Safety of telephone triage in out-of-hours care: a systematic review

Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting

BACKGROUND

Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC).

OBJECTIVES

To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC.

METHODS

Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary.

RESULTS

The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive.

CONCLUSION

The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

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.

"I think we should wait and see": A qualitative study of call-takers' decision-making in consultations with patients suffering unrecognized myocardial infarction

OBJECTIVES

Call-takers face a complex situation when assessing medical problems in emergency medical services calls. Patients with myocardial infarction experiencing atypical symptoms risk misinterpretation. We examined development in call-takers' decision-making process in telephone consultations with patients having imminent myocardial infarction.

METHODS

Recording of 38 calls among 19 patients (two per patient) who contacted Copenhagen Emergency Medical Services (Denmark) at least twice within one week before myocardial infarction diagnosis. The penultimate and last call were compared using qualitative content analysis.

RESULTS

Call-takers' assessment of the condition changed from unclear symptom picture and dismissal of heart disease in penultimate call to severe condition, not heart-related, and possible heart disease in last call. Call-takers recommended watchful waiting in the penultimate call. Both calls involved response negotiation, while caution regarding misinterpretation was only seen in the penultimate call.

CONCLUSION

Call-takers used different decision-making approaches when the caller's symptom descriptions appeared unclear and not corresponding with the medical understanding of severe conditions. Call-takers did not negotiate the condition's assessment but engaged in discussions about the response choice.

PRACTICE IMPLICATIONS

A protocol to negotiate response choice with callers having unclear clinical conditions should be developed. Clarifying watchful waiting as a recommendation may assist call-takers' decision-making.

Telephone triage of chest pain in out-of-hours primary care: external validation of a symptom-based prediction rule to rule out acute coronary syndromes

INTRODUCTION

Telephone triage is pivotal for evaluating the urgency of patient care, and in the Netherlands, the Netherlands Triage Standard (NTS) demonstrates moderate discrimination for chest pain. To address this, the Safety First Prediction Rule (SFPR) was developed to improve the safety of ruling out acute coronary syndrome (ACS) during telephone triage.

METHODS

We conducted an external validation of the SFPR using data from the TRACE study, a retrospective cohort study in out-of-hours primary care. We evaluated the diagnostic accuracy assessment for ACS, major adverse cardiovascular events (MACE), and major events within 6 weeks. Moreover, we compared its performance with that of the NTS algorithm.

RESULTS

Among 1404 included patients (57.3% female, 6.8% ACS, 8.6% MACE), the SFPR demonstrated good discrimination for ACS (C-statistic: 0.79; 95%-CI: 0.75-0.83) and MACE (C-statistic: 0.79; 95%-CI: 0.0.76-0.82). Calibration was satisfactory, with overestimation observed in high-risk patients for ACS. The SFPR (risk threshold 2.5%) trended toward higher sensitivity (95.8% vs. 86.3%) and negative predictive value (99.3% vs. 97.6%) with a lower negative likelihood ratio (0.10 vs. 0.34) than the NTS algorithm.

CONCLUSION

The SFPR proved robust for risk stratification in patients with acute chest pain seeking out-of-hours primary care in the Netherlands. Further prospective validation and implementation are warranted to refine and establish the rule's clinical utility.

The effectiveness of tele-triage during the COVID-19 pandemic: A systematic review and narrative synthesis

BACKGROUND

Telehealth services were used by healthcare centers during the COVID-19 pandemic in order to identify and manage patients at the forefront of the healthcare system. As one of these technologies, tele-triage refers to the assessment of a patient's health status through telephone or another means of communication and recommending treatment or providing appropriate referrals in emergency rooms and primary care offices. This study aimed to perform a systematic review of the evidence on the effectiveness of tele-triage, as one of these technologies, during the COVID-19 pandemic.

METHODS

Medline (via PubMed), Scopus, and Web of Science databases were searched for relevant English articles published since the pandemic's onset until December 30, 2021. Studies investigating the tele-triage's effect on patient safety, clinical outcomes, and patient satisfaction were included. Data on study characteristics, intervention characteristics, and their effects on study outcomes were extracted separately by two authors. A narrative synthesis of the included studies was ultimately performed.

RESULTS

Out of the 6312 retrieved studies, 14 met the inclusion criteria. The tele-triage intervention was offered by an algorithm-based system in eight studies (57.14%) and by healthcare providers in six other studies (42.86%) to determine the patient's level of care. According to the results, tele-triage interventions during COVID-19 can reduce unnecessary emergency room visits (by 1.2-22.2%), improve clinical outcomes after intervention (such as would closure in diabetic feet), reduce mortality and injuries, and ensure patient satisfaction with tele-triage (53-98%).

CONCLUSIONS

This study found that tele-triage interventions reduced unnecessary visits, improved clinical outcomes, reduced mortality, and injuries, increased patient satisfaction, reduced healthcare provider workload, improved access to primary care consultation, and increased patient safety and satisfaction. Therefore, tele-triage systems are not only suitable for providing acute and emergency care remotely but they are also recommended as an alternative tool to monitor and diagnose COVID-19.

The need for a broad perspective when assessing value-for-money for out-of-hours primary care

BACKGROUND

Out-of-hours primary care (OOH-PC) has emerged as a promising solution to improve efficiency, accessibility, and quality of care and to reduce the strain on emergency departments. As this modality gains traction in diverse healthcare settings, it is increasingly important to fully assess its societal value-for-money and conduct thorough process evaluations. However, current economic evaluations mostly emphasise direct- and short-term effect measures, thus lacking a broader societal perspective.

AIM

This study offers a comprehensive overview of current effect measures in OOH-PC evaluations and proposes additional measures from the evaluation of integrated care programmes.

APPROACH AND DEVELOPMENT

First, we systematically identified the effect measures from published cost-effectiveness studies and classified them as process, outcome, and resource use measures. Second, we elaborate on the incorporation of 'productivity gains', 'health promotion and early intervention', and 'continuity of care' as additional effects into economic evaluations of OOH-PC. Seeking care affects personal and employee time, potentially resulting in decreased productivity. Challenges in taking time off work and limited access to convenient care are often cited as barriers to accessing primary care. As such, OOH-PC can potentially reduce opportunity costs for patients. Furthermore, improving access to healthcare is important in determining whether people receive promotional and preventive services. Health promotion involves empowering people to take control of their health and its determinants. Given the unscheduled nature and the fragmented or rotational care in OOH-PC, the degree to which interventions and modalities provide continuity should be monitored, assessed, and included in economic evaluations. Continuity of care in primary care improves patient satisfaction, promotes adherence to medical advice, reduces reliance on hospitals, and reduces mortality.

CONCLUSION

Although it is essential to also address local settings and needs, the integration of broader scope measures into OOH-PC economic evaluations improves the comprehensive evaluation that aligns with welfare gains.

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis

BACKGROUND

Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.

SETTING AND SAMPLE

UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023.

METHODS

Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts.

RESULTS

Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions.

CONCLUSION

While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

Building a performance measurement framework for telephone triage services in Finland: a consensus-making study based on nominal group technique

BACKGROUND

There has been a significant expansion in the measurement of healthcare system performance. However, there is a lack of a comprehensive performance measurement framework to assess the effects of telephone triage services on the urgent care system. The aim of our Delphi study was to construct and validate a performance measurement framework designed explicitly for telephone triage services.

METHODS

This study was conducted in Finland with a group of eight experienced senior physicians from the country's 20 largest joint emergency departments, serving over 90% of the population for urgent care. The Nominal Group Technique (NGT) was utilised to achieve consensus on measuring telephone triage performance. Initially, performance indicators (PIs) were identified through Delphi method rounds from December 10th to December 27th, 2021, with eight experts participating, and from December 29th, 2021, to January 23rd, 2022, where five of these experts responded. NGT further deepened these themes and perspectives, aiding in the development of a comprehensive performance measurement framework. The final framework validation began with an initial round from February 13th to March 3rd, 2022, receiving five responses. Due to the limited number of responses, an additional validation round was conducted from October 29th to November 7th, 2023, resulting in two more responses, increasing the total number of respondents in the validation phase to seven.

RESULTS

The study identified a strong desire among professionals to implement a uniform framework for measuring telephone triage performance. The finalised framework evaluates telephone triage across five dimensions: service accessibility, patient experience, quality and safety, process outcome, and cost per case. Eight specific PIs were established, including call response metrics, service utility, follow-up care type and distribution, ICPC-2 classified encounter reasons, patient compliance with follow-up care, medical history review during assessment, and service cost per call.

CONCLUSIONS

This study validated a performance measurement framework for telephone triage services, utilising existing literature and the NGT method. The framework includes five key dimensions: patient experience, quality and safety, outcome of the telephone triage process, cost per case, and eight PIs. It offers a structured and comprehensive approach to measuring the overall performance of telephone triage services, enhancing our ability to evaluate these services effectively.

Assessing the Revised Safer Dx Instrument® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics

OBJECTIVES

We sought within an ambulatory safety study to understand if the Revised Safer Dx instrument may be helpful in identification of diagnostic missed opportunities in care of children with type 1 diabetes (T1D) and autism spectrum disorder (ASD).

METHODS

We reviewed two months of emergency department (ED) encounters for all patients at our tertiary care site with T1D and a sample of such encounters for patients with ASD over a 15-month period, and their pre-visit communication methods to better understand opportunities to improve diagnosis. We applied the Revised Safer Dx instrument to each diagnostic journey. We chose potentially preventable ED visits for hyperglycemia, diabetic ketoacidosis, and behavioral crises, and reviewed electronic health record data over the prior three months related to the illness that resulted in the ED visit.

RESULTS

We identified 63 T1D and 27 ASD ED visits. Using the Revised Safer Dx instrument, we did not identify any potentially missed opportunities to improve diagnosis in T1D. We found two potential missed opportunities (Safer Dx overall score of 5) in ASD, related to potential for ambulatory medical management to be improved. Over this period, 40 % of T1D and 52 % of ASD patients used communication prior to the ED visit.

CONCLUSIONS

Using the Revised Safer Dx instrument, we uncommonly identified missed opportunities to improve diagnosis in patients who presented to the ED with potentially preventable complications of their chronic diseases. Future researchers should consider prospectively collected data as well as development or adaptation of tools like the Safer Dx.

A Symptom-Checker for Adult Patients Visiting an Interdisciplinary Emergency Care Center and the Safety of Patient Self-Triage: Real-Life Prospective Evaluation

BACKGROUND

Symptom-checkers have become important tools for self-triage, assisting patients to determine the urgency of medical care. To be safe and effective, these tools must be validated, particularly to avoid potentially hazardous undertriage without leading to inefficient overtriage. Only limited safety data from studies including small sample sizes have been available so far.

OBJECTIVE

The objective of our study was to prospectively investigate the safety of patients' self-triage in a large patient sample. We used SMASS (Swiss Medical Assessment System; in4medicine, Inc) pathfinder, a symptom-checker based on a computerized transparent neural network.

METHODS

We recruited 2543 patients into this single-center, prospective clinical trial conducted at the cantonal hospital of Baden, Switzerland. Patients with an Emergency Severity Index of 1-2 were treated by the team of the emergency department, while those with an index of 3-5 were seen at the walk-in clinic by general physicians. We compared the triage recommendation obtained by the patients' self-triage with the assessment of clinical urgency made by 3 successive interdisciplinary panels of physicians (panels A, B, and C). Using the Clopper-Pearson CI, we assumed that to confirm the symptom-checkers' safety, the upper confidence bound for the probability of a potentially hazardous undertriage should lie below 1%. A potentially hazardous undertriage was defined as a triage in which either all (consensus criterion) or the majority (majority criterion) of the experts of the last panel (panel C) rated the triage of the symptom-checker to be "rather likely" or "likely" life-threatening or harmful.

RESULTS

Of the 2543 patients, 1227 (48.25%) were female and 1316 (51.75%) male. None of the patients reached the prespecified consensus criterion for a potentially hazardous undertriage. This resulted in an upper 95% confidence bound of 0.1184%. Further, 4 cases met the majority criterion. This resulted in an upper 95% confidence bound for the probability of a potentially hazardous undertriage of 0.3616%. The 2-sided 95% Clopper-Pearson CI for the probability of overtriage (n=450 cases,17.69%) was 16.23% to 19.24%, which is considerably lower than the figures reported in the literature.

CONCLUSIONS

The symptom-checker proved to be a safe triage tool, avoiding potentially hazardous undertriage in a real-life clinical setting of emergency consultations at a walk-in clinic or emergency department without causing undesirable overtriage. Our data suggest the symptom-checker may be safely used in clinical routine.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04055298; https://clinicaltrials.gov/study/NCT04055298.

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.

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.

The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study

BACKGROUND

Clarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study.

METHODS

The present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts' opinions and results of the AGREE II tool.

RESULTS

The guideline included the items for evaluating the severity of obstetric symptoms at five levels including "critical", "urgent", "less urgent", "no urgent", and "recommendations". The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively.

CONCLUSION

The OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.

Psychosocial working conditions as determinants of slips and lapses, and poor social interactions with patients among medical assistants in Germany: A cohort study

OBJECTIVE

We sought to examine the relationship of unfavorable psychosocial working conditions with slips and lapses and poor patient interaction as well as potential intermediate factors among medical assistants (MAs) in Germany based on prospective data.

METHODS

We used data from 408 MAs from a 4-year cohort study (follow-up: 2021). At baseline, psychosocial working conditions were assessed by the established effort-reward-imbalance questionnaire and a MA-specific questionnaire with 7 subscales. Frequency of slips and lapses (e.g., pertaining to measurements and documentation) and the quality of patient interactions (e.g., unfriendliness or impatience) due to work stress were assessed at follow-up with three items each (potential score ranges = 3-15). Potential intermediate factors at baseline included work engagement (i.e., vitality and dedication (UWES)), work satisfaction (COPSOQ), anxiety (GAD-2), depressiveness (PHQ-2), and self-reported health. We ran multivariable linear regression using z-standardized exposures to estimate unstandardized coefficients (B) and 95% confidence intervals (CI). Potential intermediate factors were added separately to the regression models. Attenuation of the association between exposure and outcome toward the null value (B = 0) was interpreted as mediation.

RESULTS

High reward and lack of resources were weakly associated with the frequency of slips and lapses (the Bs were -0.18 and 0.23, respectively; p<0.05), with little evidence of mediation. With the exception of low recognition, all unfavorable psychosocial working conditions predicted a higher frequency of poor interactions with patients (p-values<0.01). These associations were attenuated by work engagement, work satisfaction, and health outcomes.

CONCLUSION

We found mostly non-significant associations between adverse psychosocial working conditions and the frequency of slips and lapses. However, unfavorable psychosocial working conditions among MAs predicted a higher frequency of poor interaction with patients due to stress.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Association between mortality and phone-line waiting time for non-urgent medical care: a Danish registry-based cohort study

BACKGROUND AND IMPORTANCE

Telephone calls are often patients' first healthcare service contact, outcomes associated with waiting times are unknown.

OBJECTIVES

Examine the association between waiting time to answer for a medical helpline and 1- and 30-day mortality.

DESIGN, SETTING AND PARTICIPANTS

Registry-based cohort study using phone calls data (January 2014 to December 2018) to the Capital Region of Denmark's medical helpline. The service refers to hospital assessment/treatment, dispatches ambulances, or suggests self-care guidance.

EXPOSURE

Waiting time was grouped into the following time intervals in accordance with political service targets for waiting time in the Capital Region: <30 s, 0:30-2:59, 3-9:59, and ≥10 min.

OUTCOME MEASURES AND ANALYSIS

The association between time intervals and 1- and 30-day mortality per call was calculated using logistic regression with strata defined by age and sex.

MAIN RESULTS

In total, 1 244 252 callers were included, phoning 3 956 243 times, and 78% of calls waited <10 min. Among callers, 30-day mortality was 1% (16 560 deaths). For calls by females aged 85-110 30-day mortality increased with longer waiting time, particularly within the first minute: 9.6% for waiting time <30 s, 10.8% between 30 s and 1 minute and 9.1% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 11.1%, 12.9% and 11.1%, respectively. Additionally, among calls with a Charlson score of 2 or higher, longer waiting times were likewise associated with increased mortality. For calls by females aged 85-110 30-day mortality was 11.6% for waiting time <30 s, 12.9% between 30 s and 1 minute and 11.2% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 12.7%, 14.1% and 12.6%, respectively. Fewer ambulances were dispatched with longer waiting times (4%/2%) with waiting times <30 s and >10 min.

CONCLUSION

Longer waiting times for telephone contact to a medical helpline were associated with increased 1- and 30-day mortality within the first minute, especially among elderly or more comorbid callers.

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.

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.

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.

Evaluation of Telephone Visits in Primary Care: Satisfaction of Pediatricians and Family Physicians and Their Perceptions of Quality of Care and Safety

Telehealth has accelerated since the outbreak of the COVID-19 virus. As telephone visits become more common, it is important to examine the challenges involved in using this modality of care. In this study, we examined family physicians' and pediatricians' perceptions regarding three aspects of the use of telephone visits: quality of care, safety of care, and physicians' satisfaction. A total of 342 family physicians and pediatricians responded to an online survey. Respondents were asked to rate their degree of agreement with 17 statements inquiring about quality, safety, and satisfaction with telephone visits on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). This was followed by in-depth interviews between January and April 2023 with 26 physicians. Participants expressed satisfaction (3.66 ± 0.80) with the use of telephone visits and lower assessments of safety (3.03 ± 0.76) and quality (2.27 ± 0.76) of care using the telephone modality. Eighty percent of the respondents think combining a face-to-face visit with a telephone visit is recommended, and 51% noted that the inability to examine patients closely affects and impedes a physician's decision making. Most interviewees indicated that telephone visits are safe only with former patients they had already seen in the clinic. The findings shed light on the perceptions of family physicians and pediatricians regarding telephone visits. The lower assessments of quality and safety compared to the assessment of satisfaction underscore the need for careful use of telephone visits in healthcare. A proper and balanced selection of patients, implementing technological upgrades to the modality, and performing patient education practices are recommended.

"ChatGPT, Can You Help Me Save My Child's Life?" - Diagnostic Accuracy and Supportive Capabilities to Lay Rescuers by ChatGPT in Prehospital Basic Life Support and Paediatric Advanced Life Support Cases - An In-silico Analysis

BACKGROUND

Paediatric emergencies are challenging for healthcare workers, first aiders, and parents waiting for emergency medical services to arrive. With the expected rise of virtual assistants, people will likely seek help from such digital AI tools, especially in regions lacking emergency medical services. Large Language Models like ChatGPT proved effective in providing health-related information and are competent in medical exams but are questioned regarding patient safety. Currently, there is no information on ChatGPT's performance in supporting parents in paediatric emergencies requiring help from emergency medical services. This study aimed to test 20 paediatric and two basic life support case vignettes for ChatGPT and GPT-4 performance and safety in children.

METHODS

We provided the cases three times each to two models, ChatGPT and GPT-4, and assessed the diagnostic accuracy, emergency call advice, and the validity of advice given to parents.

RESULTS

Both models recognized the emergency in the cases, except for septic shock and pulmonary embolism, and identified the correct diagnosis in 94%. However, ChatGPT/GPT-4 reliably advised to call emergency services only in 12 of 22 cases (54%), gave correct first aid instructions in 9 cases (45%) and incorrectly advised advanced life support techniques to parents in 3 of 22 cases (13.6%).

CONCLUSION

Considering these results of the recent ChatGPT versions, the validity, reliability and thus safety of ChatGPT/GPT-4 as an emergency support tool is questionable. However, whether humans would perform better in the same situation is uncertain. Moreover, other studies have shown that human emergency call operators are also inaccurate, partly with worse performance than ChatGPT/GPT-4 in our study. However, one of the main limitations of the study is that we used prototypical cases, and the management may differ from urban to rural areas and between different countries, indicating the need for further evaluation of the context sensitivity and adaptability of the model. Nevertheless, ChatGPT and the new versions under development may be promising tools for assisting lay first responders, operators, and professionals in diagnosing a paediatric emergency.

TRIAL REGISTRATION

Not applicable.

Video triage in calls concerning children with fever at an out-of-hours medical helpline: a prospective quality improvement study

BACKGROUND

Parents often contact out-of-hours services due to worry concerning febrile children, despite the children rarely being severely ill. As telephone triage of children is challenging, many children are referred to hospital assessment. This study investigated if video triage resulted in more children staying at home. Secondary aims included safety, acceptability and feasibility of this new triage tool.

METHODS

In this prospective quality improvement study, nurse call-handlers enrolled febrile children aged 3 months-5 years to video or telephone triage (1:1), with follow-up within 48 h after call. The setting was an out-of-hours call-center for non-urgent illness in Copenhagen, Denmark, receiving over 1 million calls annually and predominately staffed by registered nurses. Main outcome measure was difference in number of children assessed at hospital within 8 h after call between video-and telephone triage group. Rates of feasibility, acceptability and safety (death, lasting means, transfer to intensive care unit) were compared between the triage groups.

RESULTS

There was no difference in triage outcome (home care vs. hospital referral) or number of patients assessed at hospital between triage groups. However, more video triaged patients received in-hospital treatment, testing and hospitalization.

CONCLUSION

Video triage was feasible to conduct, acceptable to parents and as safe as telephone triage. The study did not show that more children stayed at home after video triage, possibly because the allocation strategy was not upheld, as video triage sometimes was chosen in cases of complex and severe symptoms, and this likely has changed study outcome.

TRIAL REGISTRATION

Clinicaltrials.gov.: Id NCT04074239. Registered 2019-08-30. https://clinicaltrials.gov/ct2/show/study/NCT04074239.

Safer Type 1 Diabetes Care at Home: SEIPS-based Process Mapping with Parents and Clinicians

Introduction

The limited data indicate that pediatric medical errors in the outpatient setting, including at home, are common. This study is the first step of our Ambulatory Pediatric Patient Safety Learning Lab to address medication errors and treatment delays among children with T1D in the outpatient setting. We aimed to identify failures and potential solutions associated with medication errors and treatment delays among outpatient children with T1D.

Methods

A transdisciplinary team of parents, safety researchers, and clinicians used Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping of data we collected through in-home medication review, observation of administration, chart reviews, parent surveys, and failure modes and effects analysis (FMEA).

Results

Eight (57%) of the 14 children who had home visits experienced 18 errors (31 per 100 medications). Four errors in two children resulted in harm, and 13 had the potential for harm. Two injuries occurred when parents failed to treat severe hypoglycemia and lethargy, and two were due to repeated failures to administer insulin at home properly. In SEIPS-based process maps, high-risk errors occurred during communication between the clinic and home or in management at home. Two FMEAs identified interventions to better communicate with families and support home care, especially during evolving illness.

Conclusion

Using SEIPS-based process maps informed by multimodal methods to identify medication errors and treatment delays, we found errors were common. Better support for managing acute illness at home and improved communication between the clinic and home are potentially high-yield interventions.

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction

OBJECTIVES

Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers.

METHODS

Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied.

RESULTS

Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see".

CONCLUSION

Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response.

PRACTICE IMPLICATIONS

Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

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.

Factors associated with undertriage and overtriage in telephone triage in Danish out-of-hours primary care: a natural quasi-experimental cross-sectional study of randomly selected and high-risk calls

OBJECTIVES

We aim to explore undertriage and overtriage in a high-risk patient population and explore patient characteristics and call characteristics associated with undertriage and overtriage in both randomly selected and in high-risk telephone calls to out-of-hours primary care (OOH-PC).

DESIGN

Natural quasi-experimental cross-sectional study.

SETTING

Two Danish OOH-PC services using different telephone triage models: a general practitioner cooperative with GP-led triage and the medical helpline 1813 with computerised decision support system-guided nurse-led triage.

PARTICIPANTS

We included audio-recorded telephone triage calls from 2016: 806 random calls and 405 high-risk calls (defined as patients ≥30 years calling with abdominal pain).

MAIN OUTCOME MEASURES

Twenty-four experienced physicians used a validated assessment tool to assess the accuracy of triage. We calculated the relative risk (RR) for clinically relevant undertriage and overtriage for a range of patient characteristics and call characteristics.

RESULTS

We included 806 randomly selected calls (44 clinically relevant undertriaged and 54 clinically relevant overtriaged) and 405 high-risk calls (32 undertriaged and 24 overtriaged). In high-risk calls, nurse-led triage was associated with significantly less undertriage (RR: 0.47, 95% CI 0.23 to 0.97) and more overtriage (RR: 3.93, 95% CI 1.50 to 10.33) compared with GP-led triage. In high-risk calls, the risk of undertriage was significantly higher for calls during nighttime (RR: 2.1, 95% CI 1.05 to 4.07). Undertriage tended to be more likely for calls concerning patients ≥60 years compared with 30-59 years (11.3% vs 6.3%) in high-risk calls. However, this result was not significant.

CONCLUSION

Nurse-led triage was associated with less undertriage and more overtriage compared with GP-led triage in high-risk calls. This study may suggest that to minimise undertriage, the triage professionals should pay extra attention when a call occurs during nighttime or concerns elderly. However, this needs confirmation in future studies.

Exploratory study: Evaluation of a symptom checker effectiveness for providing a diagnosis and evaluating the situation emergency compared to emergency physicians using simulated and standardized patients

BACKGROUND

The overloading of health care systems is an international problem. In this context, new tools such as symptom checker (SC) are emerging to improve patient orientation and triage. This SC should be rigorously evaluated and we can take a cue from the way we evaluate medical students, using objective structured clinical examinations (OSCE) with simulated patients.

OBJECTIVE

The main objective of this study was to evaluate the efficiency of a symptom checker versus emergency physicians using OSCEs as an assessment method.

METHODS

We explored a method to evaluate the ability to set a diagnosis and evaluate the emergency of a situation with simulation. A panel of medical experts wrote 220 simulated patients cases. Each situation was played twice by an actor trained to the role: once for the SC, then for an emergency physician. Like a teleconsultation, only the patient's voice was accessible. We performed a prospective non-inferiority study. If primary analysis had failed to detect non-inferiority, we have planned a superiority analysis.

RESULTS

The SC established only 30% of the main diagnosis as the emergency physician found 81% of these. The emergency physician was also superior compared to the SC in the suggestion of secondary diagnosis (92% versus 52%). In the matter of patient triage (vital emergency or not), there is still a medical superiority (96% versus 71%). We prove a non-inferiority of the SC compared to the physician in terms of interviewing time.

CONCLUSIONS AND RELEVANCE

We should use simulated patients instead of clinical cases in order to evaluate the effectiveness of SCs.

Evaluation of telephone triage among chest pain patients in out-of-hours primary care in the Netherlands (TRACE)

BACKGROUND

Telephone triage is fully integrated in Dutch out-of-hours primary care (OOH-PC). Patients presenting with chest pain are initially assessed according to a standardized protocol ("Netherlands Triage Standard" [NTS]). Nevertheless, little is known about its (diagnostic) performance, nor on the impact of subsequent clinical judgements made by triage assistants and general practitioners (GPs).

OBJECTIVE

To evaluate the performance of the current NTS chest pain protocol.

METHODS

Observational, retrospective cohort study of adult patients with chest pain who contacted a regional OOH-PC facility in the Netherlands, in 2017. The clinical outcome measure involved the occurrence of a "major event," which is a composite of all-cause mortality and urgent cardiovascular and noncardiovascular conditions, occurring ≤6 weeks of initial contact. We assessed the performance using diagnostic and discriminatory properties.

RESULTS

In total, 1,803 patients were included, median age was 54.0 and 57.5% were female. Major events occurred in 16.2% of patients with complete follow-up, including 99 (6.7%) cases of acute coronary syndrome and 22 (1.5%) fatal events. NTS urgency assessment showed moderate discriminatory abilities for predicting major events (c-statistic 0.66). Overall, NTS performance showed a sensitivity and specificity of 83.0% and 42.4% with a 17.0% underestimated major event rate. Triage assistants' revisions hardly improved urgency allocation. Further consideration of the clinical course following OOH-PC contact did generate a more pronounced improvement with a sensitivity of 89.4% and specificity of 61.9%.

CONCLUSION

Performance of telephone triage of chest pain appears moderate at best, with acceptable safety yet limited efficiency, even after including further work-up by GPs.

Effect of an educational intervention for telephone triage nurses on out-of-hours attendance: a pragmatic randomized controlled study

BACKGROUND

Telephone triage has been established in many countries as a response to the challenge of non-urgent use of out-of-hours primary care services. However, limited evidence is available regarding the effect of training interventions on clinicians' telephone consultation skills and patient outcomes.

METHODS

This was a pragmatic randomized controlled educational intervention for telephone triage nurses in 59 Norwegian out-of-hours general practitioners' (GPs) cooperatives, serving 59% of the Norwegian population. Computer-generated randomization was performed at the level of out-of-hours GP cooperatives, stratified by the population size. Thirty-two out-of-hours GP cooperatives were randomized to intervention. One cooperative did not accept the invitation to participate in the educational programme, leaving 31 cooperatives in the intervention group. The intervention comprised a 90-minute e-learning course and 90-minute group discussion about respiratory tract infections (RTIs), telephone communication skills and local practices. We aimed to assess the effect of the intervention on out-of-hours attendance and describe the distribution of RTIs between out-of-hours GP cooperatives and list-holding GPs. The outcome was the difference in the number of doctor's consultations per 1000 inhabitants between the intervention and control groups during the winter months before and after the intervention. A negative binomial regression model was used for the statistical analyses. The model was adjusted for the number of nurses who had participated in the e-learning course, the population size and patients' age groups, with the out-of-hours GP cooperatives defined as clusters.

RESULTS

The regression showed that the intervention did not change the number of consultations for RTIs between the two groups of out-of-hours GP cooperatives (incidence rate ratio 0.99, 95% confidence interval 0.91-1.07). The winter season's out-of-hours patient population was younger and had a higher proportion of RTIs than the patient population in the list-holding GP offices. Laryngitis, sore throat, and pneumonia were the most common diagnoses during the out-of-hours primary care service.

CONCLUSIONS

The intervention did not influence the out-of-hours attendance. This finding may be due to the intervention's limited scope and the intention-to-treat design. Changing a population's out-of-hours attendance is complicated and needs to be targeted at several organizational levels.

Implementation costs of telephone nurse triage service

Telephone nurse triage services are becoming increasingly common in healthcare systems worldwide. Florianópolis (Santa Catarina State, Brazil) is the first municipality in the country to provide this service in its public health system. This study adopted a quantitative, descriptive, and analytical methodology to evaluate the impact of this program on overall costs of the public health system. The research examined all 33,869 calls received by the telephone triage service from March 16 to October 31 in 2020, and calculated the program costs during the period. Avoided cost were calculated by the difference between estimated consultation costs considering patient-stated first alternative and the program recommendation after triage. Analyzing only the costs for the municipality of Florianópolis, the program's costs exceeded avoided costs by almost BRL 2.5 million during the period. By expanding the analysis to include costs of emergency department consultation - not administered by the municipality - based on data from previous research, we found that the program spares BRL 34.59 per call, a 21% cost reduction for the health system. Considering the preliminary results of the study and its limitations, it is understood that the service of telephone nurse triage can reduce costs in the healthcare system.

Machine learning models predicting undertriage in telephone triage

BACKGROUND

Undertriaged patients have worse outcomes than appropriately triaged patients. Machine learning provides better triage prediction than conventional triage in emergency departments, but no machine learning-based undertriage prediction models have yet been developed for prehospital telephone triage. We developed and validated machine learning models for telephone triage.

MATERIALS AND METHODS

We conducted a retrospective cohort study with the largest after-hour house-call (AHHC) service dataset in Japan. Participants were ≥16 years and used the AHHC service between 1 November 2018 and 31 January 2021. We developed five prediction models based on support vector machine (SVM), lasso regression (LR), random forest (RF), gradient-boosted decision tree (XGB), and deep neural network (DNN). The primary outcome was undertriage, and predictors were telephone triage level and routinely available telephone-based data, including age, sex, 80 chief complaint categories and 10 comorbidities. We measured the area under the receiver operating characteristic curve (AUROC) for all the models.

RESULTS

We identified 15,442 eligible patients (age: 38.4 ± 16.6, male: 57.2%), including 298 (1.9%; age: 58.2 ± 23.9, male: 55.0%) undertriaged patients. RF and XGB outperformed the other models, with the AUROC values (95% confidence interval; 95% CI) of the SVM, LR, RF, XGB and DNN for undertriage being 0.62 (0.55-0.69), 0.79 (0.74-0.83), 0.81 (0.76-0.86), 0.80 (0.75-0.84) and 0.77 (0.73-0.82), respectively.

CONCLUSIONS

We found that RF and XGB outperformed other models. Our findings suggest that machine learning models can facilitate the early detection of undertriage and early intervention to yield substantially improved patient outcomes.KEY MESSAGESUndertriaged patients experience worse outcomes than appropriately triaged patients; thus, we developed machine learning models for predicting undertriage in the prehospital setting. In addition, we identified the predictors of risk factors associated with undertriage.Random forest and gradient-boosted decision tree models demonstrated better prediction performance, and the models identified the risk factors associated with undertriage.Machine learning models aid in the early detection of undertriage, leading to significantly improved patient outcomes and identifying undertriage-associated risk factors, including chief complaint categories, could help prioritize conventional telephone triage protocol revision.

"Like a rainy weather inside of me": Qualitative content analysis of telephone consultations concerning back pain preceding out-of-hospital cardiac arrest

INTRODUCTION

Cardiac arrest patients presenting with back pain are at risk of not receiving the appropriate help when calling emergency medical services. In telephone consultations regarding patients with back pain preceding an out-of-hospital cardiac arrest, we investigated how communication between caller and call-taker influenced the call-taker's interpretation of back pain descriptions and decision-making about choice of response.

METHOD

The study was conducted using 20 recorded phone calls from 17 patients who contacted the Copenhagen Emergency Medical Services (Denmark) reporting back pain up to 24 hours before an out-of-hospital cardiac arrest. Qualitative content analysis was applied.

RESULTS

Two main categories emerged: (1) reasons, including subcategories: reported conditions, descriptions of conditions, patient's interpretation of condition and patient's own remedial actions; and (2) considerations, including subcategories: assessment of the severity, call-taker's interpretation of the condition, arguments for chosen response and conditions not facilitating further communication by the call-taker.

CONCLUSION

In telephone consultations regarding patients with back pain preceding an out-of-hospital cardiac arrest the communication was influenced by the communicative preconditions of the call-taker. Communication in consultations where ambulances were not dispatched was characterized by complex descriptions of symptoms not easily fitting into the health system's interpretations of conditions warranting an urgent response.

Patient-reported orofacial-dental pain severity and tele-triage decisions during COVID-19 pandemic: Does the severity of pain drive tele-triage decisions?

Background

Globally, with the COVID-19 pandemic, dental services were limited to emergency/ urgent conditions and were provided only after tele-triage referral for face-to-face management. However, no previous research explored whether the pain severity (PS) drives the tele-triage decisions. The current study examined the association between PS and tele-triage decision of whether to manage the condition remotely or refer the caller for face-to-face management.

Methods

This retrospective cross-sectional study analyzed the PS reported by hotline callers, using numerical rating scale (NRS-11), during the first wave of COVID-19 lockdown (23 March–31 August 2020) and its association with tele-triage decision controlling for age, sex, history of chronic illness, and dental discipline needed. Binomial logistic regression assessed the association between the PS (exposure) and tele-triage decision (outcome). ANOVA compared PS across tele-triage categories, dental history and tentative diagnosis.

Results

PS was significantly associated with tele-triage decisions (p < 0.05). An increase in pain score by 1 unit was associated with 1.4 times increased odds of face-face referral (95% CI: 1.26–1.54). Pediatric/ adolescent patients (9–18 years) (odds ratio (OR) = 2.07; 95% CI: 1.07–4.02), history of chronic illness (OR = 2.12; 95% CI:1.28–3.51), need for surgical specialty (OR = 1.93; 95% CI: 1.22–3.04) and orthodontic specialty (OR = 7.02; 95% CI: 3.54–13.87) were independently associated with tele-triage decision. PS was highest for the emergency triage category (8.00 ± 2.83, P < 0.0001), dental history of tooth with cavity or filling (6.65 ± 2.024, P < 0.0001), and the tentative tele-diagnosis of cellulitis (7.75 ± 2.872, P < 0.0001).

Conclusions

During COVID-19 pandemic, tele-triage decisions were significantly influenced by patient-reported PS, adjusting for a range of variables. Despite this, referral for face-to-face management was individualized and driven by the tripartite considerations of the reported pain, clinical judgement, and the high transmission characteristics of COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02340-w.

Remote care and triage of obstetric patients with COVID-19 in the community: operational considerations

Background

During the SARS-CoV-2 (COVID-19) pandemic, routine antenatal care was disrupted, and pregnant women positive for COVID-19 were at increased risk of caesarean section, intensive care admission or neonatal unit admission for their baby. Virtual care and telehealth can reduce barriers to care and improve maternity outcomes, and adoption has been encouraged by health authorities in the United Kingdom.

Methods

Norfolk and Norwich University Hospitals Trust deployed a flexible maternity virtual ward (MVW) service using the Current Health platform to care for pregnant women during the pandemic. Patients were monitored either intermittently with finger pulse oximetry or continuously with a wearable device. We outline the MVW technology, intervention and staffing model, triage criteria and patient feedback, as an example of an operational model for other institutions.

Results

Between October 2021 and February 2022, 429 patients were referred, of which 228 were admitted to the MVW. Total bed-days was 1,182, mean length of stay was 6 days (SD 2.3, range 1–14 days). Fifteen (6.6%) required hospital admission and one (0.4%) critical care. There were no deaths. Feedback alluded to feelings of increased safety, comfort, and ease with the technology.

Conclusions

The MVW offered a safety net to pregnant women positive for COVID-19. It provided reassurance for staff, while relieving pressures on infrastructure. When setting up similar services in future, attention should be given to identifying clinical champions, triage criteria, technology and alarm selection, and establishing flexible escalation pathways that can adapt to changing patterns of disease.

Triage Errors in Primary and Pre-Primary Care

Triage errors are a major concern in health care due to resulting harmful delays in treatments or inappropriate allocation of resources. With the increasing popularity of digital symptom checkers in pre–primary care settings, and amid claims that artificial intelligence outperforms doctors, the accuracy of triage by digital symptom checkers is ever more scrutinized. This paper examines the context and challenges of triage in primary care, pre–primary care, and emergency care, as well as reviews existing evidence on the prevalence of triage errors in all three settings. Implications for development, research, and practice are highlighted, and recommendations are made on how digital symptom checkers should be best positioned.

Reliability and validity of an original nurse telephone triage tool for out-of-hours primary care calls: the SALOMON algorithm

OBJECTIVES

Due to the persistent primary care physicians shortage and the substantial increase in their workload, the organization of primary care calls during out-of-hours periods has become an everyday challenge. The SALOMON algorithm is an original nurse telephone triage tool allowing to dispatch patients to the best level of care according to their conditions. This study evaluated its reliability and criterion validity in rea-life settings.

METHODS

In this 5-year study, out-of-hours primary care calls were dispatched into four categories: Emergency Medical Services Intervention (EMSI), Emergency Department referred Consultation (EDRC), Primary Care Physician Home visit (PCPH), and Primary Care Physician Delayed visit (PCPD). We included data of patients' triage category, resources, and destination. Patients included into the primary care cohort were classified undertriaged if they had to be redirected to an emergency department (ED). Patients from the ED cohort were considered overtriaged if they did not require at least three diagnostic resources, one emergency-specific treatment or any hospitalization. In the ED cohort, only patients from the University Hospitals were considered.

RESULTS

10,207 calls were triaged using the SALOMON tool: 19.2% were classified as EMSI, 15.8% as EDRC, 62.8% as PCPH, and 2.2% as PCPD. The triage was appropriate for 85.5% of the calls with a 14.5% overtriage rate. In the PCPD/PCPH cohort, 96.9% of the calls were accurately triaged and 3.1% were undertriaged. SALOMON sensitivity and specificity reached 76.6% and 98.3%, respectively.

CONCLUSION

SALOMON algorithm is a valid triage tool that has the potential to improve the organization of out-of-hours primary care work.

“We can’t do without it”: Parent and call-handler experiences of video triage of children at a medical helpline

Background

Pediatric out-of-hours calls are common, as parents worry and seek reassurance and shared responsibility. Nevertheless, most children assessed in this context are not seriously ill. Conventional telephone triage lacks visual cues and is further limited by third part communication in calls concerning children. We investigated implementation of video triage in two previous studies. The aim of the present study was to investigate 1) How video triage versus telephone triage in children was experienced by parents and call-handlers, and 2) call-handlers’ evaluation of the video triage projects.

Methods

We triangulated data from surveys and interviews in five sub-studies. Sub-study 1: Parents’ experience of video triage reported in closed-ended questionnaire items using quantitative analysis; Sub-study 2: Parents’ experience of video triage reported as questionnaire free-text using qualitative content analysis; Sub-study 3: Call-handlers’ experience of video triage reported in closed-ended questionnaire items using quantitative analysis; and Sub-studies 4 and 5: Individual interviews of call-handlers’ experience of 1) video triage using thematic analysis and 2) the video triage project using process evaluation.

Results

Most parents’ comments regarding video triage were positive (n = 164, 83%). Video triage was perceived as reassuring and reducing the likelihood of misunderstandings and unnecessary hospital visits. Call-handlers experienced that video triage improved patient assessment and caller reassurance. Some call-handlers complained that the time allocated for study participation was inadequate and requested a more accessible video set-up. Both parents and call-handlers were significantly more satisfied and reassured after video triage than after telephone triage and suggested video triage as a permanent option.

Conclusion

Video triage was appreciated by parents and call-handlers and was recommended as a permanent option. The call-handlers suggested that designated time for participation in the studies would have been desirable in this busy call-center. We recommend video triage as a contemporary solution in out-of-hours service.

Unscheduled care pathways in patients with myocardial infarction in Scotland

Objective

Treatment of acute myocardial infarction (MI) requires rapid transfer of people with chest pain to hospital, however, unscheduled care pathways vary in their directness (the minimal number of contacts to hospital admission). The aim was to examine unscheduled care pathways and the associations with mortality in people admitted with MI.

Methods

Retrospective population study of all people admitted to Scottish hospitals with a diagnosis of MI between 1 January 2015 and 31 December 2017. Linked data for all National Health Service Scotland unscheduled care services (NHS24 telephone triage service, primary care out of hours, ambulance, emergency department (ED)) was used to define continuous unscheduled care pathways (pathways), which were categorised by initial contact, and whether they were ‘direct’ (had minimum number of contacts between first contact and admission). Analysis estimated ORs and 95% CIs in adjusted models in which all covariates were included.

Results

26 325 people admitted with MI (63.1% men, 61.6% aged 65+ years), of whom 5.6% died from coronary heart disease within 28 days. For 47.0%, the first unscheduled care contact was ambulance, 23.3% attended ED directly and 18.7% called telephone triage. 92.1% of pathways were direct. Pathways starting with telephone triage were more likely to be indirect compared with other initial contacts (adjusted OR (aOR) 1.97, 95% CI 1.61 to 2.40). Compared to direct pathways, indirect pathways starting with telephone triage were associated with higher mortality (aOR 1.97, 95% CI 1.61 to 2.40) as were indirect pathways starting with another service (aOR 1.55, 95% CI 1.19 to 2.01), but not direct pathways starting with telephone triage (aOR 0.87, 95% CI 0.74 to 1.02).

Conclusion

Unscheduled care pathways leading to admission with MI in Scotland are usually direct, but those starting with telephone triage were more commonly indirect. Those indirect pathways were associated with higher mortality.

Role of Newly Introduced Teledentistry Service in the Management of Dental Emergencies During COVID-19 Pandemic in Qatar: A Cross-Sectional Analysis

Introduction: The lockdown imposed by the COVID-19 pandemic rendered teledentistry (TD) necessary to maintain the continuity of oral health services and avoid missing emergency dental conditions, while minimizing face-to-face visits. Our objective was to evaluate the ability of a newly introduced triage-based TD service to deliver its goals, by evaluating its processes and outcomes and assessing the demand for TD. Methods: This cross-sectional report assessed the triage processes and outcomes (triage category, referral to emergency/dental facility undertaken, remote medications prescribed, and procedures performed at the point of referral); and evaluated the demand for the newly introduced TD service during 5 months of the first wave of the pandemic. Results: Of 850 calls, about 70.6% of the samples were managed remotely; 29.4% were categorized as emergency/urgent and referred to the emergency/dental facility. Compared with other complaints, orofacial dental pain was the most common reason for the calls (41.6%, p < 0.0001). About 14.71% of callers received prescription for medications remotely. The most demanded disciplines were general dentistry, orthodontics, and oral surgery, respectively (p < 0.0001). Of those referred to a dental facility, 31.84% required no clinical intervention, 28.7% received orthodontic appliance repair, and 14.3% and 11.2% had urgent dental extractions or root canal treatments. Demand on the service fluctuated through various distinct stages of the lockdown. Conclusions: There has been continuous demand for the newly introduced TD service throughout the period of the current report despite the fluctuations, with most complaints managed remotely. TD was effective and suitable for triage, service delivery, and care during the pandemic.

Staff perceptions of patient safety in the NHS ambulance services: an exploratory qualitative study

Objectives

Most research investigating staff perceptions of patient safety has been based in primary care or hospitals, with little research on emergency services. Therefore, this study aimed to explore staff perceptions of patient safety in the NHS ambulance services.

Design

A stratified qualitative study using semi-structured interviews.

Setting

Three urban or rural ambulance service NHS trusts in England.

Participants

A total of 44 participants from three organisational levels, including executives, managers and operational staff.

Methods

The semi-structured interviews explored the interpretation and definition of patient safety, perceived risks, incident reporting, communication and organisational culture. The framework method of qualitative data analysis was used to analyse the interviews and NVivo software was used to manage and organise the data.

Results

We identified five dominant themes: varied interpretation of patient safety; significant patient safety risks; reporting culture shift; communication; and organisational culture. The findings demonstrated that staff perceptions of patient safety ranged widely across the three organisational levels, while they remained consistent within those levels across the participating ambulance service NHS trusts in England.

Conclusions

The findings suggest that participants from all organisational levels perceive that the NHS ambulance services have become much safer for patients over recent years, which signifies an awareness of the historical issues and how they have been addressed. The inclusion of three distinct ambulance service NHS trusts and organisational levels provides deepened insight into the perceptions of patient safety by staff. As the responses of participants were consistent across the three NHS trusts, the identified issues may be generic and have application in other ambulance and emergency service settings, with implications for health policy on a national basis.

Service use, clinical outcomes and user experience associated with urgent care services that use telephone-based digital triage: a systematic review

OBJECTIVE

To evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Medline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings.

RESULTS

Thirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients' adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions.

CONCLUSIONS

Further research is needed into patient level service use, including patients' adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery.

PROSPERO REGISTRATION NUMBER

CRD42020178500.

Review of Systematic Reviews in the Field of Telemedicine

Background: Although the systematic reviews regarding telemedicine have increased in recent decades, no comprehensive studies have been conducted to review these systematic reviews. The present study aimed to review the published systematic reviews regarding telemedicine applications for the report and appraisal of several aspects. Methods: The literature search was performed in the PubMed database for the systematic reviews published during January 2010-June 2020 in the field of telemedicine using "telemedicine" Mesh terms. The extracted data from the selected articles were the year of publication, telemedicine specialty, clinical outcomes, cost evaluation, and satisfaction assessment. Data analysis was performed using descriptive statistics. Results: Among 746 retrieved articles, 191 cases were selected and reviewed. Most of the studies were focused on telemedicine (n=35; 18.3%), followed by telerehabilitation (n=22; 11.5%), tele-diabetes (n=18; 9.4%), telecardiology (n=16; 8.3%), home telecare (n=13; 6.8%), telepsychiatry (n=12; 6.3%), teledermatology (n=11; 5.7%), and teleneurology (n=9; 4.7%). The selected studies were primarily focused on clinical outcomes (72.7%), followed by cost-effectiveness (32.4%) and user satisfaction (29.3%). In addition, they mostly indicated that telemedicine services yielded acceptable clinical outcomes (72.5%), cost-effectiveness (67.7%), and healthcare provider/patient satisfaction (83.9%). Conclusion: Although telerehabilitation, tele-diabetes, telecardiology, home telecare, and telepsychiatry were studied further, there are still some specific specialties such as teleradiology, telepathology, and telepediatric that should be considered more. Moreover, investigation of various outcomes could result in a more comprehensive view of this field. Therefore, further investigations in this regard would improve telemedicine applications and encourage potential telemedicine providers to initiate these applications.

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.

Associations between Psychosocial Working Conditions and Quality of Care (i.e., Slips and Lapses, and Perceived Social Interactions with Patients)-A Cross-Sectional Study among Medical Assistants

Adverse psychosocial working conditions in the health care sector are widespread and have been associated with a reduced quality of patient care. Medical assistants (MA) assume that their unfavorable working conditions predominantly lead to a poorer quality of care in terms of slips and lapses, and poorer social interactions with patients. We examined those associations for the first time among MAs. A total of 944 MAs in Germany participated in a survey (September 2016–April 2017). Psychosocial working conditions were measured by the effort-reward imbalance (ERI) questionnaire and a questionnaire specifically designed for MAs. Slips and lapses (3 items, e.g., measurement or documentation errors) and the quality of interactions (3 items) with patients were measured by a questionnaire developed by the study team based on prior qualitative research. We ran Poisson regression to estimate multivariable prevalence ratios (PRs). The ERI ratio and MA-specific working conditions were significantly associated with frequent self-reported slips and lapses (PR = 2.53 and PR ≥ 1.22, respectively) or poor interactions with patients (PR = 3.62 and PR ≥ 1.38, respectively) due to work stress. Our study suggests that various types of adverse psychosocial working conditions are associated with perceptions of slips and lapses or poorer interaction with patients due to work stress among MAs.

Reliability of Dutch Obstetric Telephone Triage

Background

Safety and efficiency of emergency care can be optimized with a triage system which uses urgency to prioritize care. The Dutch Obstetric Telephone Triage System (DOTTS) was developed to provide a basis for assessing urgency of unplanned obstetric care requests by telephone. Reliability and validity are important components in evaluating such (obstetric) triage systems.

Objective

To determine the reliability of Dutch Obstetric Telephone Triage, by calculating the inter-rater and intra-rater reliability.

Methods

To evaluate the urgency levels of DOTTS by testing inter-rater and intra-rater reliability, 90 vignettes of possible requests were developed. Nineteen participants, from hospitals where DOTTS had been implemented, rated in two rounds a set of ten vignettes. The five urgency levels and five presenting symptoms had an equal spread and had to be entered in accordance with DOTTS per vignette. Urgency levels were dichotomized into high urgency and intermediate urgency. Inter-rater reliability was rated as degree of agreement between two different participants with the same vignette. Intra-rater reliability was rated as agreement by the same participants at different moments in time. The degree of inter-rater and intra-rater reliability was tested using weighted Cohen’s Kappa and ICC.

Results

The agreement of urgency level between participants in accordance with predefined urgency level per vignette was 90.5% (95% CI 87.5–93.6) [335 of 370]. Agreement of urgency level between participants was 88.5% (95% CI 84.9–93.0) [177 of 200] and 84.9% (95% CI 78.3–91.4) after re-rating [101 of 119]. Inter-rater reliability of DOTTS expressed as Cohen’s Kappa was 0.77 and as ICC 0.87; intra-rater reliability of DOTTS expressed as Cohen’s Kappa was 0.70 and as ICC 0.82.

Conclusion

Inter-rater and intra-rater reliability of DOTTS showed substantial correlation, and is comparable to other studies. Therefore, DOTTS is considered reliable.

The Development of a Video Intervention to Improve Senior Medical Students' Performance on Outpatient Telephone Encounters: a Delphi Analysis and Randomized Controlled Trial

Introduction

Postgraduate trainees address outpatient telephone calls (OTCs) with little prior training. This study determines the skills necessary for OTCs and examines whether a video intervention improves medical students' performance on simulated OTCs.

Materials and Methods

We utilized a Delphi technique to determine skills needed for OTCs and created a 9-min video teaching these skills. Senior medical students were randomized to Intervention (viewed video) and Control (did not view video) groups. Students were assessed pre-/post-intervention on simulated OTCs. The primary outcome was the between-group difference in improvement.

Results

The Delphi yielded 34 important skills with the highest focus on communication (n = 13) and triage (n = 6). Seventy-two students completed assessments (Control, n = 41; Intervention, n = 31). The score (mean ± SD) improved 4.3% in the Control group (62.3 ± 14.3% to 66.6 ± 25.0%) and 12.2% in the Intervention group (60.7 ± 15.2% to 72.9 ± 20.4%, p = 0.15). The effect size measured by Cohen's d was 0.55, considered effective (> 0.33) for an educational intervention.

Conclusions

This project fills a gap in OTC training. The use of the Delphi technique, intervention development based on the results, and evaluation of efficacy is a process that could be reproduced for other educational gaps.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-021-01331-w.

Phone triage nurses' assessment of respiratory tract infections - the tightrope walk between gatekeeping and service providing. A qualitative study

BACKGROUND

Phone nurses triage callers to Norwegian out-of-hours cooperatives to estimate the appropriate urgency and level of care for the caller. Many callers with mild symptoms of respiratory tract infections receive a doctor's consultation, which may lead to busy sessions and in turn impair clinical decisions.

OBJECTIVE

This study explores how phone triage nurses assess callers with mild-to-moderate symptoms of respiratory tract infections and their views and experiences on triaging and counselling these callers.

METHODS

We conducted four focus groups with 22 nurses (five men and 17 women aged 24-66 years) in three different locations in Norway. The interviews were transcribed verbatim and analysed by systematic text condensation.

RESULTS

The informants were reluctant to call themselves gatekeepers. However, their description of their work indicates that they practice such a role. When nurses and callers disagreed about the right level of care, the informants sought consensus through strategies and negotiations. The informants described external factors such as organisational or financial issues as decisive for the population's use of out-of-hours services. They also described callers' characteristics, such as language deficiency and poor ability to describe symptoms, as determining their own clinical assessments.

CONCLUSIONS

Nurses perceive assessments of callers with respiratory tract infections as challenging. They need skills and time to reach a consensus with the callers and guide them to the right level of health care. This should be considered when planning nurse training and staffing of out-of-hours cooperatives.KEY-POINTSPhone triage nurses assess callers to the out-of-hours service and estimate the level of urgencyThis study explores how phone triage nurses assess callers with respiratory tract infections and their views and experiences on this taskThe nurses describe their professional role as a tightrope walk between gatekeeping and service providingThe nurses seek consensus with callers through strategies and negotiations.

Validation of Dutch Obstetric Telephone Triage System: A Prospective Validation Study

Objective and Purpose

A triage system that prioritizes care according to medical urgency has a favorable effect on safety and efficiency of emergency care. The Dutch obstetric telephone triage system is comparable to physical triage systems. It consists of five urgency levels: resuscitation and life threatening (U1), emergency (U2), urgent (U3), non-urgent (U4) and self-care advice (U5). The purpose of this study was to determine the diagnostic and external validity of the Dutch obstetric telephone triage system in obstetric emergency care.

Patients and Methods

The validity of the Dutch obstetric telephone triage system was studied in a prospective observational study in four hospitals. Diagnostic validity of usual care was determined by comparing the assigned urgency level of the Dutch obstetric telephone triage system with a reference standard. This reference standard was obtained by face-to-face clinical assessment in hospital following telephone triage. Clinical follow-up after assessment was also recorded. For statistical analyses, urgency levels were dichotomized into high urgency (U1, U2) and intermediate urgency (U3, U4). Self-care advice (U5) could not be studied because these patients were not referred to hospital.

Results

In total, 983 cases (U1-U4) across the four hospitals were included, 625 (64%) cases were categorized as high urgency and 358 (36%) as intermediate urgency. The Dutch obstetric telephone triage system’s urgency level agreed with the reference standard in 53% (n=525; 95% CI 50–57%). According to the reference standard the Dutch obstetric telephone triage system had undertriage in 16% (n=160) and overtriage in 30% (n=298) of the cases. Sensitivity for high urgency was 76% (95% CI 72–80), specificity 49% (95% CI 44–53). Positive predictive value and negative predictive value were 60% (95% CI 56–63) and 67% (95% CI 62–72), respectively. After clinical assessment, urgent care was needed in 8.7% (n=31) of the intermediate-urgency cases, none of these cases were life threatening situations.

Conclusion

DOTTS shows an acceptable diagnostic validity with room for improvement.

Revision of the Protocol of the Telephone Triage System in Tokyo, Japan

Introduction

The Emergency Telephone Consultation Center in Tokyo (#7119) was the first telephone triage system in Japan and has operated since 2007. This study examined the revision of the #7119 protocol by referring the linked data to each code of the triage protocol.

Methods

We selected candidates based on the medical codes targeted by the revision, linking data from the nurses' decisions in triage and the patients' condition severity when the ambulance arrived at the hospital, gathering data from June 1, 2016, to December 31, 2017. Then, several emergency physicians evaluated the cases and decided whether the code should be moved to the more or less urgent category or if new protocols and codes would be established.

Results

In this revision, 371 codes were moved to the less urgent category, 35 codes were moved to the more urgent category, and 128 codes were newly established. In all, 59 red codes (transfer to the ambulance dispatcher) were reduced, while 254 orange codes (attendance at hospital within 1 hour) and yellow codes (within 6 hours) were moved to less urgent, and 12 yellow and green codes (within 24 hours) were moved to more urgent.

Conclusion

We adjusted the triage codes for the revision by linking the call data with the case data. This revision should decrease the inappropriate use of ambulances and reduce the primary care workload. To achieve a more accurate revision, we need to refine the process of evaluating the validity of patients' acuity over the telephone during triage.

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.