fifty-five patients were allocated to the intervention group and 53 to the control group with no difference regarding age, BMI, parity, menopausal status and primary diagnosis. Mean duration of the telephone call was 10.8 min (SD 4.4). The consultation was significantly shorter in the intervention group than in the control group (mean difference: 4 min and 8 s, p = 0.017). In the intervention group, 79% of the patients found the consultation quality “excellent,” 86% would return, and 77% would recommend our clinic to a relative or friend compared with 68%, 67% and 66%, respectively, in the control group. Physicians were “very satisfied” or “satisfied” with the patient preparation.

Conclusions

A nurse-led intervention reduces the duration of the first uroynecologic consultation and is associated with high patient and physician satisfaction. Further research should evaluate whether it also decreases the number of follow-up visits and further referrals.

Electronic supplementary material

The online version of this article (10.1007/s00192-020-04318-0) contains supplementary material, which is available to authorized users.

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.

Age and Sex Differences in the Use of Emergency Telephone Consultation Services in Saitama, Japan: A Population-Based Observational Study

The frequency of use of emergency telephone consultation (ETC) services, which is a telephone triage system in Japan, was explored to determine age- and sex-related trends on symptoms/events among Japanese adults. Data were obtained from records of the initial year of ETC services in Saitama Prefecture (from October 2014 to September 2015). Residents who used the ETC services were divided into four age groups (20–39, 40–64, 65–74, and ≥75 years old). The number of calls per 1000 persons (call rate, CR) was compared between the groups. The annual CR for the top 10 symptoms/events were assessed. The annual CR was 2.6/1000 persons. The annual CR was significantly higher for women (2.9) than for men (2.3) (p < 0.05). ETC use was the highest in the 20–39 age group for both sexes (3.3 and 4.4 in men and women, respectively). All groups had fever, abdominal pain, and nausea/vomiting in common. In older adults, the frequency of events such as bruises and head injury was high. Women and younger adults tended to use ETC services. There were similarities and differences in symptoms/events among the groups, which should be recognized by call centers to help foster call center staff.

Giving advice to callers with mental illness: adaptation among telenurses at Swedish Healthcare Direct

Purpose: Our aim was to describe Swedish Healthcare Direct (SHD) and its features as a complex system.

Methods: Qualitative interviews were conducted with 20 SHD telenurses, covering their experiences and skills when encountering and advising callers with mental illness. Complexity science was used as an a priori theoretical framework to enhance understanding of the complex nature of telenursing.

Results: SHD was described as a complex system as nurses were constantly interacting with other agents and agencies. During these interactions, dynamic processes were found between the agents in which the nurses adapted to every new situation. They were constantly aware of their impact on the care-seekers, and perceived their encounters with callers with psychiatric illness as “balancing on a thin line”. SHD was also described as both an authority and a dumping ground. The openness of the system did not give the nurses possibility to control the number of incoming calls and the callers’ intentions.

Conclusions: These new insights into SHD have important implications for organization developers and nursing management in terms of overcoming linear thinking.

Triage for out-of-hours primary care calls: a reliability study of a new French-language algorithm, the SALOMON rule

Introduction: Triage systems for out-of-hours primary care physician (PCP) calls have been implemented empirically but no triage algorithm has been validated to date. A triage algorithm named SALOMON (Système Algorithmique Liégeois d'Orientation pour la Médecine Omnipraticienne Nocturne) was developed to guide triage nurses. This study assessed the performance of the algorithm using simulated PCP calls. Methods: Ten nurses were involved in 130 simulated PCP call scenarios, allowing the determination of SALOMON's inter-rater agreement by comparing the actual choices of a specific triage flowchart and the level of care selected as compared with reference assignments. Intra-rater agreement was estimated by comparing triage after training (T1) and 3 to 6 months after SALOMON use in clinical practice (T2). Results: Overall selection of flowcharts was accurate for 94 .1% of scenarios at T1 and 98.7% at T2. Level of triage was adequate for 93.4% of scenarios at T1 and 98.5% at T2. Both flowchart and triage level accuracy improved significantly from T1 to T2 (p < 0.0001). SALOMON algorithm use is associated with a 0.97/0.99 sensitivity and 0.97/0.99 specificity, at T1/T2 respectively. Conclusions: Results revealed that using the SALOMON algorithm is valid for out-of-hours PCP calls triage by nurses. The criterion validity of this algorithm should be further evaluated through its implementation in a real life setting.

Help-seeking behaviour outside office hours in Denmark, the Netherlands and Switzerland: a questionnaire study exploring responses to hypothetical cases

OBJECTIVES

We aim to study the preferred behaviour among individuals from different age groups in three countries when acute health problems occur outside office hours and thereby to explore variations in help-seeking behaviour.

DESIGN

A questionnaire study exploring responses to six hypothetical cases describing situations with a potential need for seeking medical care and questions on background characteristics.

SETTING

General population in Denmark, the Netherlands and Switzerland.

POPULATION

Danish, Dutch and Swiss individuals from three age groups (0-4, 30-39, 50-59 years).

MAIN OUTCOME MEASURES

Distribution of intended help-seeking preferences per case per age group, compared between countries. Differences in percentage of help-seeking outside office hours per age group and country, crude and adjusted for background characteristics.

RESULTS

Danish and Dutch parents of children aged 0-4 years differed in intended help-seeking behaviour for five out of six cases (abdominal pain, red eyes, rash, relapse fever, chickenpox); Danish parents significantly more often chose to contact out-of-hours (OOH) care than Dutch parents. For adults aged 30-39 years, no significant difference between the three countries was found for contacting OOH care. Swiss adults aged 50-59 years had the highest percentage of OOH contacts (38.3%), followed by the Danish (33.4%) and the Dutch (32.5%).

CONCLUSION

Some differences in help-seeking behaviour outside office hours exist between Danish, Dutch and Swiss individuals, particularly for parents of young children. The question remains whether these differences result from individual preferences, cultural disparities and/or health services variations. Future research should focus on identifying explanations for these differences to reduce undesirable use of OOH care.

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.

A Semantic-Based Model for Triage Patients in Emergency Departments

Triage is a process performed in an emergency department that aims to sort patients according to their need for care. When performed speedily and correctly, this process can potentially increase the chances of survival for a patient with serious complications. This study aims to develop a computer model, called UbiTriagem, which supports the process of triage using the concepts of web semantics and ubiquitous computing focused on healthcare. For evaluating the proposal, we performed an analysis of scenario-driven triage based on previously determined ratings. In addition, we conducted a usability evaluation in emergency department with the developed prototype with two user groups: nurses and patients. The main scientific contribution is the automatic triage assessment based on the gathering of patient data on mobile devices, performed automatically through the use of a reasoning technique in an ontology. The results for all evaluations were very positive. The automatic triage assessment has been assertive in 93.3% of the cases and, after adjustments in the model, in 100% of the cases. Regarding user satisfaction, we obtained rates of 98.7% and 96% when considering perception of utility and ease of use, respectively.

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.

The league of extraordinary generalists: a qualitative study of professional identity and perceptions of role of GPs working on a national after hours helpline in Australia

Background

Telephone triage and advice services (TTAS) have become commonplace in western health care systems particularly as an aid to patient access and demand management in the after hours period. In 2011 an after hours general practitioner (GP) helpline was established as a supplementary service to existing 24-h nurse-TTAS in Australia. Callers to the service in the after hours period who are triaged by a nurse as needing to see a GP immediately or within 24 h may speak with a GP on the line to obtain further assessment and advice.

While much research has been undertaken on the roles of nurses in TTAS and the professional identities and attitudes to new technology of community-based GPs, little is known of the perceptions of role and identity of GPs providing after hours advice on primary care helplines. This qualitative study explored the perceptions of professional identity and role, motivations and contributions to the health system of GPs employed on the Australian afterhours GP helpline in 2011–2013.

Methods

The study took a phenomenographic approach seeking to understand the essence of being a telephone GP, probing professional identity while also exploring role tensions. Twelve GPs, or 15 % of the helpline GP workforce participated in the qualitative study.

Results

The GPs experienced both personal and professional benefits and believed they were strengthening patient care and the Australian health system. However the role required a re-alignment of practice that challenged professional autonomy, the doctor-patient relationship and commitment to continuity of care. Some GPs made this role realignment more readily than others and were well suited to the helpline role. There was a strong collegial bond amongst the helpline GPs which facilitated the maintenance of professional autonomy.

Conclusions

Telephone GP assessment and advice does not demonstrate the same breadth as face-to-face practice and provides little opportunity for continuity of care, but this has not prevented those performing the role from identifying as a new form of generalist. The establishment of an after hours GP helpline in Australia has seen the emergence of a new generalist primary care identity as telehealth innovators.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1387-5) contains supplementary material, which is available to authorized users.

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.

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.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

The nurse training intervention improved the quality of telephone triage.

RELEVANCE TO CLINICAL PRACTICE

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Acesso ao cuidado na Estratégia Saúde da Família: equilíbrio entre demanda espontânea e prevenção/promoção da saúde

Este artigo propõe algumas diretrizes para a organização do trabalho na Atenção Primária à Saúde (APS) e na Estratégia Saúde da Família (ESF), relacionadas aos desafios de prover acesso e equilibrar no cotidiano dos serviços ações de prevenção de agravos e promoção da saúde com o cuidado ao adoecimento. Primeiramente, apresenta algumas ideias específicas sobre a importância do acesso para a qualidade dos serviços de saúde, seguidas de uma crítica sintética - fundamentada nos conceitos de Geoffrey Rose - à estratégia preventiva de alto risco, que tem tido alto impacto na organização das rotinas assistenciais. A seguir, contextualiza a promoção da saúde relacionada ao cuidado individual na APS/ESF, discutindo o potencial sinérgico do cuidado e da promoção da saúde, em suas dimensões individuais e coletivas, para transcender o modelo biomédico/mecanicista. Finalmente, apoiado nos tópicos anteriores, no que tange aos seus desdobramentos operacionais e utilizando um exemplo concreto, propõe algumas diretrizes para a organização do trabalho e das agendas de médicos e enfermeiros da ESF, de modo a viabilizar equilíbrio e sinergia entre acesso ao cuidado e prevenção/promoção, com vistas ao fortalecimento da ESF como coordenadora local do cuidado e principal porta de entrada do Sistema Único de Saúde.

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.

Why parents use the emergency department during evening hours for nonemergent pediatric care

BACKGROUND

Emergency departments (EDs) are commonly used by pediatric patients for nonemergent reasons. There is little information regarding how parents perceive their use of the ED and primary care availability during evening hours.

METHODS

We conducted a survey of parental perspectives of ED use during evening hours. Participants were parents of pediatric patients (age 0-18 years) at a large quaternary medical center's ED presenting between 17:00 and 22:00 hours from January 15, 2013 to March 12, 2013.

RESULTS

Most patients had a primary care pediatrician (98/102, 96.1%); 80% of their pediatricians (78/98) did not have evening hour availability. Overall, 46.7% of parents would have preferred to go to their primary care pediatrician.

CONCLUSIONS

Many parents who expect outpatient treatment prefer to take their child to a primary care pediatrician during evening hours, but present to the ED because of lack of primary care access.

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.

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

OBJECTIVE

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

STUDY DESIGN

Cross-sectional qualitative focus group study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

[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.

Major incident preparedness and on-site work among Norwegian rescue personnel - a cross-sectional study

BACKGROUND

A major incident has occurred when the number of live casualties, severity, type of incident or location requires extraordinary resources. Major incident management is interdisciplinary and involves triage, treatment and transport of patients. We aimed to investigate experiences within major incident preparedness and management among Norwegian rescue workers.

METHODS

A questionnaire was answered by 918 rescue workers across Norway. Questions rated from 1 (doesn't work) to 7 (works excellently) are presented as median and range.

RESULTS

Health-care personnel constituted 34.1% of the participants, firefighters 54.1% and police 11.8%. Training for major incident response scored 5 (1, 7) among health-care workers and 4 (1, 7) among firefighters and police. Preparedness for major incident response scored 5 (1, 7) for all professions. Interdisciplinary cooperation scored 5 (3, 7) among health-care workers and police and 5 (1, 7) among firefighters. Among health-care workers, 77.5% answered that a system for major-incident triage exists; 56.3% had triage equipment available. The majority - 45.1% of health-care workers, 44.7% of firefighters and 60.4% of police - did not know how long it would take to get emergency stretchers to the scene.

CONCLUSIONS

Rescue personnel find major incident preparedness and on-scene multidisciplinary cooperation to function well. Some shortcomings are reported with regard to systems for major incident triage, tagging equipment for triage and knowledge about access to emergency stretchers.

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.

The effectiveness of nurse practitioners working at a GP cooperative: a study protocol

Background

In many countries out-of-hours care faces serious challenges, including shortage of general practitioners, a high workload, reduced motivation to work out of hours, and increased demand for out-of-hours care. One response to these challenges is the introduction of nurse practitioner as doctor substitutes, in order to maintain the (high) accessibility and safety of out of hours care. Although nurse practitioners have proven to provide equally safe and efficient care during daytime primary care, it is unclear whether substitution is effective and efficient in the more complex out of hours primary care. This study aims to assess the effects of substitution of care from general practitioners to nurse practitioners in an out of hours primary care setting.

Design

A quasi experimental study is undertaken at one “general practitioner cooperative” to offer out-of-hours care for 304.000 people in the South East of the Netherlands. In the experimental condition patient care is provided by a team of one nurse practitioner and four general practitioners; where the nurse practitioner replaces one general practitioner during one day of the weekend from 10 am to 5 pm. In the control condition patient care is provided by a team of five general practitioners during the other day of the weekend, also from 10 am to 5 pm. The study period last 15 months, from April 2011 till July 2012.

Methods

Data will be collected on number of different outcomes using a range of methods. Our primary outcome is substitution of care. This is calculated using the number and characteristics of patients that have a consultation at the GP cooperative. We compare the number of patients seen by both professionals, type of complaints, resource utilization (e.g. prescription, tests, investigations, referrals) and waiting times in the experimental condition and control condition. This data is derived from patient electronic medical records. Secondary outcomes are: patient satisfaction; general practitioners workload; quality and safety of care and barriers and facilitators.

Discussion

The study will provide evidence whether substitution of care in out-of-hours setting is safe and efficient and give insight into barriers and facilitators related to the introduction of nurse practitioners in out-of-hours setting.

Trial registration

ClinicalTrials.gov ID NCT01388374

The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis

AIM

This paper is a report of the synthesis of evidence on the appropriateness of, and compliance with, telephone triage decisions.

BACKGROUND

Telephone triage plays an important role in managing demand for health care. Important questions are whether triage decisions are appropriate and patients comply with them.

DATA SOURCES

CINAHL, Cochrane Clinical Trials Database, Medline, Embase, Web of Science, and Psyc Info were searched between 1980-June 2010.

DESIGN

LITERATURE REVIEW

Rapid Evidence Synthesis.

REVIEW METHODS

The principles of rapid evidence assessment were followed.

RESULTS

We identified 54 relevant papers: 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision, and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44-98% and compliance ranged from 56-98%. Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care may have lower compliance than decisions to contact emergency services or self care.

CONCLUSION

Telephone triage services can offer appropriate decisions and decisions that callers comply with. However, the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged.