Consistency of decision support software-integrated telephone triage and associated factors: a systematic review

Identifying system adaptations to overcome technology-based workflow challenges in a telephone triage organization

Call-center-based telephone triage is an example of a complex sociotechnical system relying on successful interactions between patients, callers, and the integration of many digital technologies. Digital technologies such as computer decision support systems are used to standardize triage outcomes with little consideration of how these unique healthcare systems adapt to maintain functionality in response to real-world operating challenges. Using structured observations of call handlers in two call centers and guided by usability heuristics and the concept of 'workarounds', this paper aims to investigate the effects of technology design on workflow and system adaptations. Opportunities for improvement are highlighted, particularly, assessment prompts, and updating software to reflect dynamic real-world situations. Interactions between system components, especially technological and organizational processes affected workflow, making adaptations at the individual and organizational levels necessary to ensure callers could be triaged safely. System designers could consider these findings to improve systems and procedures during challenging periods.

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.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study

BACKGROUND

This study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium.

METHODS

A three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses.

RESULTS

N = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason.

CONCLUSION

Our findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

Changes in the use and uptake of a national out-of-hours telephone triage service by younger and older patients seeking non-urgent unplanned care surrounding the COVID-19 pandemic in Flanders (Belgium)

BACKGROUND

This study seeks to examine if and how the COVID-19 pandemic has prompted changes in the use and uptake of a national out-of-hours (OOH) telephone triage service by younger and older patients seeking non-urgent unplanned care in Flanders (Belgium).

METHODS

A descriptive study was conducted using registry data obtained from the 1733 OOH telephone triage service in a Flemish region of Belgium. All calls received between 1 January 2019 and 31 December 2020 were analyzed.

RESULTS

A significant association was found between patient age and period of call (χ² = 594.54, p < .001). Calls made to the 1733 OOH telephone triage service were significantly less likely to be dispatched to a higher level of urgency by operators compared to calls made before the COVID-19 period (OR = 0.80, 95% CI [0.74-0.85]). While calls concerning older adults were significantly more likely to be dispatched to a higher level of urgency by operators compared to younger adults (regardless of period of call) (65 to 74 yrs: OR = 5.75, 95% CI [4.86-6.80]; 75 to 84 yrs: OR = 15.21, 95% CI [13.18-17.56]; ≥ 85 yrs: OR = 28.77, 95% CI [25.01-33.09]), only 6.7% of all COVID-19 related calls involved older adults over 65 years of age.

CONCLUSION

Findings showed that there was a general decline in the number of calls dispatched to a higher level of urgency by operators during the COVID-19 period but that there were differences in the use and uptake of these services by younger and older age segments.