Dataset Information

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

ABSTRACT:

Objective

Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.

Methods

A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem).

Results

Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5-97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7-90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7-49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6).

Conclusions

There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.

SUBMITTER: Huibers L

PROVIDER: S-EPMC3308461 | biostudies-literature | 2011 Dec

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

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

Huibers Linda L Smits Marleen M Renaud Vera V Giesen Paul P Wensing Michel M

Scandinavian journal of primary health care 20111201 4

<h4>Objective</h4>Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.<h4>Methods</h4>A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours m ...[more]

PMID: 22126218

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Project description:BACKGROUND:To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities. METHODS:Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n?=?423), nurses using CDSS (n?=?430), or physicians with different medical specialities (n?=?441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage. RESULTS:The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2?min 57?s, SD: 105?s) than nurses (mean: 4?min 44?s, SD: 168?s). CONCLUSIONS:Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

Project description:INTRODUCTION:In the Netherlands, the 'Netherlands Triage Standard' (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain. METHODS AND ANALYSIS:An observational study in which 3000 telephone triage recordings (period 2014-2016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers' own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses. ETHICS AND DISSEMINATION:The Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.

Project description:BackgroundTelephone 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.MethodsThis 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.ResultsThe 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.ConclusionsThe 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.

Project description:ObjectivesTo compare the quality of communication in out-of-hours (OOH) telephone triage conducted by general practitioners (GPs), nurses using a computerised decision support system and physicians with different medical specialities, and to explore the association between communication quality and efficiency, length of call and the accuracy of telephone triage.DesignNatural quasi-experimental cross-sectional study.SettingTwo Danish OOH services using different telephone triage models: a GP cooperative and the medical helpline 1813.Participants1294 audio-recorded randomly selected OOH telephone triage calls from 2016 conducted by GPs (n=423), nurses using CDSS (n=430) and physicians with different medical specialities (n=441).Main outcome measuresTwenty-four physicians assessed the calls. The panel used a validated assessment tool (Assessment of Quality in Telephone Triage, AQTT) to measure nine aspects of communication, overall perceived communication quality, efficiency and length of call.ResultsThe risk of poor quality was significantly higher in calls triaged by GPs compared with calls triaged by nurses regarding 'allowing the caller to describe the situation' (GP: 13.5% nurse: 9.8%), 'mastering questioning techniques' (GP: 27.4% nurse: 21.1%), 'summarising' (GP: 33.0% nurse: 21.0%) and 'paying attention to caller's experience' (GP: 25.7% nurse: 17.0%). The risk of poor quality was significantly higher in calls triaged by physicians compared with calls triaged by GPs in five out of nine items. GP calls were significantly shorter (2 min 57 s) than nurse calls (4 min 44 s) and physician calls (4 min 1 s). Undertriaged calls were rated lower than optimally triaged calls for overall quality of communication (p<0.001) and all specific items.ConclusionsCompared with telephone triage by GPs, the communication quality was higher in calls triaged by nurses and lower in calls triaged by physicians with different medical specialities. However, calls triaged by nurses and physicians were longer and perceived less efficient. Quality of communication was associated with accurate triage.

Project description:ObjectivesWe 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).DesignNatural quasi-experimental cross-sectional study.SettingTwo 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.ParticipantsWe 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 measuresTwenty-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.ResultsWe 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.ConclusionNurse-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.

Dataset Information

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

Objective

Methods

Results

Conclusions

Publications

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

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