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

Triage through telemedicine in paediatric emergency care—Results of a concordance study

Background

In the German health care system, parents with an acutely ill child can visit an emergency room (ER) 24 hours a day, seven days a week. At the ER, the patient receives a medical consultation. Many parents use these facilities as they do not know how urgently their child requires medical attention. In recent years, paediatric departments in smaller hospitals have been closed, particularly in rural regions. As a result of this, the distances that patients must travel to paediatric care facilities in these regions are increasing, causing more children to visit an ER for adults. However, paediatric expertise is often required in order to assess how quickly the patient requires treatment and select an adequate treatment. This decision is made by a doctor in German ERs. We have examined whether remote paediatricians can perform a standardised urgency assessment (triage) using a video conferencing system.

Methods

Only acutely ill patients who were brought to a paediatric emergency room (paedER) by their parents or carers, without prior medical consultation, have been included in this study. First, an on-site paediatrician assessed the urgency of each case using a standardised triage. In order to do this, the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was translated into German and adapted for use in a standardised IT-based data collection tool. After the initial on-site triage, a telemedicine paediatrician, based in a different hospital, repeated the triage using a video conferencing system. Both paediatricians used the same triage procedure. The primary outcome was the degree of concordance and interobserver agreement, measured using Cohen’s kappa, between the two paediatricians. We have also included patient and assessor demographics.

Results

A total of 266 patients were included in the study. Of these, 227 cases were eligible for the concordance analysis. In n = 154 cases (68%), there was concordance between the on-site paediatrician’s and telemedicine paediatrician’s urgency assessments. In n = 50 cases (22%), the telemedicine paediatrician rated the urgency of the patient’s condition higher (overtriage); in 23 cases (10%), the assessment indicated a lower urgency (undertriage). Nineteen medical doctors were included in the study, mostly trained paediatric specialists. Some of them acted as an on-site doctor and telemedicine doctor. Cohen’s weighted kappa was 0.64 (95% CI: 0.49–0.79), indicating a substantial agreement between the specialists.

Conclusions

Telemedical triage can assist in providing acute paediatric care in regions with a low density of paediatric care facilities. The next steps are further developing the triage tool and implementing telemedicine urgency assessment in a larger network of hospitals in order to improve the integration of telemedicine into hospitals’ organisational processes. The processes should include intensive training for the doctors involved in telemedical triage.

Trial registration

DRKS00013207.

To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study

National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote healthcare services going forward.

The Role of a Decision Support System in Back Pain Diagnoses: A Pilot Study

It is the main goal of this study to investigate the concordance of a decision support system and the recommendation of spinal surgeons regarding back pain. 111 patients had to complete the decision support system. Furthermore, their illness was diagnosed by a spinal surgeon. The results showed significant medium relation between the DSS and the diagnosis of the medical doctor. Besides, in almost 50% of the cases the recommendation for the treatment was concordant and overestimation occurred more often than underestimation. The results are discussed in relation to the “symptom checker” literature and the claim of further evaluations.

Telemedicine in Pediatric Gastroenterology: An Overview of Utility

BACKGROUND

The availability of pediatric subspecialty services is a problem evident throughout the United States. Access to pediatric gastroenterology services, especially in rural areas, can be scarce. Telemedicine has been proposed as a tool capable of decreasing healthcare costs while extending medical care.

OBJECTIVE

The purpose of this article is to review available literature regarding the utility of telemedicine as it applies to pediatric gastroenterology, specifically its role in eliminating healthcare disparities.

METHODS

Research articles were identified through a PubMed search with key words focusing on telemedicine initiatives in pediatric gastroenterology, pediatric subspecialty, rural pediatric care, and adult gastroenterology. Studies were categorized based on the following areas of application: financial, time management, communication/community, and patient health and satisfaction.

RESULTS

We reached the conclusion that evidence-supported trends in available literature provide a framework for pediatric gastroenterology telemedicine initiatives that can provide resource-sparing, community-enriching, and physician-improving services that ultimately serve to better patient health.

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study

Background

Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call.

Methods

Records of calls to the Australian healthdirect helpline (July 2008–December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice “Attend ED immediately”; “See a doctor (immediately, within 4 hours, or within 24 hours)”; “Self-care”; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics.

Results

This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices “Attend ED immediately”, “See a doctor” and “Self-care” were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice “Attend ED immediately” was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice “See a doctor” was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient’s behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice “Self-care”. The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED.

Conclusions

Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2458-y) contains supplementary material, which is available to authorized 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.

Evaluation of symptom checkers for self diagnosis and triage: audit study

OBJECTIVE

To determine the diagnostic and triage accuracy of online symptom checkers (tools that use computer algorithms to help patients with self diagnosis or self triage).

DESIGN

Audit study.

SETTING

Publicly available, free symptom checkers.

PARTICIPANTS

23 symptom checkers that were in English and provided advice across a range of conditions. 45 standardized patient vignettes were compiled and equally divided into three categories of triage urgency: emergent care required (for example, pulmonary embolism), non-emergent care reasonable (for example, otitis media), and self care reasonable (for example, viral upper respiratory tract infection).

MAIN OUTCOME MEASURES

For symptom checkers that provided a diagnosis, our main outcomes were whether the symptom checker listed the correct diagnosis first or within the first 20 potential diagnoses (n=770 standardized patient evaluations). For symptom checkers that provided a triage recommendation, our main outcomes were whether the symptom checker correctly recommended emergent care, non-emergent care, or self care (n=532 standardized patient evaluations).

RESULTS

The 23 symptom checkers provided the correct diagnosis first in 34% (95% confidence interval 31% to 37%) of standardized patient evaluations, listed the correct diagnosis within the top 20 diagnoses given in 58% (55% to 62%) of standardized patient evaluations, and provided the appropriate triage advice in 57% (52% to 61%) of standardized patient evaluations. Triage performance varied by urgency of condition, with appropriate triage advice provided in 80% (95% confidence interval 75% to 86%) of emergent cases, 55% (47% to 63%) of non-emergent cases, and 33% (26% to 40%) of self care cases (P<0.001). Performance on appropriate triage advice across the 23 individual symptom checkers ranged from 33% (95% confidence interval 19% to 48%) to 78% (64% to 91%) of standardized patient evaluations.

CONCLUSIONS

Symptom checkers had deficits in both triage and diagnosis. Triage advice from symptom checkers is generally risk averse, encouraging users to seek care for conditions where self care is reasonable.