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Karen Smith - One of the best experts on this subject based on the ideXlab platform.
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ambulance dispatch of older patients following primary and secondary Telephone Triage in metropolitan melbourne australia a retrospective cohort study
BMJ Open, 2020Co-Authors: Kathryn Eastwood, Dhanya Nambiar, Rosamond Dwyer, Judy Lowthian, Peter Cameron, Karen SmithAbstract:BACKGROUND Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary Telephone Triage. Ambulance Victoria uses clinician-led secondary Telephone Triage for patients identified as low-acuity during primary Triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches. OBJECTIVES To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch. DESIGN A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted. SETTING The secondary Telephone Triage service operated in metropolitan Melbourne, Victoria, Australia during the study period. PARTICIPANTS There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses. MAIN OUTCOME MEASURES Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients. RESULTS The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005). CONCLUSION Secondary Triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.
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the appropriateness of low acuity cases referred for emergency ambulance dispatch following ambulance service secondary Telephone Triage a retrospective cohort study
PLOS ONE, 2019Co-Authors: Kathryn Eastwood, Amee Morgans, Johannes Uiltje Stoelwinder, Karen SmithAbstract:Objective Ambulance-based secondary Telephone Triage systems have been established in ambulance services to divert low-acuity cases away from emergency ambulance dispatch. However, some low-acuity cases still receive an emergency ambulance dispatch following secondary Triage. To date, no evidence exists identifying whether these cases required an emergency ambulance. The aim of this study was to investigate whether cases were appropriately referred for emergency ambulance dispatch following secondary Telephone Triage. Methods A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch in Melbourne, Australia following secondary Telephone Triage between September 2009 and June 2012. Appropriateness was measured by assessing the frequency of advanced life support (ALS) treatment by paramedics, and paramedic transport to hospital. Results There were 23,696 cases included in this study. Overall, 54% of cases received paramedic treatment, which was similar to the state-wide rate for emergency ambulance cases (55.5%). All secondary Telephone Triage cases referred for emergency ambulance dispatch had transportation rates higher than all metropolitan emergency ambulance cases (82.2% versus 71.1%). Two-thirds of the cases that were transported were also treated by paramedics (66.5%), and 17.7% of cases were not transported to hospital by ambulance following paramedic assessment. Conclusions Overall, the cases returned for emergency ambulance dispatch following secondary Telephone Triage were appropriate. Nevertheless, the paramedic treatment rates in particular indicate a considerable rate of overTriage requiring further investigation to optimize the efficacy of secondary Telephone Triage.
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patient and case characteristics associated with no paramedic treatment for low acuity cases referred for emergency ambulance dispatch following a secondary Telephone Triage a retrospective cohort study
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine, 2018Co-Authors: Kathryn Eastwood, Amee Morgans, Johannes Uiltje Stoelwinder, Karen SmithAbstract:Predicting case types that are unlikely to be treated by paramedics can aid in managing demand for emergency ambulances by identifying cases suitable for alternative management pathways. The aim of this study was to identify the patient characteristics and Triage outcomes associated with ‘no paramedic treatment’ for cases referred for emergency ambulance dispatch following secondary Telephone Triage. A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch following secondary Telephone Triage between September 2009 and June 2012. Multivariable logistic regression modelling was used to identify explanatory variables associated with ‘no paramedic treatment’. There were 19,041 cases eligible for inclusion in this study over almost three years, of which 8510 (44.7%) were not treated after being sent an emergency ambulance following secondary Triage. Age, time of day, pain, Triage guideline group, and comorbidities were associated with ‘no paramedic treatment’. In particular, cases 0–4 years of age or those with psychiatric conditions were significantly less likely to be treated by paramedics, and increasing pain resulted in higher rates of paramedic treatment. This study highlights that case characteristics can be used to identify particular case types that may benefit from care pathways other than emergency ambulance dispatch. This process is also useful to identify gaps in the alternative care pathways currently available. These findings offer the opportunity to optimise secondary Telephone Triage services to support their strategic purpose of minimising unnecessary emergency ambulance demand and to match the right case with the right care pathway.
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appropriateness of cases presenting in the emergency department following ambulance service secondary Telephone Triage a retrospective cohort study
BMJ Open, 2017Co-Authors: Kathryn Eastwood, Amee Morgans, Karen Smith, Johannes Uiltje StoelwinderAbstract:Objective To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary Telephone Triage. Design A pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary Telephone Triage. Setting The secondary Telephone Triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary Triage of cases classified as low acuity when calling the Australian emergency Telephone number. Population Cases Triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary Triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways. Main outcome measures Appropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’). Results Planned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p Conclusions Secondary Telephone Triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately Triaged away from the emergency care pathways.
Linda Huibers - One of the best experts on this subject based on the ideXlab platform.
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socioeconomic inequality in Telephone Triage on Triage response hospitalization and 30 day mortality
European Journal of Public Health, 2021Co-Authors: Hejdi Gamstjensen, Ingrid Egerod, Mikkel Brabrand, Janne Schurmann Tolstrup, Lau Caspar Thygesen, Erika Frischknecht Christensen, Freddy Lippert, Andrea Nedergaard Jensen, Linda HuibersAbstract:We investigated socioeconomic inequality (measured by the indicators highest attained education level and household income) in Telephone Triage on Triage response (face-to-face contact), hospitalization and 30-day mortality among Danish citizens calling the medical helpline 1813 between 23 January and 9 February 2017. The analysis included 6869 adult callers from a larger prospective cohort study and showed that callers with low socioeconomic status (SES) were less often Triaged to a face-to-face contact and had higher 30-day mortality than callers with high SES.
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self rated worry is associated with hospital admission in out of hours Telephone Triage a prospective cohort study
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine, 2020Co-Authors: Hejdi Gamstjensen, Linda Huibers, Fredrik Folke, Ingrid Egerod, Mikkel Brabrand, Janne Schurmann Tolstrup, Erika Frischknecht Christensen, Freddy Lippert, Lau Caspar ThygesenAbstract:Telephone Triage manages patient flow in acute care, but a lack of visual cues and vague descriptions of symptoms challenges clinical decision making. We aim to investigate the association between the caller’s subjective perception of illness severity expressed as “degree-of-worry” (DOW) and hospital admissions within 48 h. A prospective cohort study was performed from January 24th to February 9th, 2017 at the Medical Helpline 1813 (MH1813) in Copenhagen, Denmark. The MH1813 is a primary care out-of-hours service. Of 38,787 calls received at the MH1813, 11,338 met the inclusion criteria (caller being patient or close friend/relative and agreement to participate). Participants rated their DOW on a 5-point scale (1 = minimum worry, 5 = maximum worry) before talking to a call handler. Information on hospitalization within 48 h after the call, was obtained from the Danish National Patient Register. The association was assessed using logistic regression in three models: 1) crude, 2) age-and-gender adjusted and 3) age, gender, co-morbidity, reason for calling and caller status adjusted. A total of 581 participants (5.1%) were admitted to the hospital, of whom 170 (11.3%) presented with a maximum DOW, with a crude odds ratio (OR) for hospitalization of 6.1 (95% confidence interval (CI) 3.9 to 9.6) compared to minimum DOW. Estimates showed dose-response relationship between DOW and hospitalization. In the fully adjusted model, the ORs decreased to 3.1 (95%CI 2.0 to 5.0) for DOW = 5, 3.2 (2.0 to 5.0) for DOW = 4, 1.6 (1.0 to 2.6) for DOW = 3 and 0.8 (0.5 to 1.4) for DOW = 2 compared to minimum DOW. Patients’ self-assessment of illness severity as DOW was associated with subsequent hospital admission. Further, it may be beneficial in supporting clinical decision making in Telephone Triage. Finally, it might be useful as a measure to facilitate patient participation in the Triage process.
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safety efficiency and health related quality of Telephone Triage conducted by general practitioners nurses or physicians in out of hours primary care a quasi experimental study using the assessment of quality in Telephone Triage aqtt to assess audio
BMC Family Practice, 2020Co-Authors: Dennis Schou Graversen, Morten Bondo Christensen, Anette Fischer Pedersen, Anders Helles Carlsen, Flemming Bro, H C Christensen, C H Vestergaard, Linda HuibersAbstract: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. 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. 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). 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.
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quality of out of hours Telephone Triage by general practitioners and nurses development and testing of the aqtt an assessment tool measuring communication patient safety and efficiency
Scandinavian Journal of Primary Health Care, 2019Co-Authors: Dennis Schou Graversen, Linda Huibers, Anette Fischer Pedersen, Flemming Bro, Anders Helle Carlsen, Morten Bondo ChristensenAbstract:Objective: To develop a valid and reliable assessment tool able to measure quality of communication, patient safety and efficiency in out-of-hours (OOH) Telephone Triage conducted by both general p...
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67 self rated worry predicts hospitalisation in out of hours services Telephone Triage
BMJ Open, 2018Co-Authors: Hejdi Gamstjensen, Linda Huibers, E Frishknecht, F K Lippert, Fredrik Folke, Ingrid Egerod, Mikkel Brabrand, Janne Schurmann Tolstrup, Lau Caspar ThygesenAbstract:Aim Telephone-Triage poses a challenge in estimating urgency and determining the best response in acute health care. Lack of visual cues, vague symptom description, interpretation of symptoms, and spoken word contribute to the complexity.1 The aim of the study was to include information that would enrich the Telephone-Triage with a measure of the callers’ subjective feeling of urgency defined as ‘degree-of worry’ (DOW). We tested the hypothesis that high DOW would be associated with hospitalisation within 48 hours. Method A prospective cohort study was performed between 24.01–9.02 2017. Callers rated their DOW on a 1–5 scale (1=minimum worry, 5=maximum worry) before transferred to a call-handler. Length of hospital stay was obtained from National Patient Register. The association between DOW and hospitalisation was assessed using logistic regression. Results Of 11 413 calls to the helpline, 581 individuals (5.1%) were hospitalised. Most of the hospitalised individuals (n=374, 64.4%) presented a high DOW (DOW 4–5). A high DOW had an odds ratio for being hospitalised of 5.38 (95% CI: 4.05 to 7.15) compared to those with a low DOW (DOW 1–2). Medium DOW (DOW 3) had intermediate odds ratio of 2.24 (95% CI 1.65 to 3.06). We observed this in all age groups, both genders, all levels of comorbidity, regardless if the caller was the patient or a close relative/friend. Conclusion A high DOW increased the odds for hospitalisation five-fold. DOW could be beneficial in supporting assessment and clinical decision-making in Telephone-Triage as well as directly involving the caller in the decision-making process. Reference . Leprohon J, Patel VL. Decision-making strategies for Telephone Triage in emergency medical services. Medical Decision Making: An International Journal of the Society for Medical Decision Making 1995;15:240–253. Conflict of interest None Funding Trygfonden, Danish Nurses Association and Laerdal Foundation.
Kathryn Eastwood - One of the best experts on this subject based on the ideXlab platform.
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ambulance dispatch of older patients following primary and secondary Telephone Triage in metropolitan melbourne australia a retrospective cohort study
BMJ Open, 2020Co-Authors: Kathryn Eastwood, Dhanya Nambiar, Rosamond Dwyer, Judy Lowthian, Peter Cameron, Karen SmithAbstract:BACKGROUND Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary Telephone Triage. Ambulance Victoria uses clinician-led secondary Telephone Triage for patients identified as low-acuity during primary Triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches. OBJECTIVES To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch. DESIGN A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted. SETTING The secondary Telephone Triage service operated in metropolitan Melbourne, Victoria, Australia during the study period. PARTICIPANTS There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses. MAIN OUTCOME MEASURES Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients. RESULTS The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005). CONCLUSION Secondary Triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.
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the appropriateness of low acuity cases referred for emergency ambulance dispatch following ambulance service secondary Telephone Triage a retrospective cohort study
PLOS ONE, 2019Co-Authors: Kathryn Eastwood, Amee Morgans, Johannes Uiltje Stoelwinder, Karen SmithAbstract:Objective Ambulance-based secondary Telephone Triage systems have been established in ambulance services to divert low-acuity cases away from emergency ambulance dispatch. However, some low-acuity cases still receive an emergency ambulance dispatch following secondary Triage. To date, no evidence exists identifying whether these cases required an emergency ambulance. The aim of this study was to investigate whether cases were appropriately referred for emergency ambulance dispatch following secondary Telephone Triage. Methods A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch in Melbourne, Australia following secondary Telephone Triage between September 2009 and June 2012. Appropriateness was measured by assessing the frequency of advanced life support (ALS) treatment by paramedics, and paramedic transport to hospital. Results There were 23,696 cases included in this study. Overall, 54% of cases received paramedic treatment, which was similar to the state-wide rate for emergency ambulance cases (55.5%). All secondary Telephone Triage cases referred for emergency ambulance dispatch had transportation rates higher than all metropolitan emergency ambulance cases (82.2% versus 71.1%). Two-thirds of the cases that were transported were also treated by paramedics (66.5%), and 17.7% of cases were not transported to hospital by ambulance following paramedic assessment. Conclusions Overall, the cases returned for emergency ambulance dispatch following secondary Telephone Triage were appropriate. Nevertheless, the paramedic treatment rates in particular indicate a considerable rate of overTriage requiring further investigation to optimize the efficacy of secondary Telephone Triage.
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patient and case characteristics associated with no paramedic treatment for low acuity cases referred for emergency ambulance dispatch following a secondary Telephone Triage a retrospective cohort study
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine, 2018Co-Authors: Kathryn Eastwood, Amee Morgans, Johannes Uiltje Stoelwinder, Karen SmithAbstract:Predicting case types that are unlikely to be treated by paramedics can aid in managing demand for emergency ambulances by identifying cases suitable for alternative management pathways. The aim of this study was to identify the patient characteristics and Triage outcomes associated with ‘no paramedic treatment’ for cases referred for emergency ambulance dispatch following secondary Telephone Triage. A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch following secondary Telephone Triage between September 2009 and June 2012. Multivariable logistic regression modelling was used to identify explanatory variables associated with ‘no paramedic treatment’. There were 19,041 cases eligible for inclusion in this study over almost three years, of which 8510 (44.7%) were not treated after being sent an emergency ambulance following secondary Triage. Age, time of day, pain, Triage guideline group, and comorbidities were associated with ‘no paramedic treatment’. In particular, cases 0–4 years of age or those with psychiatric conditions were significantly less likely to be treated by paramedics, and increasing pain resulted in higher rates of paramedic treatment. This study highlights that case characteristics can be used to identify particular case types that may benefit from care pathways other than emergency ambulance dispatch. This process is also useful to identify gaps in the alternative care pathways currently available. These findings offer the opportunity to optimise secondary Telephone Triage services to support their strategic purpose of minimising unnecessary emergency ambulance demand and to match the right case with the right care pathway.
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appropriateness of cases presenting in the emergency department following ambulance service secondary Telephone Triage a retrospective cohort study
BMJ Open, 2017Co-Authors: Kathryn Eastwood, Amee Morgans, Karen Smith, Johannes Uiltje StoelwinderAbstract:Objective To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary Telephone Triage. Design A pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary Telephone Triage. Setting The secondary Telephone Triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary Triage of cases classified as low acuity when calling the Australian emergency Telephone number. Population Cases Triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary Triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways. Main outcome measures Appropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’). Results Planned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p Conclusions Secondary Telephone Triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately Triaged away from the emergency care pathways.
Dorien L M Zwart - One of the best experts on this subject based on the ideXlab platform.
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interactional implications of either or questions during Telephone Triage of callers with chest discomfort in out of hours primary care a conversation analysis
Patient Education and Counseling, 2021Co-Authors: Daphne C Erkelens, Dorien L M Zwart, Frans H Rutten, Loes T Wouters, Roger A M J Damoiseaux, Tessa Cyrina Charldorp, Vera Vinck, Esther De GrootAbstract:Abstract Objective To explore the interactional implications of either/or-questions on the interaction between people who call out-of-hours services in primary care (OHS-PC) and Triage nurses who use a decision support tool called the ‘Netherlands Triage Standard’ (NTS) during Telephone Triage. Methods A qualitative study of 68 Triage conversations at six Dutch OHS-PC. Patients called the OHS-PC with symptoms, e.g. chest discomfort, suggestive of acute coronary syndrome. Using conversation analysis, we identified two categories of multiple-choice either/or-questions that indicated interactional difficulties, shown in hesitation markers within callers’ responses. Results Our analysis shows that interactional difficulties mainly arise when (i) questions are poorly designed by the Triage nurse; or (ii) when the caller’s complaints are ambiguously presented reflecting patient’s difficulties to verbalize them (e.g. “not feeling well”). Conclusion The way NTS displays key diagnostic options encourages Triage nurses to use multiple-choice either/or-questions. More awareness among Triage nurses is needed on undesirable implications of either/or-questions on the interaction. Practice implications We recommend changing the NTS display of diagnostic options and to use questions with fewer options in order to decrease the chance of formulating ambiguous questions soliciting unclear responses. Furthermore, asking content questions when complaints are ambiguously formulated may specify the presentation of complaints.
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missed acute coronary syndrome during Telephone Triage at out of hours primary care lessons from a case control study
Journal of Patient Safety, 2020Co-Authors: Daphne C Erkelens, Loes Wouters, Arno W Hoes, Roger Damoiseaux, Frans H Rutten, Esther De Groot, Harmke G Kirkels, Judith M Poldervaart, Dorien L M ZwartAbstract:OBJECTIVES Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the Telephone Triage process but are hampered by hindsight bias. This study compared the recorded Triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with Triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS. METHODS A case-control study with data from 2013 to 2017 of 9 OHS-PC in the Netherlands. The cases were matched 1:8 with controls based on age and sex. Clinical, patient, and call characteristics were univariably assessed, and general practitioner experts evaluated the Triage while blinded to the final diagnosis or the case-control status. RESULTS Fifteen missed ACS calls and 120 matched control calls were included. Cases used less cardiovascular medication (38.5% versus 64.1%, P = 0.05) and more often experienced pain other than retrosternal chest pain (63.3% versus 24.7%, P = 0.02) compared with controls. Consultation of the supervising general practitioner (86.7% versus 49.2%, P = 0.02) occurred more often in cases than in controls. Experts rated the Triage of cases more often as "poor" (33.3% versus 10.9%, P = 0.001) and "unsafe" (73.3% versus 22.5%, P < 0.001) compared with controls. CONCLUSIONS To facilitate learning from serious adverse events in the future, these should also be bundled and carefully assessed without hindsight bias and within the context of "normal" clinical practice.
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accuracy of Telephone Triage in patients suspected of transient ischaemic attack or stroke a cross sectional study
BMC Family Practice, 2020Co-Authors: Daphne Carmen Erkelens, Frans H Rutten, Esther De Groot, Loes T Wouters, Servaas L Dolmans, Roger A M J Damoiseaux, Dorien L M ZwartAbstract:The Netherlands Triage Standard (NTS) is a widely used decision support tool for Telephone Triage at Dutch out-of-hours primary care services (OHS-PC), which, however, has never been validated against clinical outcomes. We aimed to determine the accuracy of the NTS urgency allocation for patients with neurological symptoms suggestive of a transient ischaemic attack (TIA) or stroke, with the clinical outcomes TIA, stroke, and other (neurologic) life-threatening events (LTEs) as the reference. A cross-sectional study of Telephone Triage recordings of patients with neurological symptoms calling the OHS-PC between 2014 and 2016.The allocated NTS urgencies were derived from the electronic medical records of the OHS-PC. The clinical outcomes were retrieved from the electronic medical records of the patients’ own general practitioners. The accuracy of a high NTS urgency allocation (medical help within 3 h) was calculated in terms of sensitivity, specificity, positive and negative predictive values (PPV and NPV) with the clinical outcomes TIA/stroke/other LTEs as the reference. Of 1269 patients, 635 (50.0%) received the diagnosis TIA/stroke (34.2% TIA/minor stroke, 15.8% major ischaemic or haemorrhagic stroke), and 4.8% other LTEs. For TIA/stroke/other LTEs, the sensitivity and specificity of the NTS urgency allocation were 0.72 (95%CI 0.68–0.75) and 0.48 (95%CI 0.43–0.52), and the PPV and NPV were 0.62 (95%CI 0.60–0.64) and 0.58 (95%CI 0.54–0.62). The NTS decision support tool used in Dutch OHS-PC performed poor to moderately regarding safety (sensitivity) and efficiency (specificity) in allocating adequate urgencies to patients with and without TIA/stroke/other LTEs. The Netherlands National Trial Register, identification number NTR7331 /Trial NL7134 .
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limited reliability of experts assessment of Telephone Triage in primary care patients with chest discomfort
Journal of Clinical Epidemiology, 2020Co-Authors: Daphne C Erkelens, Loes Wouters, Arno W Hoes, Frans H Rutten, Esther De Groot, Roger A M J Damoiseaux, Dorien L M ZwartAbstract:Abstract Objective Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in Telephone Triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of Triage of patients with chest discomfort, and we quantified inter-rater reliability. Study Design and Setting This is a case-control study with Triage recordings from 2013–2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of Triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation. Results In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71–0.95) and a specificity of 0.51 (95% CI: 0.43–0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P Conclusions Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.
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tinkering and overruling the computer decision support system working strategies of Telephone Triage nurses who assess the urgency of callers suspected of having an acute cardiac event
Journal of Clinical Nursing, 2020Co-Authors: Loes Wouters, Dorien L M Zwart, Daphne C Erkelens, Marlies Huijsmans, Arno W Hoes, Roger Damoiseaux, Frans H Rutten, Esther De GrootAbstract:AIMS AND OBJECTIVES: To understand clinical reasoning and decision-making of Triage nurses during Telephone conversations with callers suspected of having acute cardiac events, and support from a computer decision support system (CDSS) herewith. BACKGROUND: In Telephone Triage, nurses assess the urgency of callers' conditions with clinical reasoning, often supported by CDSS. The use of CDSS may trigger interactional workability dilemmas. DESIGN: Qualitative study using principles of a grounded theory approach following COREQ criteria for qualitative research. METHODS: Audio-stimulated recall interviews were conducted amongst twenty-four Telephone Triage nurses at nine out-of-hours primary care centres (OHS-PC). RESULTS: Telephone Triage nurses use clinical reasoning elements for urgency assessment. Typically in Telephone Triage, they interpret the vocal-but not worded-elements in communication (paralanguage) such as tone of voice and shortness of breath and create a mental image to compensate for lack of visual information. We confirmed that interactional workability dilemmas occur. Congruence, established when the CDSS supports the Triage nurses' decision-making, is essential for the CDSS' value. If congruence is absent, Triage nurses may apply four working strategies: (a) tinker to make CDSS final recommendation align with their own assessment, (b) overrule the CDSS recommendation, (c) comply with the CDSS recommendation or (d) transfer responsibility to the GP. CONCLUSION: Triage nurses who assess urgency may experience absence of congruence between the CDSS and their decision-making. Awareness of how Triage nurses reason and make decisions about urgency and what aspects influence their working strategies can help in achieving optimal Triage of callers suspected of acute cardiac events at OHS-PC. RELEVANCE TO CLINICAL PRACTICE: Triage nurses' reasoning and their working strategies are vital for outcome of Triage decisions. Understanding these processes is essential for CDSS developers and OHS-PC managers, who should value how Triage nurses interact with the CDSS, while they have the benefit of callers in mind.
Emily Fletcher - One of the best experts on this subject based on the ideXlab platform.
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Telephone Triage systems in uk general practice analysis of consultation duration during the index day in a pragmatic randomised controlled trial
British Journal of General Practice, 2016Co-Authors: Tim Holt, Emily Fletcher, Colin Green, David Richards, Suzanne H Richards, Chris Salisbury, Raff Calitri, Fiona C Warren, Rod S Taylor, Anna VarleyAbstract:© British Journal of General Practice. Background Telephone Triage is an increasingly common means of handling requests for same-day appointments in general practice. Aim To determine whether Telephone Triage (GP-led or nurse-led) reduces clinician-patient contact time on the day of the request (the index day), compared with usual care. Design and setting A total of 42 practices in England recruited to the ESTEEM trial. Method Duration of initial contact (following the appointment request) was measured for all ESTEEM trial patients consenting to case notes review, and that of a sample of subsequent face-to-face consultations, to produce composite estimates of overall clinician time during the index day. Results Data were available from 16 711 initial clinician-patient contacts, plus 1290 GP, and 176 nurse face-to-face consultations. The mean (standard deviation) duration of initial contacts in each arm was: GP Triage 4.0 (2.8) minutes; nurse Triage 6.6 (3.8) minutes; and usual care 9.5 (5.0) minutes. Estimated overall contact duration (including subsequent contacts on the same day) was 10.3 minutes for GP Triage, 14.8 minutes for nurse Triage, and 9.6 minutes for usual care. In nurse Triage, more than half the duration of clinician contact (7.7 minutes) was with a GP. This was less than the 9.0 minutes of GP time used in GP Triage. Conclusion Telephone Triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led Triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.
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exploring demographic and lifestyle associations with patient experience following Telephone Triage by a primary care doctor or nurse secondary analyses from a cluster randomised controlled trial
BMJ Quality & Safety, 2015Co-Authors: Fiona C Warren, Emily Fletcher, Tim Holt, Valerie Lattimer, David Richards, Suzanne H Richards, Chris Salisbury, Raff Calitri, Anna Varley, Rod S TaylorAbstract:Background The ESTEEM trial was a cluster randomised controlled trial that compared two Telephone Triage management systems (general practitioner (GP) or a nurse supported by computer decision support software) with usual care, in response to a request for same-day consultation in general practice. Aim To investigate associations between trial patients’ demographic, health, and lifestyle characteristics, and their reported experiences of care. Setting Recruitment of 20 990 patients occurred between May 2011 and December 2012 in 42 GP practices in England (13 GP Triage, 15 nurse Triage, 14 usual care). Method Patients reported their experiences via a postal questionnaire issued 4 weeks after their initial request for a same-day consultation. Overall satisfaction, ease of accessing medical help/advice, and convenience of care were analysed using linear hierarchical modelling. Results Questionnaires were returned by 12 132 patients (58%). Older patients reported increased overall satisfaction compared with patients aged 25–59 years, but patients aged 16–24 years reported lower satisfaction. Compared with white patients, patients from ethnic minorities reported lower satisfaction in all three arms, although to a lesser degree in the GP Triage arm. Patients from ethnic minorities reported higher satisfaction in the GP Triage than in usual care, whereas white patients reported higher satisfaction with usual care. Patients unable to take time away from work or who could only do so with difficulty reported lower satisfaction across all three trial arms. Conclusions Patient characteristics, such as age, ethnicity and ability to attend their practice during work hours, were associated with their experiences of care following a same-day consultation request in general practice. Telephone Triage did not increase satisfaction among patients who were unable to attend their practice during working hours. Trial registration number ISCRTN20687662.
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distance from practice moderates the relationship between patient management involving nurse Telephone Triage consulting and patient satisfaction with care
Health & Place, 2015Co-Authors: Raff Calitri, Emily Fletcher, Suzanne H Richards, Jamie Murdoch, Anna Varley, Fiona C Warren, Benedict W Wheeler, Katherine Chaplin, Rod S Taylor, John CampbellAbstract:The ESTEEM trial was a randomised-controlled trial of Telephone Triage consultations in general practice. We conducted exploratory analyses on data from 9154 patients from 42 UK general practices who returned a questionnaire containing self-reported ratings of satisfaction with care following a request for a same-day consultation. Mode of care was identified through case notes review. There were seven main types: a GP face-to-face consultation, GP or nurse Telephone Triage consultation with no subsequent same day care, or a GP or nurse Telephone Triage consultation with a subsequent face-to-face consultation with a GP or a nurse. We investigated the contribution of mode of care to patient satisfaction and distance between the patient׳s home and the practice as a potential moderating factor. There was no overall association between patient satisfaction and distance from practice. However, patients managed by a nurse Telephone consultation showed lowest levels of satisfaction, and satisfaction for this group of patients increased the further they lived from the practice. There was no association between any of the other modes of management and distance from practice.
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implementing Telephone Triage in general practice a process evaluation of a cluster randomised controlled trial
BMC Family Practice, 2015Co-Authors: Jamie Murdoch, Emily Fletcher, Nicky Britten, Colin Green, Valerie Lattimer, Suzanne H Richards, Raff Calitri, Anna Varley, Linnie Price, David RichardsAbstract:Background: Telephone Triage represents one strategy to manage demand for face-to-face GP appointments in primary care. However, limited evidence exists of the challenges GP practices face in implementing Telephone Triage. We conducted a qualitative process evaluation alongside a UK-based cluster randomised trial (ESTEEM) which compared the impact of GP-led and nurse-led Telephone Triage with usual care on primary care workload, cost, patient experience, and safety for patients requesting a same-day GP consultation. The aim of the process study was to provide insights into the observed effects of the ESTEEM trial from the perspectives of staff and patients, and to specify the circumstances under which Triage is likely to be successfully implemented. Here we report perspectives of staff. Methods: The intervention comprised implementation of either GP-led or nurse-led Telephone Triage for a period of 2-3 months. A qualitative evaluation was conducted using staff interviews recruited from eight general practices (4 GP Triage, 4 Nurse Triage) in the UK, implementing Triage as part of the ESTEEM trial. Qualitative interviews were undertaken with 44 staff members in GP Triage and nurse Triage practices (16 GPs, 8 nurses, 7 practice managers, 13 administrative staff). Results: Staff reported diverse experiences and perceptions regarding the implementation of Telephone Triage, its effects on workload, and on the benefits of Triage. Such diversity were explained by the different ways Triage was organised, the staffing models used to support Triage, how the introduction of Triage was communicated across practice staff, and by how staff roles were reconfigured as a result of implementing Triage. Conclusion: The findings from the process evaluation offer insight into the range of ways GP practices participating in ESTEEM implemented Telephone Triage, and the circumstances under which Telephone Triage can be successfully implemented beyond the context of a clinical trial. Staff experiences and perceptions of Telephone Triage are shaped by the way practices communicate with staff, prepare for and sustain the changes required to implement Triage effectively, as well as by existing practice culture, and staff and patient behaviour arising in response to the changes made.
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the impact of using computer decision support software in primary care nurse led Telephone Triage interactional dilemmas and conversational consequences
Social Science & Medicine, 2015Co-Authors: Jamie Murdoch, Emily Fletcher, Valerie Lattimer, Rebecca K Barnes, Jillian Pooler, John CampbellAbstract:Telephone Triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to Triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded Telephone Triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during Triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of Telephone Triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of Triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe Triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.
