Nurse telephone triage in out-of-hours GP practice: determinants of independent advice and return consultation

[Initial assessment of ENT emergencies-a feasibility study]

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

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.

The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial

Background

Nurse-led telephone triage is increasingly used to manage demand for general practitioner consultations in UK general practice. Previous studies are equivocal about the relationship between clinical experience and the call outcomes of nurse triage. Most research is limited to investigating nurse telephone triage in out-of-hours settings.

Objective

To investigate whether the professional characteristics of primary care nurses undertaking computer decision supported software telephone triage are related to call disposition.

Design

Questionnaire survey of nurses delivering the nurse intervention arm of the ESTEEM trial, to capture role type (practice nurse or nurse practitioner), prescriber status, number of years’ nursing experience, graduate status, previous experience of triage, and perceived preparedness for triage.

Our main outcome was the proportion of triaged patients recommended for follow-up within the practice (call disposition), including all contact types (face-to-face, telephone or home visit), by a general practitioner or nurse.

Settings

15 general practices and 7012 patients receiving the nurse triage intervention in four regions of the UK.

Participants

45 nurse practitioners and practice nurse trained in the use of clinical decision support software.

Methods

We investigated the associations between nursing characteristics and triage call disposition for patient ‘same-day’ appointment requests in general practice using multivariable logistic regression modelling.

Results

Valid responses from 35 nurses (78%) from 14 practices: 31/35 (89%) had ≥10 years’ experience with 24/35 (69%) having ≥20 years. Most patient contacts (3842/4605; 86%) were recommended for follow-up within the practice. Nurse practitioners were less likely to recommend patients for follow-up odds ratio 0.19, 95% confidence interval 0.07; 0.49 than practice nurses. Nurses who reported that their previous experience had prepared them less well for triage were more likely to recommend patients for follow-up (OR 3.17, 95% CI 1.18–5.55).

Conclusion

Nurse characteristics were associated with disposition of triage calls to within practice follow-up. Nurse practitioners or those who reported feeling ‘more prepared’ for the role were more likely to manage the call definitively. Practices considering nurse triage should ensure that nurses transitioning into new roles feel adequately prepared. While standardised training is necessary, it may not be sufficient to ensure successful implementation.

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.

Health services for children in western Europe

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

GP cooperative and emergency department: an exploration of patient flows

RATIONALE, AIMS AND OBJECTIVES

In most countries, different health care providers are involved in emergency care. In the Netherlands, out-of-hours care is provided by general practitioner cooperatives (GPCs) and emergency departments (EDs). Our aim was to describe the flow of patients attending emergency care in these settings.

METHOD

A retrospective record review was performed, concerning patients who had visited a GPC or ED. Recorded information included urgency, diagnostic tests, and follow-up contacts. Descriptive figures were determined for patient flows in GPC and ED for urgent contacts and non-urgent contacts.

RESULTS

We included 319 GPC contacts and 356 ED contacts, of which 78% were non-urgent. The majority of GPC contacts were completed at the GPC without follow-up; 37% of non-urgent patients had a follow-up contact, usually with primary care. Only 5% of non-urgent GPC patients received diagnostic tests compared to 63% of non-urgent ED patients (mostly X-rays). The majority of non-urgent ED patients (88%) had a follow-up contact, usually at an outpatient clinic (67%). Most non-urgent ED patients (83%) who received a diagnostic test also had an outpatient clinic follow-up contact. Of urgent ED patients, the majority had a follow-up contact (85%), mostly with an outpatient clinic (74%).

CONCLUSION

Although most out-of-hours care patients present non-urgent health problems, at the ED they are more likely to receive diagnostic tests and follow-up contacts. This may reflect differences in patient populations between the ED and GPC or suggest opportunities for improving efficiency of planning follow-up contacts.

[Paediatric emergency triage in Spanish primary care using mobile phones. Analysis of a model in a health area]

OBJECTIVES

To conduct a pilot study of telephone consultation in the paediatric population of an urban health centre. To evaluate the telephone consultation as an effective tool when it comes to exercising prior triage of patients requiring urgent attention.

MATERIAL AND METHODS

The study was conducted in two phases. In the first, data were collected from all calls received for six months. In a second phase, we conducted a telephone intervention study to analyse what a random sample of users remembered of the care provided. All those who requested a telephone consultation were included in the study. Demographic, social-welfare, epidemiological, and clinical features, of each patient were recorded. Data were processed using a statistical package SPSS version 17.0 for Windows.

RESULTS

There were 439 telephone inquiries in our pilot project, of which 35.1% were attended by residents, 36% by paediatricians, and 28.9% by paediatric nurses. There were more telephone calls in the afternoons and on weekends. Patients less than or equal to 2 years accounted for 57.9% of cases handled, and there were no differences between sexes. The most frequent reasons for consultation were gastrointestinal symptoms, fever and respiratory problems. The health problem was resolved in 85.8% of cases, requiring only home care instructions, and only 13.3% of children were referred to emergency services. We obtained a mean score of satisfaction of 9.2.

CONCLUSIONS

The pilot project had a high level of satisfaction and resolution, demonstrating cost savings by reducing 55% of face to face visits, with a saving of 35.2 euros per telephone consultation. A teleconsultation model for dealing with emergencies in primary care by telephone would be comparable to a practice staffed by trained paediatric nurses.

Understanding of and adherence to advice after telephone counselling by nurse: a survey among callers to a primary emergency out-of-hours service in Norway

BACKGROUND

To investigate how callers understand the information given by telephone by registered nurses in a casualty clinic, to what degree the advice was followed, and the final outcome of the condition for the patients.

METHODS

The study was conducted at a large out-of-hours inter-municipality casualty clinic in Norway during April and May 2010. Telephone interviews were performed with 100 callers/patients who had received information and advice by a nurse as a sole response. Six topics from the interview guide were compared with the telephone record files to check whether the caller had understood the advice. In addition, questions were asked about how the caller followed the advice provided and the patient's outcome.

RESULTS

99 out of 100 interviewed callers stated that they had understood the nurse's advice, but interpreted from the telephone records, the total agreement for all six topics was 82.6%. 93 callers/patients stated that they followed the advice and 11 re-contacted the casualty clinic. 22 contacted their GP for the same complaints the same week, of whom five patients received medical treatment and one was hospitalised. There were significant difference between the native-Norwegian and the non-native Norwegian regarding whether they trusted the nurse (p = 0.017), and if they got relevant answers to their questions (p = 0.005).

CONCLUSION

Callers to the out-of-hours service seem to understand the advice given by the registered nurses, and a large majority of the patients did not contact their GP or other health services again with the same complaints.

PRACTICE IMPLICATION

Medical and communicative training must be an important part of the continuous improvement strategy within the out-of-hour services.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Out of hours care: a profile analysis of patients attending the emergency department and the general practitioner on call

Background

Overuse of emergency departments (ED) is of concern in Western society and it is often referred to as 'inappropriate' use. This phenomenon may compromise efficient use of health care personnel, infrastructure and financial resources of the ED. To redirect patients, an extensive knowledge of the experiences and attitudes of patients and their choice behaviour is necessary. The aim of this study is to quantify the patients and socio-economical determinants for choosing the general practitioner (GP) on call or the ED.

Methods

Data collection was conducted simultaneously in 4 large cities in Belgium. All patients who visited EDs or used the services of the GP on call during two weekends in January 2005 were enrolled in the study in a prospective manner. We used semi-structured questionnaires to interview patients from both services.

Results

1611 patient contacts were suitable for further analysis. 640 patients visited the GP and 971 went to the ED. Determinants that associated with the choice of the ED are: being male, having visited the ED during the past 12 months at least once, speaking another language than Dutch or French, being of African (sub-Saharan as well as North African) nationality and no medical insurance. We also found that young men are more likely to seek help at the ED for minor trauma, compared to women.

Conclusions

Patients tend to seek help at the service they are acquainted with. Two populations that distinctively seek help at the ED for minor medical problems are people of foreign origin and men suffering minor trauma. Aiming at a redirection of patients, special attention should go to these patients. Informing them about the health services' specific tasks and the needlessness of technical examinations for minor trauma, might be a useful intervention.

After-hours services in capitation-funded primary care practice: use and satisfaction

OBJECTIVE

To examine patients' use of and satisfaction with the nurse-staffed Telephone Health Advisory Service (THAS) and physician after-hours care in a rostered Family Health Organization, as well as physicians' satisfaction with both types of services.

DESIGN

Cross-sectional telephone survey.

SETTING

A Family Health Organization in Hamilton, Ont.

PARTICIPANTS

Nineteen family physicians and their patients who used an after-hours service during 9 selected weeks between March and December of 2007.

MAIN OUTCOME MEASURES

Distribution of encounters directed to the on-call physician or to the THAS; types of health problems; and patient and physician satisfaction.

RESULTS

A total of 817 calls were recorded from 774 patients. Of these patients, 606 were contacted and 94.4% (572/606) completed encounter-specific surveys: 358 completed the on-call physician survey and 214 completed the THAS survey. Mean age of respondents was 40.8 years; most were women, and approximately one-third called on behalf of children. Most calls (66.8%, 546/817) were made directly to the on-call physicians. The most common problems were respiratory (34.3%, 271/789), gastrointestinal (10.1%, 80/789), and genitourinary (9.3%, 73/789). Most patients reported being very satisfied with the after-hours care provided by the THAS (62.5%, 125/200) or the on-call physicians (70.9%, 249/351). Almost all callers who bypassed the THAS knew about it (89.8%, 316/352), but either felt their problems were too serious or wished to talk to a physician. Most physicians agreed or strongly agreed that they were satisfied with their colleagues' on-call care (81.0%, 17/21); 47.6% (10/21) agreed that the THAS was helpful in managing on-call duty.

CONCLUSION

When direct after-hours physician contact is available, a minority of patients uses a nurse-staffed triage. Physicians find the arrangements onerous and would prefer to see after-hours care managed and remunerated differently.

Should the general practitioner be prepared for the patient with decreased consciousness or coma?

BACKGROUND

Data are scarce about the possible role for the general practitioner (GP) in patients with decreased consciousness (DC) or coma. We wanted to investigate how often a GP is confronted with DC or coma during out-of-hours service in an urban region and to compare the patients presented to primary care to those who were immediately treated by the emergency medical services (EMS).

METHOD

In a prospective observational study during 2 weekends in the city of Ghent, Belgium, which has 232 500 inhabitants, 724 patients were seeking emergency care, and DC or coma was the reason for encounter in 27 patients (3.8%). Eight patients initially seen by a GP had more heterogeneous diagnoses than the 19 patients immediately transferred to the emergency department without intervention by a GP.

RESULTS AND CONCLUSION

This study shows that about one-third (N=8) of emergencies involving patients with DC or coma were initially evaluated by a GP; five out of these eight patients were subsequently transported by the EMS. We conclude that telephone triage guidelines providing simultaneous alerts of the GP and the EMS for DC or coma patients, tailored training of GPs with skills maintenance, adequate equipment and close collaboration with the EMS are recommended for GP out-of-hours services.

Nurse practitioner management of acute in-hours home visit or assessment requests: a pilot study

BACKGROUND

GPs often perceive home-visit requests as a time-consuming aspect of general practice. The new general medical services contract provides for practices to be relieved of responsibility for home-visits, although there is no model for the transfer of care. One such model could be to employ nurse practitioners to manage such requests. Nurse practitioners can effectively substitute for GPs in managing same-day in-hours emergency care in the surgery, but their role in managing all such requests, including those requiring home visits, has not been assessed.

AIM

To explore the feasibility and clinical management outcomes of nurse practitioner management of same-day care requests, including those requiring home visits, to inform a proposed randomised controlled trial.

DESIGN OF STUDY

Non-randomised comparative trial.

SETTING

One large general practice (14 600 patients) in south London.

METHOD

Nurse practitioner assessment and management of all same-day care requests for 2 days per week was compared with normal GP management on another 2 days, over a 6-month period. Clinical management outcome data were collected from patient records and from data-collection forms completed by a nurse practitioner and GPs. Patient and staff satisfaction was assessed by questionnaire.

RESULTS

The nurse practitioner was more likely than GPs to assess patients in person, less likely to give advice alone, and more likely to issue a prescription. There was no significant difference between the nurse practitioner and GPs regarding any other clinical management outcomes or patient satisfaction; however, the response rate of the patient satisfaction questionnaire in this pilot study was poor.

CONCLUSION

Nurse practitioner management of acute in-hours care requests, including home visits, appears feasible in practice and merits further assessment.

Out-of-hours demand for GP care and emergency services: patients' choices and referrals by general practitioners and ambulance services

Background

Over the last five years, Dutch provision of out-of-hours primary health care has shifted from practice-based services towards large-scale general practitioner (GP) cooperatives. Only few population-based studies have been performed to assess the out-of-hours demand for GP and emergency care, including the referral patterns to the Accident and Emergency Department (AED) by GPs and ambulance services.

Method

During two four-month periods (five-year interval), a prospective cross-sectional study was performed for a Dutch population of 62,000 people. Data were collected on all patient contacts with one GP cooperative and three AEDs bordering the region.

Results

Overall, GPs handled 88% of all out-of-hours contacts (275/1000 inhabitants/year), while the AED dealt with the remaining 12% of contacts (38/1000 inhabitants/year). Within the AED, the self-referrals represented a substantial number of contacts (43%), although within the total out-of-hours demand they only represented 5% of all contacts. Self-referrals were predominantly young adult males presenting with an injury, nineteen percent of whom had a fracture. Compared to self-referrals, patients who were referred by the GP or brought in by the ambulance services were generally older and were more frequently admitted for both injury and non-injury (p < 0.01 for all differences).

Conclusion

The GP cooperative deals with the large majority of out-of-hours problems presented. Within the total demand, self-referrals constitute a stable, yet small group of patients, many of whom seem to have made a reasonable choice to attend the AED. The GPs and the ambulance services appear to be effectively selecting the problems that are presented to the AED.