Development and testing of the KERNset: an instrument to assess the quality of telephone triage in out-of-hours primary care services

Factors affecting communication during telephone triage in medical call centres: a mixed methods systematic review

BACKGROUND

Telephone triage is used to optimise patient flow in emergency primary healthcare. Poor communication can lead to misunderstandings and compromise patient safety. To improve quality, a comprehensive understanding of factors affecting communication in medical call centres in primary care is needed. The aim of this review was to identify such factors and to describe how they affect communication during telephone triage.

METHOD

A mixed-method systematic review was performed. In April 2021 and June 2023, MEDLINE, Embase, CINAHL, and Web of Science were searched for original studies describing communication during telephone triage in primary care medical call centres handling all types of medical problems from an unselected population. All studies were screened by two authors, blinded to each other's decisions. Disagreements were resolved by a third author. A framework was created by the thematic synthesis of the qualitative data and later used to synthesise the quantitative data. By using convergent integrated synthesis, the qualitative and quantitative findings were integrated. The Mixed Methods Appraisal Tool was used to assess methodological limitations.

RESULTS

Out of 5087 studies identified in the search, 62 studies were included, comprising 40 qualitative, 16 quantitative and six mixed-method studies. Thirteen factors were identified and organised into four main themes: organisational factors, factors related to the operator, factors related to the caller and factors in the interaction. Organisational factors included availability, working conditions and decision support systems. Factors related to the operator were knowledge and experience, personal qualities and communication strategies. Factors related to the caller were individual differences and the presented medical problem. Factors in the interaction were faceless communication, connection between operator and caller, third-person caller and communication barriers. The factors seem interrelated, with organisational factors affecting all parts of the conversation, and the operator's communication in particular.

CONCLUSION

Many factors affect the structure, content, and flow of the conversation. The operators influence the communication directly but rely on the organisation to create a working environment that facilitates good communication. The results are mainly supported by qualitative studies and further studies are needed to explore and substantiate the relevance and effect of individual factors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022298022.

How Healthcare Providers Decide on a Referral Location in Telephone Triage: A Cross-sectional Study

BACKGROUND

Approximately 25% of patients that present to the emergency department (ED) do so after contact with a healthcare professional. Many of these patients could be effectively managed in non-ED ambulatory settings. Aligning patients with safe and appropriate outpatient care has the potential to improve ED overcrowding, patient experience, outcomes, and costs. Little is understood about how healthcare providers approach triage decision-making and what factors influence their choices.

OBJECTIVES

To evaluate how providers think about patient triage, and what factors influence their decision-making when triaging patient calls.

DESIGN

Cross-sectional survey-based study in which participants make triage decisions for hypothetical clinical scenarios.

PARTICIPANTS

Healthcare providers in the specialties of internal medicine, family medicine, or emergency medicine within a large integrated healthcare system in the Southeast.

MAIN MEASURES

Differences in individual training and practice characteristics were used to compare observed differences in triage outcomes. Free-response data were evaluated to identify themes and factors affecting triage decisions.

KEY RESULTS

Out of 72 total participants, substantial variability in triage decision-making was observed among all patient cases. Attending physicians triaged 1.4 fewer cases to ED care compared with resident physicians (p < 0.001, 95% CI 0.62-2.1). Academic attendings demonstrated a trend toward fewer cases to ED care compared with community attendings (0.61, p = 0.188, 95% CI - 0.31-1.5). Qualitative data highlighted the complex considerations in provider triage and led to the development of a novel conceptual model to describe the cognitive triage process and the main influencing factors.

CONCLUSIONS

Triage decision-making for healthcare providers is influenced by many factors related to clinical resources, care coordination, patient factors, and clinician factors. The complex considerations involved yield variability in triage decisions that is largely unexplained by descriptive physician factors.

Identifying performance indicators to measure overall performance of telephone triage - a scoping review

OBJECTIVE

This article aims to summarize performance indicators used in telephone triage services research, and make recommendations for the selection of valid indicators to measure the performance of telephone triage. We describe what kind of frameworks, performance indicators, or variables have been used for evaluating telephone triage performance by systematically mapping the telephone triage performance measurement. The objective was to find measures for each Triple Aim dimension.

DESIGN

A scoping review method was used following Joanna Briggs Institute guidelines. Using this method, we defined indicators to measure the performance of telephone triage. We used the Triple Aim framework to identify indicators to measure the overall performance of telephone triage. The Triple Aim framework consists of improving the patient experience of care, improving the health of populations, and reducing cost per capita.

SETTING

The scoping review was performed using CINAHL, Medline, EBSCOhost, and PubMed electronic databases. The eligibility criterion was research published in English between 2015 and 2023. The inclusion focused on the use and performance of telephone triage services and system-focused studies.

RESULTS

A total of 1098 papers were screened for inclusion, with 57 papers included in our review. We identified 13 performance indicators covering all Triple Aim dimensions: waiting times, access, patient satisfaction, the accuracy of triage decision, severity and urgency of the symptoms, triage response, patient compliance with the advice given, follow-up healthcare service use, and running costs of service. We didn't find any earlier framework covering all Triple Aim dimensions properly.

CONCLUSIONS

Measuring the performance of telephone triage requires an extensive and comprehensive approach. We presented performance indicators that may be included in the framework for measuring the performance of telephone triage to support overall performance measurements of telephone triage.

Effects of Telephone Consultation on Safety, Service Use, Patient Satisfaction, and Workload: Systematic Review and Meta-Analysis of Randomized Trials

Objective: Telephone consultation (TC) is widely used for its easy access and convenience. This review aimed to assess the effects of TC including triage on safety, service use, patient satisfaction, and health professionals' workload to inform directions for future health service practice. Methods: CENTRAL, MEDLINE, Embase, CINAHL, ProQuest Dissertation & Theses (Health & Medicine), ClinincalTrials.gov, and International Clinical Trial Registry Platform were searched on April 7, 2022. The included were randomized controlled trials that compared TC with standard (face-to-face [F2F]) management or that by another group of call advisers. Cochrane methods were used to select eligible studies, assess the risk of bias, estimate summary effect measure, and grade evidence certainty. Meta-analysis was performed on important outcomes with moderate- or high-quality evidence. Results: Eight studies were included involving 40,002 participants. TC could increase call resolution-proportion of callers' concerns being addressed by telephone advice alone (two studies; high certainty) and reduce F2F contacts with doctors for the first consultation (two studies, moderate certainty) compared with standard management or TC by doctors. None of included studies reported increases in adverse events, including all-cause mortality, acute and emergency department visit, and hospitalization. There was inadequate evidence regarding the effects of TC on patient satisfaction and length of consultation. Conclusion: The findings support the benefits of TC on improving call resolution and reducing F2F contacts with doctors on the day of first management for regular day service; and TC by nurses can provide better effects than that by doctors for out-of-hours service.

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.

Factors associated with undertriage in patients classified by the need to visit a hospital by telephone triage: a retrospective cohort study

BACKGROUND

Prehospital telephone triage stratifies patients into five categories, "need immediate hospital visit by ambulance," "need to visit a hospital within 1 hour," "need to visit a hospital within 6 hours," "need to visit a hospital within 24 hours," and "do not need a hospital visit" in Japan. However, studies on whether present and past histories cause undertriage are limited in patients triaged as need an early hospital visit. We investigated factors associated with undertriage by comparing patient assessed to be appropriately triaged with those assessed undertriaged.

METHODS

We included all patients classified by telephone triage as need to visit a hospital within 1 h and 6 h who used a single after-hours house call (AHHC) medical service in Tokyo, Japan, between November 1, 2019, and November 31, 2020. After home consultation, AHHC doctors classified patients as grade 1 (treatable with over-the-counter medications), 2 (requires hospital or clinic visit), or 3 (requires ambulance transportation). Patients classified as grade 2 and 3 were defined as appropriately triaged and undertriaged, respectively.

RESULTS

We identified 10,742 eligible patients triaged as need to visit a hospital within 1 h and 6 h, including 10,479 (97.6%) appropriately triaged and 263 (2.4%) undertriaged patients. Multivariable logistic regression analyses revealed patients aged 16-64, 65-74, and ≥ 75 years (adjusted odds ratio [OR], 2.40 [95% confidence interval {CI} 1.71-3.36], 8.57 [95% CI 4.83-15.2], and 14.9 [95% CI 9.65-23.0], respectively; reference patients aged < 15 years); those with diabetes mellitus (2.31 [95% CI 1.25-4.26]); those with dementia (2.32 [95% CI 1.05-5.10]); and those with a history of cerebral infarction (1.98 [95% CI 1.01-3.87]) as more likely to be undertriaged.

CONCLUSIONS

We found that older adults and patients with diabetes mellitus, dementia, or a history of cerebral infarction were at risk of undertriage in patients triaged as need to visit a hospital within 1 h and 6 h, but further studies are needed to validate these findings.

Income-related differences in out-of-hours primary care telephone triage using national registration data

BACKGROUND

Telephone triage is used to facilitate efficient and adequate acute care allocation, for instance in out-of-hours primary care services (OPCSs). Remote assessment of health problems is challenging and could be impeded by a patient's ambiguous formulation of his or her healthcare need. Socioeconomically vulnerable patients may experience more difficulty in expressing their healthcare need. We aimed to assess whether income differences exist in the patient's presented symptoms, assessed urgency and allocation of follow-up care in OPCS.

METHOD

Data were derived from Nivel Primary Care Database encompassing electronic health record data of 1.3 million patients from 28 OPCSs in 2017 in the Netherlands. These were linked to sociodemographic population registry data. Multilevel logistic regression analyses (contacts clustered in patients), adjusted for patient characteristics (eg, age, sex), were conducted to study associations of symptoms, urgency assessment and follow-up care with patients' income (standardised for household size as socioeconomic status (SES) indicator).

RESULTS

The most frequently presented symptoms deduced during triage slightly differed across SES groups, with a larger relative share of trauma in the high-income groups. No SES differences were observed in urgency assessment. After triage, low income was associated with a higher probability of receiving telephone advice and home visits, and fewer consultations at the OPCS.

CONCLUSIONS

SES differences in the patient's presented symptom and in follow-up in OPCS suggest that the underlying health status and the ability to express care needs affect the telephone triage process . Further research should focus on opportunities to better tailor the telephone triage process to socioeconomically vulnerable patients.

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.

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.

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations

BACKGROUND

During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful.

OBJECTIVE

To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk.

METHODS

Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient's general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age.

RESULTS

The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39-2.34, P < 0.001): 2.33 (1.68-3.22, P < 0.001) for men and 1.29 (0.83-1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07-3.10, P = 0.039).

CONCLUSIONS

Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more 'straightaway' could be considered for these patients with chest discomfort.

TRIAL NUMBER

NTR7331.

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.

Impact of a telephone-first consultation system in general practice

PURPOSE OF THE STUDY

Increasing pressure on general practice prompts innovative change in service organisation. This study sought to evaluate the impact of introducing a telephone-first consultation system in a socioeconomically deprived population.

STUDY DESIGN

An interrupted time series of preplanned outcomes for 2 years before and 1 year postintroduction of a telephone-first system was used to measure the volume and type of general practitioner (GP) consultations and the number of patients consulted per year. Emergency department (ED) and GP out-of-hours attendances, the number of outpatient referrals, and the number of requests for laboratory tests were measured as secondary outcomes.

RESULTS

The telephone-first system was associated with a 20% increase in total GP consultations (telephone and face-to-face, effect estimate at 12 months, p=0.001). Face-to-face consultations decreased by 39% (p<0.001), while telephone consultations increased by 131% (p<0.001). The volume of individual patient requests for a GP consultation and the number of treatment room nurse consultations did not change. Secondary outcome measures showed no change in hospital outpatient referrals, number of requests for laboratory tests, and ED or GP out-of-hours attendances.

CONCLUSIONS

A telephone-first system in a deprived urban general practice can decrease delays to GP-patient contacts. The number of patients seeking a medical intervention did not differ irrespective of the consultation system used. The telephone-first system did not affect GP out-of-hours, laboratory investigations or secondary care contacts.

Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study

INTRODUCTION

In the Netherlands, the 'Netherlands Triage Standard' (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain.

METHODS AND ANALYSIS

An observational study in which 3000 telephone triage recordings (period 2014-2016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers' own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses.

ETHICS AND DISSEMINATION

The Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.

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.