Safety of clinical and non-clinical decision makers in telephone triage: a narrative review

A Bibliometric Analysis of Telephone Triage Research to 2021 Using VOSviewer

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

Clinical decision support system in emergency telephone triage: A scoping review of technical design, implementation and evaluation

OBJECTIVES

Emergency department overcrowding could be improved by upstream telephone triage. Emergency telephone triage aims at managing and orientating adequately patients as early as possible and distributing limited supply of staff and materials. This complex task could be improved with the use of Clinical decision support systems (CDSS). The aim of this scoping review was to identify literature gaps for the future development and evaluation of CDSS for Emergency telephone triage.

MATERIALS AND METHODS

We present here a scoping review of CDSS designed for emergency telephone triage, and compared them in terms of functional characteristics, technical design, health care implementation and methodologies used for evaluation, following the PRISMA-ScR guidelines.

RESULTS

Regarding design, 19 CDSS were retrieved: 12 were knowledge based CDSS (decisional algorithms built according to guidelines or clinical expertise) and 7 were data driven (statistical, machine learning, or deep learning models). Most of them aimed at assisting nurses or non-medical staff by providing patient orientation and/or severity/priority assessment. Eleven were implemented in real life, and only three were connected to the Electronic Health Record. Regarding evaluation, CDSS were assessed through various aspects: intrinsic characteristics, impact on clinical practice or user apprehension. Only one pragmatic trial and one randomized controlled trial were conducted.

CONCLUSION

This review highlights the potential of a hybrid system, user tailored, flexible, connected to the electronic health record, which could work with oral, video and digital data; and the need to evaluate CDSS on intrinsic characteristics and impact on clinical practice, iteratively at each distinct stage of the IT lifecycle.

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.

The telephone nursing dialogue process: an integrative review

BACKGROUND

Telephone nursing involves triage, advice, and care management provided by a nurse over the telephone. The telephone nursing dialogue process has been used clinically in telephone nursing in Sweden for several years to structure the communication and ensure a safe assessment and advice. Studies are needed to determine whether there is sufficient scientific evidence to support the method.

AIM

To describe the scientific basis of the phases of the telephone nursing dialogue process.

DESIGN

This was an integrative review.

METHODS

The literature searches were performed in August 2023, in the PubMed, CINAHL, Cochrane Database of Systematic Reviews and SwePUB databases. Sixty-two articles were included. Data was sorted deductively according to the five phases of the telephone nursing dialogue process and categorized inductively to form subcategories describing the content of each phase.

RESULT

All five phases in the telephone nursing dialogue process were supported by a range of articles (n = 32-50): Opening (n = 32), Listening (n = 45), Analysing (n = 50), Motivating (n = 48), and Ending (n = 35). During the opening of the call, the nurse presents herself, welcomes the caller and establishes a caring relationship. In the listening phase, the nurse invites the caller to tell their story, listens actively and confirms understanding. During the analyzing phase, the nurse gathers, assesses, and verifies information. In the motivating phase, the nurse reaches a final assessment, informs the caller, gives advice and creates a mutual agreement and understanding while supporting the caller. Ultimately, the nurse ends the call after checking for mutual agreement and understanding, giving safety-net advice, deciding on whether to keep monitoring the caller and rounding off the call.

CONCLUSION

The phases of the telephone nursing dialogue process as described in the scientific literature are well aligned with the theoretical descriptions of the telephone nursing dialogue process.

The feasibility of teleconsultations in unplanned primary care: an intervention study in Belgium, 2021

INTRODUCTION

Since 2000, an increasing misuse of emergency services in Belgium was noticed. In 2015, a multidisciplinary task-force designed a triage system. Trained operators and integrated triage protocols were installed in a call center for life-threatening and non-life-threatening care needs. Teleconsultations by telephone find their way to planned care and are well studied in this context. Also unplanned care might benefit from telephone-consultations.

METHOD

This intervention study investigated the feasibility of teleconsultations in unplanned care according to medical doctors. They were present at the call center during the weekend and on public holidays in the period of April 17, 2021 to November 21, 2021. Their task was to call patients who had contacted the call center to perform a teleconsultation, without interfering with regular care.

RESULTS

21 triage doctors participated in the study, they completed 59 surveys and conducted 551 teleconsultations. They perceived the quality of the consultations as good with an average score of 82.85 out of 100 on the sliding scale. The doctors gave an average score of 72.40 for the level of certainty for diagnosis and treatment. For 415 consultations, triage doctors judged that the consultation would gain certainty if followed by a physical examination. Video was mainly considered to be valuable in psychiatric problems, allergic reactions and skin problems.

DISCUSSION

This study showed that teleconsultations are feasible in unplanned care. Videos add value in particular cases. Only few barriers are reported in terms of communication, technology and equipment.

CONCLUSION

Teleconsultations in unplanned primary care could be performed with a high quality and a sufficient level of certainty. The willingness to conduct teleconsultations in unplanned care is high. It would be useful in a future study to investigate the feasibility, obstacles and needs for implementation of video consultations as they may differ from teleconsultations.

The Role of Telemedicine in Prehospital Traumatic Hand Injury Evaluation

Unnecessary ED visits and transfers to hand clinics raise treatment costs and patient burden at trauma centers. In the present COVID-19 pandemic, needless transfers can increase patients' risk of viral exposure. Therefore, this review analyzes different aspects of the remote diagnosis and triage of traumatic hand injuries. The most common file was photography, with the most common devices being cell phone cameras. Treatment, triage, diagnosis, cost, and time outcomes were assessed, showing concordance between teleconsultation and face-to-face patient evaluations. We conclude that photography and video consultations are feasible surrogates for ED visits in patients with traumatic hand injuries. These technologies should be leveraged to decrease treatment costs and potentially decrease the time to definitive treatment after initial evaluation.

Role of interaction for caller satisfaction in telenursing-A cross-sectional survey study

AIMS AND OBJECTIVES

The aim of this study was to explore caller satisfaction with interaction, and the association to overall satisfaction with calls.

BACKGROUND

In the era of expanding healthcare at distance, the telephone remains a common tool for the provision of nursing care. Interaction between telenurse and caller in telenursing is vital for safety, satisfaction and adherence reasons. Few studies have quantitatively explored interaction in calls and how it relates to overall satisfaction with calls.

DESIGN

Cross-sectional survey study with a deductive approach.

METHODS

A total of 466 callers to the Swedish Medical Advisory Service completed the Telenursing Interaction and Satisfaction Questionnaire. Satisfaction with four theoretically defined components of interaction were compared using repeated measures ANOVA. Associations between satisfaction with interaction and overall satisfaction with calls were evaluated with ordinal logistic regression models with and without adjustment for age, sex, health status, waiting time, time for call, main result of the call and expectations. The study followed the STROBE checklist.

RESULTS

Callers were most satisfied with affective support, followed by professional-technical competence, health information and decisional control-in that order. A summated score of satisfaction with interaction was positively and significantly associated with overall satisfaction with calls before and after adjustment for waiting time, main result of call and variables related to the individual caller.

CONCLUSIONS

Caller satisfaction with interaction is generally high but can be improved, especially regarding decisional control. Satisfaction with interaction is important for overall satisfaction with calls.

RELEVANCE TO CLINICAL PRACTICE

This study provides support for professionals at all levels in telenursing organisations to pay attention to interactional matters. The development of best practice for telenurses needs to consider all four components of interaction to enhance satisfaction with calls.

Is tele-diagnosis of dental conditions reliable during COVID-19 pandemic? Agreement between tentative diagnosis via synchronous audioconferencing and definitive clinical diagnosis

Objectives

To assess the reliability of synchronous audioconferencing teledentistry (TD) in making tentative diagnosis compared to definitive clinical face-to-face (CFTF) diagnosis; and whether agreement was influenced by dentist's experience, caller-patient relationship, and time of call.

Methods

All patients calling the TD hotline during COVID-19 pandemic, triaged as emergency/ urgent and referred for CFTF care were included (N=191). Hotline dentists triaged the calls, made tentative audio-dentistry (AD) diagnosis, while dentists at point of referral made the definitive CFTF diagnosis. Cohen's weighted kappa (κ) assessed the extent of agreement between AD vs CFTF diagnosis.

Results

There was significantly very good pair-wise agreement (κ = 0.853, P < 0.0001) between AD and CFTF diagnosis. AD diagnosis of pulpitis and periodontitis exhibited the most frequent disagreements. Tele-dentists with ≥ 20 years’ experience exhibited the highest level of agreement (κ =0.872, P < 0.0001). There was perfect agreement when mothers mediated the call (κ = 1, P < 0.0001), and very good agreement for calls received between 7 am-2 pm (κ = 0.880, P < 0.0001) compared to calls received between 2-10 pm (κ = 0.793, P < 0.0001).

Conclusions

Remote tentative diagnosis using AD is safe and reliable. Reliability was generally very good but varied by dentist's experience, caller-patient relationship, and time of call.

Clinical significance

The findings suggest that using AD in the home environment is safe and reliable, deploying providers with variable years of experience. The findings have generalizability potential to a variety of similar circumstances, healthcare settings and epi/pandemic situations.

A registry-based observational study comparing emergency calls assessed by emergency medical dispatchers with and without support by registered nurses

Background

The requirement concerning formal education for emergency medical dispatcher (EMD) is debated and varies, both nationally and internationally. There are few studies on the outcomes of emergency medical dispatching in relation to professional background. This study aimed to compare calls handled by an EMD with and without support by a registered nurse (RN), with respect to priority level, accuracy, and medical condition.

Methods

A retrospective observational study, performed on registry data from specific regions during 2015. The ambulance personnel’s first assessment of the priority level and medical condition was used as the reference standard. Outcomes were: the proportion of calls dispatched with a priority in concordance with the ambulance personnel’s assessment; over- and undertriage; the proportion of most adverse over- and undertriage; sensitivity, specificity and predictive values for each of the ambulance priorities; proportion of calls dispatched with a medical condition in concordance with the ambulance personnel’s assessment. Proportions were reported with 95% confidence intervals. χ²-test was used for comparisons. P-levels < 0.05 were regarded as significant.

Results

A total of 25,025 calls were included (EMD n = 23,723, EMD + RN n = 1302). Analyses relating to priority and medical condition were performed on 23,503 and 21,881 calls, respectively. A dispatched priority in concordance with the ambulance personnel’s assessment were: EMD n = 11,319 (50.7%) and EMD + RN n = 481 (41.5%) (p < 0.01). The proportion of overtriage was equal for both groups: EMD n = 5904, EMD + RN n = 306, (26.4%) p = 0.25). The proportion of undertriage for each group was: EMD n = 5122 (22.9%) and EMD + RN n = 371 (32.0%) (p < 0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD + RN (p < 0.01), and specificity was 67.3% and 84.8% (p < 0.01) respectively. A dispatched medical condition in concordance with the ambulance personnel’s assessment were: EMD n = 13,785 (66.4%) and EMD + RN n = 697 (62.2%) (p = 0.01).

Conclusions

A higher precision of emergency medical dispatching was not observed when the EMD was supported by an RN. How patient safety is affected by the observed divergence in dispatched priorities is an area for future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00987-y.

Impact of NHS 111 Online on the NHS 111 telephone service and urgent care system: a mixed-methods study

Background

The NHS emergency and urgent care system is under pressure as demand for services increases each year. NHS 111 is a telephone triage service designed to provide advice and signposting to appropriate services for people with urgent health-care problems. A new service, NHS 111 Online, has been introduced across England as a digital alternative that can be accessed using a website or a smartphone application. The effects and usefulness of this service are unknown.

Objectives

To explore the impact of NHS 111 Online on the related telephone service and urgent care system activity and the experiences of people who use those services.

Design and methods

A mixed-methods design of five related work packages comprising an evidence review; a quantitative before-and-after time series analysis of changes in call activity (18/38 sites); a descriptive comparison of telephone and online services with qualitative survey (telephone, n = 795; online, n = 3728) and interview (32 participants) studies of service users; a qualitative interview study (16 participants) of staff; and a cost–consequences analysis.

Results

The online service had little impact on the number of triaged calls to the NHS 111 telephone service. For every 1000 online contacts, triaged telephone calls increased by 1.3% (1.013, 95% confidence interval 0.996 to 1.029; p = 0.127). Recommendations to attend emergency and urgent care services increased between 6.7% and 4.2%. NHS 111 Online users were less satisfied than users of the telephone service (50% vs. 71%; p < 0.001), and less likely to recommend to others (57% vs. 69%; p < 0.001) and to report full compliance with the advice given (67.5% vs. 88%; p < 0.001). Online users were less likely to report contacting emergency services and more likely to report not making any contact with a health service (31% vs. 16%; p < 0.001) within 7 days of contact. Thirty-five per cent of online users reported that they did not want to use the telephone service, whereas others preferred its convenience and speed. NHS 111 telephone staff reported no discernible increase or decrease in their workload during the first year of operation of NHS 111 Online. If online and telephone services operate in parallel, then the annual costs will be higher unless ≥ 38% of telephone contacts move to online contacts.

Conclusions

There is some evidence that the new service has the potential to create new demand. The service has expanded significantly, so it is important to find ways of promoting the right balance in numbers of people who use the online service instead of the telephone service if it is to be effective. There is a clear need and preference by some people for an online service. Better information about when to use this service and improvements to questioning may encourage more uptake.

Limitations

The lack of control arm means that impact could have been an effect of other factors. This work took place during the early implementation phase, so findings may change as the service expands.

Future work

Further development of the online triage process to make it more ‘user friendly’ and to enable users to trust the advice given online could improve use and increase satisfaction. Better understanding of the characteristics of the telephone and online populations could help identify who is most likely to benefit and could improve information about when to use the service.

Trial registration

Current Controlled Trials ISRCTN51801112.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 21. See the NIHR Journals Library website for further project information.

Dental practice management during COVID-19 times-Now and beyond

AIM

Coronavirus disease 2019 (COVID-19) being declared a global public health emergency has become a significant challenge for all healthcare workers, including dentistry, recognised as a high-risk profession during these times. This consensus statement aims to highlight and provide guidelines necessary to be implemented for a clinical dental practice.

MATERIALS AND METHODS

A total of nine conservative Dentists and Endodontists and one Oral and Maxillofacial Surgeon; with four panelists from government dental colleges, one each from the North, South, East and West India and six resource persons from private colleges in South India, all of them being clinicians and administrators practicing dentistry since the inception of the pandemic, collaborated in this consensus statement. The consensus statement was developed through a symposium conducted on the topics; general dental practice during COVID-19 times, the importance of aerosols in clinical dental practice in the spread of COVID-19, effective standard operating protocols for clinical dental practice and Institutional settings with scientific evidence-based justifications, followed by a panel discussion with to devise mandatory protocols to be followed in clinical and institutional settings. The symposium was attended by 46 practitioners who participated in the deliberation.

RESULTS

This consensus statement provides clinicians and researchers with protocols for the dental practice, agreed upon by experts in the field. The Consensus Statement has been formulated according to the AGREE Reporting checklist for the formulation of guidelines.

CONCLUSION

The experts and panelists reached a Consensus on the protocols and guidelines for the safe clinical and institutional dental practice.

Oral Healthcare Management of Children after COVID-19 Outbreak

The emergence of the novel 2019 coronavirus disease (COVID-19) pandemic has led to a significant challenge to healthcare professionals. Among all the healthcare providers, dental clinical setup is exposed to the generation of potentially hazardous aerosols which could be a point of cross-contamination. Dentists catering to pediatric patients need to take special precautions, as they have milder symptoms or could be asymptomatic and hence potential vectors for the transfer of infection. One needs to change the perspective to manage the oral health of children as a child's oral health presents specific problems that could be time-bound and hence need to be treated accordingly. These problems can be managed on one hand by preventive methods, and on the other by implementing specific protocols relating to the conditions that represent an emergency, or those situations that fall into the category of elective dental procedures. This article highlights the routes of transmission in a dental practice and focuses on the categorization of treatment for children based on treatment needs. It proposes a restructuring of the treatment protocol and hence shifting to minimal invasive or non-aerosol-generating procedures (AGP). These techniques are also proposed to be used even after the end of the current emergency period to minimize the aerosol splatter.

Clinical significance

The article highlights the protocol that needs to be followed after treatment categorization during and after COVID-19 pandemic.

How to cite this article

Lamba G, Nagpal DI, Chowdhari P, et al. Oral Healthcare Management of Children after COVID-19 Outbreak. Int J Clin Pediatr Dent 2021;14(2):293-297.

Observational study of the implementation of telephone advice nursing in Sweden: did callers follow recommendations and did the rate of healthcare visits change?

OBJECTIVES

Telephone advice nursing is introduced in many countries with one key aim being a reduction of avoidable healthcare visits. The aim of this study was to explore whether callers to a telephone advice nursing service followed the telenurses' recommendations, and whether there was a change in the level and trend of the rate of healthcare visits after the introduction of telephone advice nursing.

DESIGN

Observational study.

SETTING

Primary and secondary care in Jönköping Region, Sweden.

PARTICIPANTS

Telephone advice nursing calls, 6:00-23:00, 2014-2015 (n=185 994) and outpatient healthcare visits 2012-2015 (n=6 877 266).

PRIMARY OUTCOME

Proportion of callers who visited healthcare within the time period advised by the telenurse.

SECONDARY OUTCOME

Change in level or trend of the overall rate of healthcare visits per 1000 persons and 4-week period after the introduction of telephone advice nursing, with subgroup analysis for primary and secondary care.

RESULTS

77% of callers who were recommended either to visit healthcare within 24 hours or to 'wait and see' followed the recommendations. There was no significant change in level (-5.15; 95% CI -15.80 to 5.50; p=0.349) or trend (-0.24; 95% CI -0.86 to 0.38; p=0.448) of the overall rate of visits per 1000 persons and 4-week period after the introduction of telephone advice nursing. For the rate of primary care visits, an increase in level (8.01; 95% CI 6.36 to 9.66; p<0.001) and trend (1.28; 95% CI 1.17 to 1.39; p<0.001) were observed. For the rate of secondary care visits, a decrease in level (-8.77, 95% CI -14.41 to -3.13; p=0.004) and trend (-1.03, 95% CI -1.35 to -0.71; p<0.001) were observed.

CONCLUSIONS

The introduction of telephone advice nursing may have contributed to a shift in the rate of healthcare visits from secondary to primary care.

Telephone Triage Simulation Activity for Prelicensure Nursing Students

BACKGROUND

To meet the demands of a complex health care environment, nursing students need education that includes telephone triage in outpatient settings. Developing telephone triage communication skills requires the use of a different set of senses than in-person assessments. The purpose of this pilot study was to measure the effect of a telephone triage classroom simulation on prelicensure nursing students' knowledge and skills.

METHOD

A simulation was developed to learn outpatient telephone triage protocols focused on lower respiratory illness. Students documented the encounter, gave a report to the provider, and completed the Simulation Effectiveness Tool-Modified.

RESULTS

Eighty-eight percent of students strongly agreed that learning about telephone triage and outpatient nursing was useful. Student perceptions of learning pathophysiology and teaching patients about illness scored lowest. Most students had inaccurate documentation of patient encounters.

CONCLUSION

Identified areas for curricular improvement included accurate documentation, pathophysiology, and patient teaching opportunities in outpatient telephone triage. [J Nurs Educ. 2021;60(6):352-355.].

Co-location of out of hours primary care and emergency department in Belgium: patients' and physicians' view

Background

In Belgium, General Practitioner Cooperatives (GPC) aim to improve working conditions for unplanned care and to reduce the number of low acuity emergency visits. Although this system is well organized, the number of low acuity visits does not decrease.

Methods

We explored the view of patients and physicians on the co-location of a GPC and an emergency service for unplanned care. The study was carried out in a cross section design in primary and emergency care services and included patients and physicians. Main outcome measure was the view of patients and physician on co-location of a GPC and an emergency service.

Results

404 patients and 488 physicians participated. 334 (82.7%) of all patients favoured a co-location. The major advantages were fast service (104, 25.7) and adequate referral (54, 13.4%). 237 (74%) of the GPs and 38 (95%) of the emergency physicians were in favour of a co-location. The major advantage was a more adequate referral of patients. 254 (79%) of the GPs and 23 (83%) of the emergency physicians believed that a co-location would lower the workload and waiting time and increase care quality (resp. 251 (78%), 224 (70%) and 37 (93%), 34 (85%).

Conclusions

To close the expectation gap between GP’s, emergency physicians and to reach for high care quality, information campaigns and development of workflows are indispensable for a successful implementation of a co-location of primary and emergency care.

Registered nurses' understandings of emergency medical dispatch center work: A qualitative phenomenographic interview study

Non-urgent and urgent telephone nursing services are increasing globally, and phenomenographic research has shown that how work is understood may influence work performance. This descriptive study makes a qualitative inductive investigation of understandings of emergency medical dispatch center work among registered nurses. Twenty-four registered nurses at three mid Swedish emergency medical dispatch centers were interviewed. Analysis based on phenomenographic principles identified five categories in the interviews: (i) Assess, prioritize, direct, or refer; (ii) Facilitate ambulance nursing work; (iii) Perform nursing care; (iv) Always be available for the public; and (v) Have the person behind the patient in mind. The first constitutes the basis of the work. The second emphasizes cooperation with and support for the ambulance staff. The third entails remotely providing nursing care, whilst the fourth stresses serving the entire population. The fifth and most comprehensive way of understanding work involves having a holistic view of the person in need, including person-centered care. Provision of high-quality emergency medical dispatch center work involves all categories. Combined, they constitute a "work map," valuable for reflection, competence development, and introduction of new staff.

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.

A Virtual Ward Model of Care for Patients With COVID-19: Retrospective Single-Center Clinical Study

BACKGROUND

COVID-19 has necessitated the implementation of innovative health care models in preparation for an influx of patients. A virtual ward model delivers clinical care remotely to patients in isolation. We report on an Australian cohort of patients with COVID-19 treated in a virtual ward.

OBJECTIVE

The aim of this study was to describe and evaluate the safety and efficacy of a virtual ward model of care for an Australian cohort of patients with COVID-19.

METHODS

Retrospective clinical assessment was performed for 223 patients with confirmed COVID-19 treated in a virtual ward in Brisbane, Australia, from March 25 to May 15, 2020. Statistical analysis was performed for variables associated with the length of stay and hospitalization.

RESULTS

Of 223 patients, 205 (92%) recovered without the need for escalation to hospital care. The median length of stay in the virtual ward was 8 days (range 1-44 days). In total, 18 (8%) patients were referred to hospital, of which 6 (33.3%) were discharged after assessment at the emergency department. Furthermore, 12 (5.4%) patients were admitted to hospital, of which 4 (33.3%) required supplemental oxygen and 2 (16.7%) required mechanical ventilation. No deaths were recorded. Factors associated with escalation to hospital care were the following: hypertension (odds ratio [OR] 3.6, 95% CI 1.28-9.87; P=.01), sputum production (OR 5.2, 95% CI 1.74-15.49; P=.001), and arthralgia (OR 3.8, 95% CI 1.21-11.71; P=.02) at illness onset and a polymerase chain reaction cycle threshold of ≤20 on a diagnostic nasopharyngeal swab (OR 5.0, 95% CI 1.25-19.63; P=.02).

CONCLUSIONS

Our results suggest that a virtual ward model of care to treat patients with COVID-19 is safe and efficacious, and only a small number of patients would potentially require escalation to hospital care. Further studies are required to validate this model of care.

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.

Assessing patient safety in a pediatric telemedicine setting: a multi-methods study

BACKGROUND

Telemedicine and telephone-triage may compromise patient safety, particularly if urgency is underestimated. We aimed to explore the level of safety of a pediatric telemedicine service, with particular reference to the appropriateness of the medical diagnoses made by the online physicians and the reasonableness of their decisions.

METHODS

This retrospective multi-method study investigated the decision-making process of physicians in a pediatric tele-triage service provided in Israel. The first section of the study investigates several measures relating to patient safety in the telemedicine setting. Two physicians reviewed a random sample of 339 parent-physician consultations conducted via a pediatric telemedicine service provided by a healthcare organization during 2014-2017. The consultations were analyzed for factors that may have affected the online physicians' decisions, with an emphasis on the appropriateness of the diagnoses and the reasonableness of the decisions. The online physicians' decisions were also compared to the subsequent outcomes (i.e., parental compliance with the recommendations and medical follow-ups within the healthcare system) after each consultation. The second section of the study (using a qualitative approach) consisted of interviews with 15 physicians who work in the pediatric telemedicine service, in order to explore their subjective experiences and efforts for assuring patient safety. The physicians were asked about factors that may have affected their reaching an appropriate diagnosis and a reasonable decision while maintaining patient safety.

RESULTS

The first section of the study demonstrates high levels of diagnosis appropriateness (98.5%) and decision reasonableness (92%), as well as low levels of false-positive (2.65%) and false-negative (5.3%), good sensitivity (82.85%), and high specificity (96.15%). A high association between the online decisions and the subsequent outcomes was also observed. The second section of the study presents physicians' means for ensuring high patient safety - by implementing a range of factors that helped them reach appropriate diagnoses and reasonable decisions.

CONCLUSIONS

The results show overall high patient safety in the pediatric tele-triage service that was examined. However, decision makers must strive to implement additional means for further enhancing the clinicians' ability to reach accurate diagnoses and provide optimal treatments within the tele-triage settings - with the aim of ensuring patient safety.

Telephone triage performed by nurses reduces non-urgent ambulance missions: A prospective observational pilot study in Finland

BACKGROUND

The increased workload in emergency medical services (EMS) is a global phenomenon in welfare states. It has been suggested that telephone triage by nurses may reduce the increasing use of EMS services, by directing patient flow to appropriate care. This study aimed to investigate whether, after an emergency medical communication centre (EMCC) provider assessed risk, a telephone nurse could assess the patient's needs and guide patients to social and health care services in non-urgent cases.

METHODS

This prospective observational study was performed in the Kainuu Hospital District in northern Finland from March to April 2018. All EMS requests classified as non-urgent by the EMCC were transferred to a telephone triage nurse. Subsequent patient guidance was recorded. The International Classifications of Primary Care categories were recorded.

RESULTS

We studied phone calls of 700 patients with non-urgent needs. Of these, the nurse transferred 63.7% to EMS and 17.3% were guided to other social and health care services. Nineteen per cent of the calls were handled over the phone by the nurse, who provided health advice and instructions. The most common needs for care were general and unspecified symptoms, musculoskeletal symptoms, mental health problems and substance abuse.

CONCLUSION

By providing telephone counseling, care instructions and patient guidance to other social and health services than EMS, the telephone triage reduced non-urgent EMS missions by one third. The results imply that telephone triage could be a viable model for managing non-urgent missions. Patient safety issues should be monitored when developing new service concepts.

Telenurses' experiences of monitoring calls to parents of children with gastroenteritis

AIMS AND OBJECTIVE

To describe telenurses' experiences of monitoring calls in telephone advice nursing to parents of children with gastroenteritis.

BACKGROUND

In previous studies, making monitoring calls is mentioned as a method used by telenurses to assess the need for care. MonitoringTHE terms 'care-seekers', 'care-seeker' and 'careseekers' are used inconsistently in the article. Please suggest which one to follow. We suggest Care-seeker calls in telephone advice nursing have been described as when telenurses call care-seekers back once or twice after an initial call. Calls from parents of children with gastroenteritis are common, and many of these calls result in telenurses providing self-care advice.

METHODS

Nineteen telenurses from two healthcare call centres in Sweden were interviewed. Data were analysed using inductive qualitative content analysis.

RESULTS

One main category, four generic categories and eleven sub-categories emerged. The telenurses described how working with monitoring calls aimed to provide self-care at home in a patient-safe way. Their focus on the parents aimed at increasing their feeling of security and focus on the child aimed at ensuring patient safety. Monitoring calls also provided a learning opportunity for parents and telenurses, and the possibility of relieving pressure on healthcare services. The findings indicate that the use of monitoring calls aims to provide a patient-safe form of telephone advice nursing.

CONCLUSION

This study shows that many parents feel insecure when their child has gastroenteritis, and the use of monitoring calls may be an effective approach to help them feel more secure at home with their sick child.

Potential of a nurse telephone triage line to direct elderly to appropriate health care settings

AIM

To explore the potential of a nurse health triage telephone line to advise and guide elderly users' decisions regarding the appropriate health care setting and self-care.

BACKGROUND

Ageing is a concern in many countries and poses challenges to health care services. Triage and advice lines can play an important role for the (re)organisation of health care delivery. Discussion has been focused on the capacity of these lines to reduce inappropriate demand for acute and emergency departments.

METHODS

Cross-sectional descriptive analysis.

RESULTS

Nurses directed elders to a health care service both by downgrading their initial intentions (concurring to the most common objective) and by upgrading them (e.g., directing elders that intended to stay at home to acute and emergency care). The intention to comply with the nurse's disposition was high.

CONCLUSIONS

The line helped to improve the appropriateness of acute and emergency care demand and to reduce the overall demand for care by elders. There is nonetheless space for improvement given the underuse of the line by elders.

IMPLICATIONS FOR NURSING MANAGEMENT

Health telephone-based triage and advice should be promoted to increase the match between the needs of elderly patients and health resources, thus improving health equity.

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.

Trauma Team Activation: Accuracy of Triage When Minutes Count: A Synthesis of Literature and Performance Improvement Process

Accuracy and timeliness of trauma activations are vital to patient safety. The American College of Surgeons mandates the trauma surgeon's presence within 15 min of the patient's arrival to the emergency department (ED) 80% of the time. In 2015, at this Level II Pediatric Trauma Center, average mean activation times were approximately 16 min and activation accuracy (over- and undertriage) affected 27% of the trauma patient activations. This evidence-based quality improvement project set out to determine the most efficient method of Emergency Medical Services (EMS) intake. Communication Center (Com. Center) recordings were carefully reviewed to identify time when EMS notifies the Com. Center and actual time of trauma activation page. A timeline was formulated with assessment of time to activation and patient triage accuracy. An educational curriculum was developed as an intervention for the Com. Center staff. Education included a decision tree for trauma activations and the development of templates for our electronic health record and prompts to improve accurate activations. After additional focus groups analyzed present ED performance and the industry standard, a policy requiring only paramedic-trained staff was put in place. After implementation of the aforementioned intervention, the Com. Center performance revealed reduction in incorrect activations from 27.3% to 10.7% from 2015 to 2016. Mean activation time in January 2015 was 48.5 min before the intervention and 4.71 min postintervention in December 2016; this is a staggering reduction in activation times of 90%!

Quality of out-of-hours telephone triage by general practitioners and nurses: development and testing of the AQTT - an assessment tool measuring communication, patient safety and efficiency

OBJECTIVE

To develop a valid and reliable assessment tool able to measure quality of communication, patient safety and efficiency in out-of-hours (OOH) telephone triage conducted by both general practitioners (GP) and nurses.

DESIGN

The Dutch KERNset tool was translated into Danish and supplemented with items from other existing tools. Face validity, content validity and applicability in OOH telephone triage (OOH-TT) were secured through a two-round Delphi process involving relevant stakeholders. Forty-eight OOH patient contacts were assessed by 24 assessors in test-retest and inter-rater designs.

SETTING

OOH-TT services in Denmark conducted by GPs, nurses or doctors with varying medical specialisation.

PATIENTS

Audio-recorded OOH patient contacts.

MAIN OUTCOME MEASURES

Test-retest and inter-rater reliability were analysed using ICC_agreement, Fleiss' kappa and percent agreement.

RESULTS

Major adaptations during the Delphi process were made. The 24-item assessment tool (Assessment of Quality in Telephone Triage - AQTT) measured communicative quality, health-related quality and four overall quality aspects. The test-retest ICC_agreement reliability was good for the overall quality of communication (0.85), health-related quality (0.83), patient safety (0.81) and efficiency (0.77) and satisfactory when assessing specific aspects. Inter-rater reliability revealed reduced reliability in ICC_agreement and in Fleiss' kappa. Percent agreement revealed satisfactory agreements when differentiating between 'poor' and 'sufficient' quality).

CONCLUSION

The AQTT demonstrated high face, content and construct validity, satisfactory test-retest reliability, reduced inter-rater reliability, but satisfactory percent agreement when differentiating between 'poor' and 'sufficient' quality. The AQTT was found feasible and clinically relevant for assessing the quality of GP- and nurse-led OOH-TT. KEYPOINTS Comparative knowledge is sparse regarding quality of out-of-hours telephone triage conducted by general practitioners and nurses. The assessment tool (AQTT) enables assessment of quality in OOH telephone triage conducted by nurses and general practitioners AQTT is feasible and clinically relevant for assessment of communication, patient safety and efficiency. AQTT can be used to identify areas for improvement in telephone triage.

What Are the Challenges and Facilitators for Implementing a 24-Hour Telephone Cancer Service in Qatar? A Literature Review

Objective: To identify the challenges and facilitators for implementing a 24-h telephone cancer service. Data sources: English language articles were retrieved from Medline, Cumulative Index of Nursing and Allied Health Literature, and Ovid Nursing electronic databases published from 2000 to 2015. Study Design: The authors performed an integrative literature review. The qualitative and quantitative articles were evaluated using the Critical Appraisal Skills Program. All mixed-methods articles were evaluated using the Mixed Methods Appraisal Tool. Thematic analyses were used to synthesize the findings from the included articles. Findings: The literature of this review highlights the complexity of the decisions that accompany the consideration of implementing a teleoncology in Qatar. The literature review detailed challenges and facilitators for implementing 24-h call service for cancer patients. These were grouped as human, technology, documentary tools, and organizational domains. The core concept that integrates each of these domains is communication. Conclusions: If the telephone triage is to be implemented in National Center for Cancer Care and Research (NCCCR), more research is needed about the characteristics of cancer patients in Qatar. A more robust understanding of this population will inform decisions about the utility of developing a teleoncology service at NCCCR.

Interventions to reduce emergency department utilisation: A review of reviews

OBJECTIVE

To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness.

METHODS

Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied.

RESULTS

Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results.

CONCLUSION

Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.

Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study

OBJECTIVE

To determine the effect of using experienced general practitioners (GPs) to review the advice given by call handlers in NHS 111, a national service giving telephone advice to people seeking medical care.

DESIGN

Observational study following the introduction of GPs to review call handlers' decisions which had been made using decision support software.

SETTING

NHS 111 call centre covering Cambridgeshire and Peterborough.

INTERVENTION

When a call handler using standard NHS 111 decision support software would have advised the caller to attend the hospital accident and emergency (A&E) department, the decision was reviewed by an experienced GP.

MAIN OUTCOME MEASURES

Percentage of calls where an outcome other than A&E attendance was recommended by the GP.

RESULTS

Of 1474 cases reviewed, the GP recommended A&E attendance in 400 cases (27.1%). In the remainder of cases, the GP recommended attendance at a primary care out-of-hours centre or minor injury unit in 665 cases (45.2%) and self-management or some alternative strategy in 409 (27.8%).

CONCLUSIONS

Fewer callers to NHS 111 would be sent to emergency departments if the decision was reviewed by an experienced GP. Telephone triage services need to consider whether using relatively unskilled call handlers supported by computer software is the most cost-effective way to handle requests for medical care.