Multi-method approach to the development of contextual telephone triage systems

Background: In the last 10 years, at least 15 NHS physiotherapy departments have introduced telephone triage systems, e.g. PhysioDirect, with the aim of decreasing patient waiting times and increasing efficiencies. Many of these schemes appear to have been implemented with little reference to underpinning evidence. The aim of this systematic review was to investigate the effectiveness and feasibility of telephone triage systems in physiotherapy outpatient settings. Methods: The following electronic databases were searched between 1990–2013: MEDLINE, PUBMED, Cochrane Library, CINAHL, PEDro, AMED, EMBASE. In addition, reference sections of relevant articles were screened to identify appropriate articles. Primary quantitative studies published in English, which reviewed physiotherapy-led telephone triage were included. Two reviewers screened the studies for inclusion, extracted data, and assessed study quality using the Downs and Black Quality Index Assessment tool. A third reviewer arbitrated if conflict occurred. Data on clinical effectiveness, cost-effectiveness and acceptability of telephone triage and patient compliance was collated. The results were analysed and presented as a narrative synthesis. Results: Five studies met the inclusion criteria for the review. Three studies were rated as high quality, one was of moderate quality and one was of poor quality. There was strong evidence that telephone triage and usual care are similarly cost-effective. There is moderate evidence of equivalent clinical effectiveness between telephone triage and usual care, and that appointment non-attendance rates are comparable between usual care and telephone triage. There is conflicting and therefore inconclusive evidence for the acceptability to patients and staff of telephone triage. There is currently no level of evidence reviewing patient compliance with telephone triage. Conclusions: The limited published evidence indicates that telephone triage systems lead to relatively similar clinical and cost-effectiveness outcomes, but with no conclusive added efficiencies in waiting times, satisfaction levels and patients attendance. Further studies in this area would clarify the clinical usefulness of introducing telephone triage systems in musculoskeletal physiotherapy outpatient settings.

Purpose: This methodological study was done to develop a computerized telephone triage and consultation system for patients discharged with ophthalmic disease in order to provide more efficient practice guidelines for nurses, and evaluate the usability of the system. Methods: Development of the system consisted of six phases: strategic planning, analysis, design, implementation, evaluation, modification, and maintenance. Results: In the strategic planning phase, ophthalmic problems and nursing interventions of triage algorithms and practice guidelines were cross-mapped with the Omaha system. In the analysis phase, users requirements were identified. Then infrastructure in cluding database, nursing knowledge base, and user interface were designed in the implementation phase. Usability and satisfaction of the system presented as very positive. Telephone consultation took about 2 minutes less than time in the previous system. The system was modified based on users’ comments during the evaluation phase. Conclusion: This study was the first attempt in Korea to develop comput erized triage system to prompt the quality of telephone consultation. It is suggestive that the computerized triage system may improve the quality of nursing.

PurposeTelephone and virtual triage services are becoming increasingly common in ambulatory oncology settings. Few studies have evaluated their implementation from the perspective of service users. This study aims to evaluate the experiences of engaging with nurse-delivered telephone and virtual triage systems for symptom management among people undergoing cancer treatment. MethodsAn integrative review was undertaken. MEDLINE, CINAHL, PsycInfo, Academic Search Complete and Scopus were systematically searched. Twelve publications met the inclusion criteria, and data related to cancer patients’ perceptions of the triage process were extracted and analysed. ResultsTelephone-based (n=7), app-based (n=5) and video-based teleconferencing (n=2) triage systems were evaluated positively overall, enhancing ease of health system navigation, avoidance of emergency department for consultation, and the information, reassurance and support provided to support self-management of symptoms. However, several factors influenced the users’ engagement with triage services, including confidence to articulate symptoms, limited opening hours, waiting times for initial triage or follow-up and digital literacy. Collectively, these factors contributed to delayed reporting or under-reporting of symptoms, undermining the potential impact of services. Studies included variable reporting of intervention characteristics, including the qualification of nurses delivering and leading services. ConclusionsFuture evaluations of triage services must give greater consideration to the characterisation of interventions to ensure transferability, including nursing roles and qualifications. To ensure effective intervention and optimal supportive care for symptom management, patients must be prepared to engage triage services early. Future evaluations must ensure the impact of digital literacy on engagement with, and experience of, virtual triage is investigated.

BackgroundTelephone consultations are increasingly being utilised to manage patient demand for GP appointments. It’s true impact on patient care remains to be answered as existing evidence has shown mixed results.AimTo report the impact of telephone triage on: number of face-to-face (F2F) appointments offered; unplanned re-consultations with GP or urgent care services within 24 hours; and total consultation duration per patient episode.MethodA retrospective cohort study in a single suburban practice in Kent, comparing outcomes between the new telephone triage and old walk-in F2F appointment systems in managing patient requests for same-day appointments. Data was sampled across 1 week, at 3-monthly intervals over each 12-month period before and after the system change-over in April 2016.Results1198 patient encounters matched the inclusion criteria. F2F appointments were offered to 34.7% of patients after telephone triage. Although unplanned re-consultations were four times more prevalent since the system changed compared to the previous year (P<0.001), no difference was seen between those consulted by telephone only, or offered a F2F appointment after telephone triage. Overall, patient consultations by telephone triage were 2.37 minutes shorter than consultations under its predecessor (P <0.001).ConclusionTelephone triage was able to manage majority of patient problems by telephone alone, with significant reduction in consulting time per patient episode. Telephone consulting was not shown accountable for the increase in unplanned re-consultations.

Telephone triage is an increasingly common means of handling requests for same-day appointments in general practice. 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. A total of 42 practices in England recruited to the ESTEEM trial. 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. 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. 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.

Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers. Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs). Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend. We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice. Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible.

After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.

Electric-thermal energy storage using solid particles as storage media

Triage systems in emergency units play a crucial role in prioritizing patient care and optimizing resource allocation during mass casualty incidents or high-demand situations. This article provides a comprehensive review of triage systems concentrating on their evolution key components challenges and future directions. By synthesizing existing literature and incorporating insights from healthcare professionals this research aims to inform policymakers and practitioners about the latest developments in triage systems and recommend strategies for enhancing their effectiveness. Triage systems in emergency units play a crucial role in prioritizing patient care and resource allocation. This abstract delivers an overview of triage systems focusing on their structure function challenges and potential enhancements. Drawing upon a comprehensive review of literature including academic studies healthcare guidelines and expert opinions this research elucidates the multifaceted nature of triage systems and their impact on emergency care delivery. In contemporary emergency units triage systems operate on standardized protocols and algorithms aimed at rapidly assessing patients upon their arrival and assigning them to priority categories based on the severity of their condition. However these systems face challenges such as overcrowding resource constraints and variability in patient presentations which can impact their effectiveness and efficiency. To address these challenges opportunities for enhancing triage systems abound. Technological advancements such as the integration of Electronic health records EHRs and real-time data analytics offer promising avenues for improvement. Furthermore ongoing training and education programs for triage personnel can enhance their skills and decision-making abilities leading to more consistent and accurate triage assessments. Ultimately by embracing innovation and collaboration emergency units can enhance the efficiency and effectiveness of their triage systems ultimately improving patient outcomes.

The telephone has become an indispensable method of communication in the practice of obstetrics. The telephone is one of the primary methods by which the patient makes her appointments and contacts her health care provider for advice, reassurance, and referrals. Current methods of telephone triage include personal at the physicians' office, telephone answering services, labor and delivery nurses, and a dedicated telephone triage system using algorithms. Limitations of telephone triage include the inability of the provider to see the patient and receive visual clues from the interaction and the challenges of obtaining a complete history over the telephone. In addition, there are potential safety and legal issues with telephone triage. To date, there is insufficient evidence to either validate or refute the use of a dedicated telephone triage system compared with a traditional system using an answering service or nurses on labor and delivery. Obstetricians and gynecologists, family physicians. After completing this CME activity, physicians should be better able to analyze the scope of variation in telephone triage across health care providers and categorize the components that go into a successful triage system, assess the current scope of research in telephone triage in obstetrics, evaluate potential safety and legal issues with telephone triage in obstetrics, and identify issues that should be addressed in any institution that is using or implementing a system of telephone triage in obstetrics.

ED Utilization by Uninsured and Medicaid Patients after Availability of Telephone Triage

Telephone consultation and triage systems: effects on health care use and patient satisfaction

Health call centres using decision support information technology have been introduced in a number of countries ostensibly to provide standardized advice to patients in an attempt to assist in managing demand for health-care services and facilitate equity of access.1 A National Health Call Centre Network (healthdirect Australia), announced in February 2006,2 has evolved as an initiative of the Council of Australian Governments. This budget initiative of $176.4m over 5 years has been implemented by the Australian Federal Government amidst a continuing publicity blitz3–6 and is a free 24 h, 7 days a week, national telephone triage service, which gives callers advice from registered nurses according to structured algorithms with disposition options ranging from 'call an ambulance immediately' to 'medical care not required'. A similar service, Healthline, also commenced in New Zealand in 2001.7 On 1 July 2011, the Australian Government extended the healthdirect Australia service by adding general practitioner support to the nurse-led telephone triage service, as a new after-hours GP helpline,8 at an additional cost of $50m over 3 years. A frequently stated benefit of the healthdirect Australia National Health Call Centre Network is to 'act as a filter to direct people to appropriate sources of care, helping to ease demand on emergency wards and general practice',5 particularly by diverting non-urgent, low-acuity patients from attending EDs.9,10 There is no evidence to support these claims – in fact, the evidence is to the contrary. Attendances at Australian EDs are increasing at rates faster than population growth, a phenomenon that many nations with highly developed health-care systems are experiencing.11 ED attendances between 2005–2006 and 2010–2011 grew by 25.8%, whereas the population only grew by 9.3%. A number of interrelated factors are postulated to drive this growth in demand and cause increased ED overcrowding.12 Unfortunately, an enduring myth is that EDs are overrun with patients who could have received care in a general practice setting,12–15 and policies have been made based on this invalid assumption. Such policy initiatives have included stand-alone GP casualties, co-located GP clinics with EDs, GP Super Clinics and nurse walk-in-centres co-located with an ED.16–20 Formal studies to determine the effects of such initiatives are rare, although a recent review found that there was no evidence that they reduced ED demand.21 The GP casualty model has been clearly disproven as an alternative to properly set up EDs.22 An analysis by Richardson23 showed that the introduction of a Canberra nurse walk-in-centre led to an increase in patient attendances at the co-located ED. After a year of operation, still no decrease was seen in ED attendances.24 The latest healthdirect Australia quarterly report card shows the service only advised 22% of patients to stay at home, whereas over 67% were advised to seek medical care in 24 h or less.25 The recent media release from the Federal Health Minister's Office stated that 'because of the clinical advice which the GPs on the helpline can provide, thepercentage of people who were then referred on to EDs or after hours medical services was reduced from 62% to 35% – a reduction of 27% or more than 20 000 people since it was introduced in July 2011'.9 This represents less than 0.6% of total ED presentations, based on 2010–2011 Australian hospital statistics.26 Furthermore, the only conclusion that can be drawn from the Minister's statement is that the nurse-led telephone advice line was seriously over-referring patients for emergency and urgent care. No public study has been undertaken to determine the influence of healthdirect Australia on Australian ED attendances, although there are many reports on the effect of health call centres from a range of Australian states and internationally. A study by Sprivulis et al. in 2004 showed that the implementation of the healthdirect telephone triage service in Western Australia had limited capacity to influence ED use or workload.27 Ng et al. came to the same conclusion in their Western Australian study.28 Interestingly, Ng et al. showed that self-presenting ED patients had a very similar profile to healthdirect-referred patients. This may imply that patients realize when they need emergency care and call the telephone advice line to confirm this belief, a conclusion also suggested by Ström et al.29 A study of the New Zealand Healthline showed no effect on ED attendances.30 De Coster et al. showed that only 52% of patients advised to present to an ED by the Nurse Telephone Advice line in Calgary, Canada actually presented to an ED.31 Even fewer who were advised to see a doctor within 24 h did (43%). Munro et al. found no effect on NHS immediate care services following the introduction of NHS Direct telephone and digitally delivered health services.32 A Cochrane review in 200433 identified seven studies examining the effect of telephone triage on ED visits. Six studies showed no effect and one study showed an increase in presentations to the ED. No study demonstrated a decrease in ED visits. Advice prepared for Australian Health Ministers before the introduction of healthdirect Australia stated that 'direct evidence that call centres have reduced unnecessary demands on emergency departments, along with the costs and possibly the effectiveness of treatment of those cases where emergency treatment is appropriate, is weak and patchy'.34 Despite the Government's own advice that there is no good evidence that call centres reduce ED demand, the Government continues to misrepresent this in publicity of the after-hours GP helpline. Low-acuity patients are not the major problem for most EDs. As has been pointed out previously,12 it is difficult to quantify the true number of low acuity/low complexity patients who attend EDs, but the figure in most metropolitan EDs is low. Furthermore, these patients suffer uncomplicated conditions that are quick, easy and cheap to treat in EDs,35 particularly if the EDs use fast-track streaming36,37 approaches. Such patients account for a small fraction of the total ED workload and less than 5% of avoidable total costs of providing emergency services in Australia.15 Access block, not low-acuity patients, is the key driver of ED overcrowding, staff stress, patient distress and increased mortality and morbidity.12,13,35 Access block occurs when patients who have received their emergency care and need a hospital bed remain in the ED because no beds are available in the hospital.38 Low-acuity patients do not contribute to access block as generally they require only a small amount of time to be examined and treated in the ED and are rarely admitted. Therefore, telephone advice lines, even if they did reduce the number of people presenting to EDs (and the evidence quoted above suggests that this doesn't occur), are unlikely to reduce ED pressures. Addressing access block by providing funding for an increase in hospital beds along with innovative ways of managing patients needing domiciliary care, and better support for these patients in community setting will have the greatest positive effect on EDs and patient outcomes. The Rural Doctors' Association has calculated that it costs the taxpayer approximately $1000 for each person the after-hours GP helpline tells not to attend an ED.39 This is a very large amount, well above the marginal cost of providing treatment to these patients in the ED.35 It is very likely to be more effective and cost-efficient to allow this small number of patients to attend the ED rather than spend over $200m to ineffectively attempt to divert these patients to alternative care with a strategy that has not worked anywhere else in the world.30,32–34 There is no strong evidence that telephone triage improves clinical outcomes,33,34 so when the patient's problem is not resolved by the telephone triage, they are likely to attend multiple agencies, including the ED, in an attempt to solve their health problem. The evidence quoted above shows that it is likely that these patients would have presented to an ED regardless of the availability of a telephone triage service. Although health call centres are popular with consumers and healthdirect Australia reports indicate a high level of customer satisfaction with the service,40 before committing to significant ongoing expenditure of taxpayer's money on continuing the after-hours GP helpline, a comprehensive evaluation of this service must be conducted. We believe that a detailed research study is required looking at the effects of the healthdirect Australia and the after-hours GP helpline on EDs and after-hours general practices. With appropriate cooperation, such a study would be relatively easy to conduct. The Government must stop misleading the public about the effect of healthdirect Australia and the after-hours GP helpline on ED pressures. If the Government is truly concerned about the pressures facing EDs, they should tackle the real issue – overcrowding caused by lack of capacity in the hospital system – and ensure that funding and policies are directed towards solving overcrowding. DM is the Overcrowding Subcommittee Chair for ACEM.

BackgroundAlthough new technologies have increased the efficiency and convenience of medical care, patients still struggle to identify specialized outpatient departments in Chinese tertiary hospitals due to a lack of medical knowledge.ObjectiveThe objective of our study was to develop a precise and subdividable outpatient triage system to improve the experiences and convenience of patient care.MethodsWe collected 395,790 electronic medical records (EMRs) and 500 medical dialogue groups. The EMRs were divided into 3 data sets to design and train the triage model (n=387,876, 98%) and test (n=3957, 1%) and validate (n=3957, 1%) it. The triage system was altered based on the current BERT (Bidirectional Encoder Representations from Transformers) framework and evaluated by recommendation accuracies in Xinhua Hospital using the cancellation rates in 2021 and 2022, from October 29 to December 5. Finally, a prospective observational study containing 306 samples was conducted to compare the system’s performance with that of triage nurses, which was evaluated by calculating precision, accuracy, recall of the top 3 recommended departments (recall@3), and time consumption.ResultsWith 3957 (1%) records each, the testing and validation data sets achieved an accuracy of 0.8945 and 0.8941, respectively. Implemented in Xinhua Hospital, our triage system could accurately recommend 79 subspecialty departments and reduce the number of registration cancellations from 16,037 (3.83%) of the total 418,714 to 15,338 (3.53%) of the total 434200 (P<.05). In comparison to the triage system, the performance of the triage nurses was more accurate (0.9803 vs 0.9153) and precise (0.9213 vs 0.9049) since the system could identify subspecialty departments, whereas triage nurses or even general physicians can only recommend main departments. In addition, our triage system significantly outperformed triage nurses in recall@3 (0.6230 vs 0.5266; P<.001) and time consumption (10.11 vs 14.33 seconds; P<.001).ConclusionsThe triage system demonstrates high accuracy in outpatient triage of all departments and excels in subspecialty department recommendations, which could decrease the cancellation rate and time consumption. It also improves the efficiency and convenience of clinical care to fulfill better the usage of medical resources, expand hospital effectiveness, and improve patient satisfaction in Chinese tertiary hospitals.

In 2010, St. James Institute of Oncology (Leeds, UK) created a new acute oncology service (AOS) consisting of a new admissions unit with a nurse-led telephone triage (TT) system. This audit cycle (March 2011 and June 2013) evaluated patient experiences of the reconfigured AOS and staff use of the TT system. Patient views were elicited via a questionnaire and semi-structured interviews. The TT forms were analysed descriptively evaluating completion and data quality, reported symptoms and their severity and advice given (including admission rates). Patients (n=40) reported high satisfaction with the new AOS. However, 56% of patients delayed 2days or more before contacting the unit. In 2011, 26% of all the admitted patients were triaged via the TT system; 133 TT forms were completed. In June 2013, 49% of the admitted patients were triaged; 264 forms were completed. The most commonly reported symptoms on the TT forms were pain, pyrexia/rigors/infection, diarrhoea, vomiting and dyspnoea. Half of the patients using the TT system were admitted (52% in 2011, 49% in 2013). Our audit provided evidence of successful implementation of the TT system with the number of TT forms doubling from 2011 to 2013. The new AOS was endorsed by patients, with the majority satisfied with the care they received.