Advice Line Research Articles

A nurse-led rheumatology telephone advice line: service redesign to improve efficiency and patient experience.

nurse-led telephone advice line (TAL) services have been endorsed by the Royal College of Nursing (RCN) and provide patients and their carers with expert advice and self-management strategies. Identified helpline shortfalls in one rheumatology TAL included a high number of inappropriate calls, calls not recorded in patients' records, and no formal process for assigning calls to nurses. Using RCN guidelines, the service was redesigned by specialist rheumatology nurses to address these issues. troubleshooting sessions were used to identify solutions to shortcomings in the helpline processes. Following service redesign, nurse/user feedback was collated, and efficiency savings achieved from reducing face-to-face appointments were calculated. the new TAL received fewer inappropriate calls, was received positively by staff and patients, and saved approximately £354 890 a year for the local clinical commissioning group. rheumatology nurses successfully improved a TAL using RCN guidance. The approach could be used by other trusts to improve patient helplines and contribute to the NHS drive for efficiency.

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

ObjectiveTo understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively...

Advice line for dentists

Advice line for dentists

Nurse-Led Telephone Advice Line for Patients With Inflammatory Bowel Disease: A Cross-Sectional Multicenter Activity Analysis.

Telephone helplines is an effective method for helping patients with chronic diseases, including inflammatory bowel disease (IBD). The objective of this cross-sectional multicenter study was to assess reasons for consultation by patients with IBD to a nurse-led telephone service. The sample included 7,273 IBD patients from 6 public hospitals in Barcelona, Spain. Data collected included calls registered during 50 working days including caller characteristics, reason for consultation, patient's diagnosis, and action recommended. The most common reasons for consultation were suspicion of relapse, doubts regarding medication, drug monitoring, side effects, visit appointment, and request of test results. In 63.7% of cases, telephone calls were solved solely by nurses, and in 35.9% in collaboration with a physician. Patient's questions were resolved via telephone in 89.3%. Findings from this study add support of the nurse's role for providing an effective telephone service for resolution of a wide range of patient queries in IBD. Helplines managed by IBD nurses may be a key element for patient-centered care.

275 Poster: acute neurology care model – ‘the neuro network’

The neuro network is a well-developed model in North West England and North Wales, hosted by the Walton Centre Liverpool. It is based on the principle of an equitable, locally accessible service taking responsibility for a regional population, rather than one based on a single unit or small area.Centralised tertiary activity is based in Liverpool – for patients requiring specialised diagnostic or therapeutic intervention and care; particularly neurosurgery, thrombectomy, neurological ITU or frequent review of complex acute neurological disorders.Acute neurological support is delivered to 12 acute sites across the region using a combination of consultant visits and ward liaison sessions (typically 3–4 days each week), telemedicine video consultations (presently being developed at pilot sites), 24/7 telephone advice and a weekday consultant advice line for GP’s. Patients are then treated, whenever possible, by a local medical team (or HASU) supported by a neurology management plan (and subsequent on-site or remote review if necessary) or by transfer to the centre if clinically appropriate.The model offers acute neurology provision to a wide area, by the most effective, resilient and equitable deployment of limited resources.

Linking Provincial and Prospective Cohort Study Data to Estimate the Incidence and Healthcare Burden of Viral Gastroenteritis

IntroductionAcute gastroenteritis (AGE) is a major cause of morbidity in children. While viruses are known to cause the largest proportion of illnesses, slow adoption of new technology and recommendations against routine testing have blunted our ability to estimate the impact of viral AGE on the health system.
 Objectives and ApproachOur objective was to quantify the incidence of medically-attended norovirus and other viral AGE etiologic agents as a baseline for future norovirus vaccination programs. AGE cases were identified through the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) study, December 2014-December 2017, which tested participants for five viruses: rotavirus, norovirus, adenovirus, astrovirus, and sapovirus. Study data was linked to provincial health registry data to identify visits associated with the AGE episode. Comparable visits for children throughout the province were identified, and a comprehensive set of potential confounders was evaluated and used to standardize APPETITE rates to the Alberta population.
 ResultsAPPETITE received and tested specimens from 2,358 children with AGE presenting to the emergency department (ED) for care and 513 children with AGE whose parent or guardian called the provincial health advice line Health Link (HL). Norovirus was the most commonly detected pathogen, associated with 579 (24%) ED cases and 177 (19%) HL cases. After norovirus, the most common viruses were, in descending order: adenovirus (441 ED, 97 HL), rotavirus (408 ED, 88 HL), sapovirus (211 ED, 68 HL), and astrovirus (75 ED, 21 HL). Results for the incidence of viral AGE by etiologic agent, with the associated number of hospitalizations, ED visits, and primary care visits, will be available by the date of the IPDLN conference.
 Conclusion/ImplicationsBy linking data from APPETITE with the visit data available because of Alberta’s single-payer system, we are able to provide population-based estimates of disease incidence for viral AGE, as well as the burden on the health care system in terms of the number of visits associated with these viral illnesses.

Models of care for co-morbid diabetes and chronic kidney disease.

Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.

Exploring factors that influence adult presentation to an emergency department in regional Queensland: A linked, cross-sectional, patient perspective study.

Explore factors that influence presentation at a regional hospital ED and identify opportunities to reduce attendance, particularly for adults with chronic conditions. Cross-sectional survey of ED attenders, for 1 month period (March to April 2014), with linkage of survey data to administrative data sets. A total of 1000 adults completed the survey of which 549 (54.9%) self-identified as living with a chronic condition. Over half (n = 572, 57.2%) had their presenting problem for less than 24 h prior to attending the ED and 56.8% (n = 568) attended the ED outside working hours. Most ED presentations were recorded in the administrative data set as self-referred (n = 933, 93.3%); however, 29% (n = 290) of survey participants reported being referred to the ED by a medical practitioner. The majority of adults had a regular general practice (n = 863, 86.3%) with 30% (n = 258) visiting their practice in the week prior to presentation at the ED. Awareness of services such as the 13-Health telephone advice line was generally low (n = 370, 37%) and most did not consider alternative health services as suitable for their care. High-quality care, co-location of diagnostic services and extended hours of service were important to patients. Despite being connected to a general practice, people focussed their health-seeking behaviour on the ED in the immediate period prior to presentation. Patients reported a limited awareness of alternative health services and opportunities exist to potentially reduce ED attendance, particularly for young and middle-aged adults with chronic conditions.

Evaluation of a 0–19 public health-themed advice line

The 0–19 service recognised that some of the needs of children attending A&E could be met more effectively through a dedicated public health advice line, increasing access for clients and supporting primary care. This article draws on the experience of setting up an advice line, as well as the opportunities, benefits and lessons learnt. Findings from the initial service evaluation are included, which identify increased capacity for the workforce, increased access for parents and carers and cost efficiencies for the local NHS. Conclusions are that a dedicated public health advice line can help address increased demand on health visiting services, with no extra resource.

ARE YOU BEING HEARD? Getting families the care they need when they need it

Health systems across the world are afloat with new ideas and words – integration, patient-centred care, wraparound services, investing in the early years, soft entry points and making sure no child is left behind. These ideas present practical challenges to service providers developing contemporary child and family services in a rapidly changing environment. This paper describes the experience of managers in an Inner Sydney Local Health District redesigning their service system to meet the care and support needs of all families, including those most vulnerable, within limited resources. Based on literature, current thinking on child and family health and extensive consultation with community partners and stakeholders, Healthy Families Healthy Children (HFHC) is a program that supports the best development of children and enables families to lead healthy and fulfilling lives. The program is underpinned by an ecological model of child health and equity considerations of universal and proportional universalism. HFHC provides universal, tailored and flexible packages of care to ensure the right interventions are provided at the right time to the right families. Although our broad target population is families with children 0-5 years, families experiencing a number of risk factors and requiring additional support are specifically targeted. This is being done in collaboration with a range of government and non-government agencies and community. Since implementation in 2016 we have: - Formally reviewed universal home visiting services to newborns across three organisations and used the report to advocate for policy change and the ‘green light’ to pilot a new model. - Strengthened our universal service by introducing a centralised intake, referral and advice line to assist clients to navigate the care system and a new website to provide a localised online source of information on child health and development. - Designed a new service model where initial screening/risk assessment in antenatal and maternity services is supplemented with a clinical phone call to all families with newborns to review their risk level and determine the appropriate service level response or ‘package of care’. - Attracted new investment and redirected existing resources to an expanded sustained home visiting program with capacity to meet the needs of all families requiring additional support. 131 families are currently enrolled. - Revised eligibility criteria to ensure all vulnerable families and those with low English proficiency were able to receive an evidence-based, structured home visiting program. Program sustainability is a key consideration and we have developed a research and evaluation consortium including academics from three Sydney universities, workforce representatives and consumers. The preliminary framework will be discussed. Program principles are transferable to, and can be localised in other health districts. ‘What would a child and family health service look like if we took a proportionate universalism approach?’ ‘How do you redesign services to continue to provide universal services and enhance sustained services for vulnerable families?’ We will answer these questions in the context of a service design in Sydney Local Health District.

Threatened Preterm Labour: An Audit of Twelve Months of Calls to the Nsw and Act Perinatal Advice Line. What Should We Do Next?

Threatened Preterm Labour: An Audit of Twelve Months of Calls to the Nsw and Act Perinatal Advice Line. What Should We Do Next?

Characterizing the health and information-seeking behaviours of Ontarians in response to the Zika virus outbreak.

The purpose of this study is to describe the impact of the 2016 Zika virus (ZIKV) outbreak on the health-seeking and information-seeking behaviours of Ontarians. A timeline that included events and announcements from health agencies was constructed to describe the unfolding of the ZIKV outbreak between January 1 and September 30, 2016. In order to gain an understanding of the information and health-seeking behaviours of Ontarians, data from the following sources were collected and analyzed descriptively over time in 1-week intervals: trends in web searches, calls to a provincial telemedicine advice line, test submissions to the provincial laboratory and Zika-related media coverage. The World Health Organization's declaration that the ZIKV outbreak was a public health emergency of international concern (PHEIC) prompted a surge in media coverage peaking at 165 articles in a 1-week period. Concurrently, the frequency of Zika-related web searches was at its highest over the time period of the study, weekly telemedicine calls requesting Zika-related information were at their highest (177 calls/week) and requests for laboratory testing increased (162 patients submitting specimens/week). Understanding the public response to novel and re-emerging infectious disease outbreaks as they unfold has the potential to facilitate timely public messaging for disease prevention, enable resource planning and inform effective public health action.

Whistleblowing as a Protracted Process: A Study of UK Whistleblower Journeys

This paper provides an exploration of whistleblowing as a protracted process, using secondary da-ta from 868 cases from a whistleblower advice line in the UK. Previous research on whistleblow-ing has mainly studied this phenomenon as a one-off decision by someone perceiving wrongdoing within an organisation to raise a concern or to remain silent. Earlier suggestions that whistleblowing is a process and that people find themselves inadvertently turned into whistleblowers by management responses, has not been followed up by a systematic study tracking the path of how a concern is repeatedly raised by whistleblowers. This paper provides a quantitative exploration of whistleblowing as a protracted process, rather than a one-off decision. Our research finds that the whistleblowing process generally entails two or even three internal at-tempts to raise a concern before an external attempt is made, if it is made at all. We also find that it is necessary to distinguish further between different internal (e.g. line manager, higher management, specialist channels) as well as external whistleblowing recipients (e.g. regulators, professional bodies, journalists). Our findings suggest that whistleblowing is a protracted process and that this process is internally more protracted than previously documented. The overall pattern is that whistleblowers tend to search for a more independent recipient at each successive attempt to raise their concern. Formal whistleblower power seems to determine which of the available recipients are perceived as viable, and also what the initial responses are in terms of retaliation and effectiveness.

Information When and Where Needed for Safe and Effective Integrated Care

Introduction: Clinical information when and where needed is a fundamental requirement to realising the promise integrated health services and care. Unco-ordinated patient care, conflicting advice, delays in diagnosis and treatment, and redundancy in the system with unnecessary repetition of information gathering and diagnostic investigation are the hallmark of a lack of shareable healthcare records. An integrated electronic patient record (EPR), stored centrally can diminish fragmentation as the same patient information is available to each discipline involved in patient care regardless of location, multiple users of the record can have simultaneous access to the record, and an electronic record is readily interrogated to support service monitoring and planning. Aim: To improve integration of epilepsy care and services within and between healthcare agencies by incorporating a novel state-of-the-art secure web-based EPR into service delivery across Ireland. Methods: Using mixed methods of ethnography, interviews, focus groups, surveys and audits, the role of shared information in facilitating integrated care was examined. This entailed engagement with people with epilepsy (PWE) and their carers, as well as healthcare providers from multiple health service: epileptologists, epilepsy specialist nurses, researchers, health service managers, general practitioners, general practice nurses, community nurses. This analysis of the epilepsy ecosystem in Ireland informed the requirements for the development of the National Epilepsy EPR. In an iterative process of design and development these requirements were translated by software engineers into the epilepsy EPR. Implementation of the system into clinical practice also occurred incrementally with associated workflow re-design. Results: Over a 12year period, the National Epilepsy EPR in Ireland has grown from a concept to a system that contains the longitudinal healthcare records of approximately 7000 PWE. It comprises functionality to capture and record information required for optimal patient care: e.g. epilepsy history, social history, medications, investigations, co-morbidities. The system is in daily use in 12 specialist epilepsy care sites across Ireland supporting range of tasks including out-patient services, epilepsy surgery care, epilepsy telephone advice line, outreach to intellectual disability sector and to obstetric care. It is providing timely access to clinical information, promoting better communication between clinicians and supporting clinical research. Conclusion: Our innovative project is leading the way in Ireland in exploiting (ICT) to enhance quality and safety of chronic disease management while containing cost. While the clinical field of interest is epilepsy the learning is certainly applicable to the management of other similarly complex chronic conditions. The National Epilepsy EPR has been designated a Lighthouse Project for eHealth Ireland to demonstrate the potential of technology to drive better-integrated care. Limitations: Lack of interoperability between different electronic health record systems poses a challenge for the National Epilepsy EPR. However, this is currently being addressed by the wider Irish health service. Lessons learned: Achieving success with an EPR requires courage and patience. Engagement with clinicians and patients is key to understanding the ecosystem so that the appropriate and sustainable technical solution is put in place.

Gastroenteritis Severity: A Prospective Cohort Comparison of Children in Emergency Department and Home Settings

BackgroundWhile nearly 2 million children are brought to emergency department (ED) annually due to vomiting and/or diarrhea from acute gastroenteritis (AGE), it is estimated that 90% of AGE cases do not seek medical care. We sought to determine whether the disease severity and enteropathogen burden of disease of children with AGE brought for ED care is different from those cared for at home.MethodsSubjects were prospectively recruited by the APPETITE team in pediatric EDs in 2 urban centers and via HealthLink, a province-wide nurse telephone advice line. Eligibility criteria included: < 18 years old, AGE defined by ≥ 3 episodes of vomiting or diarrhea in the preceding 24 hours, and < 7 days of symptoms. The primary outcome was index encounter disease severity quantified using the modified Vesikari Scale (MVS) score. To eliminate the impact of the index encounter on the score we excluded the index ED visit and intervention from all calculations. Secondary objectives included the enteropathogen burden of disease. Two rectal swabs and stool were collected and tested for enteropathogens by enteric bacterial culture, Luminex xTAG GPP, and a 5-virus in-house RT-qPCR panel.ResultsBetween December 9, 2014 and December 31, 2016, 1,623 participants were enrolled with 81.5% from the EDs. Median age was 20.1 months. Children who went to ED were less likely to have a family physician (62 vs. 82%, P < 0.001), more likely to have clinical dehydration (Clinical Dehydration Scale score 3 vs 1, P < 0.001) and vomiting (91 vs. 85%, P = 0.004), previously received IV fluids (4.1 vs. 0.7%, P = 0.001) or been admitted (5.4 vs. 1.3%, P = 0.002). The MVS score was similar between groups when the contribution of the index visit to the score was excluded (8.1 vs. 7.8, P = 0.15). Participants recruited in the ED were not significantly more likely to have bacterial pathogens (8.0 vs. 3.7%, P = 0.09) but were less likely to have viral pathogens identified (64.1 vs. 80.7, P < 0.001).ConclusionChildren presenting for ED care had disease severity scores that were similar to children managed at home when the contribution of the index ED visit was accounted for. Viral pathogens were more common in AGE receiving care at home while those presenting to the ED and potentially have a clinically greater likelihood of having a bacterial enteropathogen.Disclosures All authors: No reported disclosures.

Implementation of a Centralized Infectious Diseases Telehealth (IDt) Service for 16 Small Community Hospitals

Abstract Background The majority of U.S. small community hospitals (SCHs) lack access to infectious diseases (ID) subspecialists. Telehealth can extend ID expertise to such facilities. We describe lessons learned from implementing a new IDt program for 16 SCHs in the Intermountain Healthcare system in Utah and Idaho. Methods From October 1, 2016 to April 30, 2017, we implemented an IDt service comprised of: a 24-hour ID physician advice line; an inpatient ID consult service that provided chart review and documentation (e-consults) and daytime telemedicine consultation (TC) using encrypted, HIPAA-compliant, synchronous, 2-way audio-video connection; and an ID pharmacist-led antibiotic stewardship program. The IDt service included a medical director, operations officer, ID pharmacist, analyst, and rotating ID physicians, and was implemented in a step-wise manner at 16 SCHs. IDt requests were received through a dedicated phone line with duplicate transcription to a monitored email inbox or generated from daily antibiotic stewardship rounds. Results The physician advice line was operational for all 16 SCHs on October 1, 2016. 312 advice-only calls were fielded (92 per 1000 hospital-days covered) through April 30, 2017. Common infections requiring phone advice included: bloodstream (16%), genitourinary (13%), and musculoskeletal (12%). E-consult and TC services were operational at 11 SCHs by April 30, 2017 (hospital-days covered: 1074). The IDt service completed 104 eConsults, 163 TCs, and 1198 stewardship reviews. Mean time [minutes (range)] spent per case was 16 (5–30) for eConsults and 55 (30–120) for TCs [on-camera time: 25 (12–46)]. Common infections requiring e-consult or TC were: bloodstream (45%), musculoskeletal (16%), and skin/soft tissue (11%). 22 patients (14%) seen by TC were surveyed: 100% felt the service improved their care and was necessary at their SCH. 97% of surveyed SCH staff felt the IDt service improved patient care and 90% felt it was a necessary service (32% response from 98 providers, nurses, pharmacists). Conclusion A new IDt service was well utilized and received by SCH staff and patients, with bloodstream infections being the most common reason for consultation. Future steps include evaluation of the IDt effect on clinical outcomes, financial metrics, and staff education on common ID conditions. Disclosures All authors: No reported disclosures.

PATIENT SPECIFIC REASONS FOR ATTENDING THE EMERGENCY DEPARTMENT IN THE SETTING OF ATRIAL FIBRILLATION

Despite the fact that patients with atrial fibrillation (AF) account for a significant percentage of attendances to the emergency department (ED), the precise reasons why patients decide to attend and the outcomes from these visits are unknown. We sought to understand why patients with a known history of AF attend the ED, what their perceptions are of the outcomes of the visit and what alternatives could be considered. Patients attending ED with a history of AF were identified using the hospital’s patient care system. Baseline data was obtained from their records. A telephone questionnaire was then conducted within 1 week of the initial presentation. The patients were asked a series of questions pertaining to their decision to attend the ER, the resultant outcomes, as well as alternative strategies which could be considered. Of the 102 patients who agreed to take part in the survey (mean age 69.54 ± 12.46 years; 52% male, 48% female), sixty-five (63.7%) patients attended ED based predominantly on their symptoms at that time, 22 (21.6%) of patients attended based on prior advice, 9 (8.8%) of patients attended based on a combination of both, while 6 (5.9%) were unsure. A total of 53 (52%) of patients felt that something bad would happen if they did not attend the ED including the fear of having a stroke in 12 (11.8%) and the fear of having a heart attack in 29 (28.4%) of patients. Hospital admission occurred for 15 (14.7%) patients. Patients were assessed by cardiology in ED in 36 (35.3%) cases. A total of 57 (55.9%) patients felt an improvement in their symptoms following attendance to the ER. Overall, 47 (46.1%) patients were unaware of an alternative management strategy, 40 (39.2%) patients perceived benefit from a telephone advice line and 10 (9.8%) patients thought a smartphone application may be useful. Although most patients present to the ER based solely on symptoms, a significant number of patients (21.6%) presented based on previous advice. A substantial percentage of patients also do not gain any perceivable improvement in their symptoms. Greater use of telephone advice and to a lesser degree a smartphone application may be helpful in reducing ER attendances.

Early outbreak detection by linking health advice line calls to water distribution areas retrospectively demonstrated in a large waterborne outbreak of cryptosporidiosis in Sweden

BackgroundIn the winter and spring of 2011 a large outbreak of cryptosporidiosis occurred in Skellefteå municipality, Sweden. This study summarizes the outbreak investigation in terms of outbreak size, duration, clinical characteristics, possible source(s) and the potential for earlier detection using calls to a health advice line.MethodsThe investigation included two epidemiological questionnaires and microbial analysis of samples from patients, water and other environmental sources. In addition, a retrospective study based on phone calls to a health advice line was performed by comparing patterns of phone calls between different water distribution areas.ResultsOur analyses showed that approximately 18,500 individuals were affected by a waterborne outbreak of cryptosporidiosis in Skellefteå in 2011. This makes it the second largest outbreak of cryptosporidiosis in Europe to date. Cryptosporidium hominis oocysts of subtype IbA10G2 were found in patient and sewage samples, but not in raw water or in drinking water, and the initial contamination source could not be determined. The outbreak went unnoticed to authorities for several months. The analysis of the calls to the health advice line provides strong indications early in the outbreak that it was linked to a particular water treatment plant.ConclusionsWe conclude that an earlier detection of the outbreak by linking calls to a health advice line to water distribution areas could have limited the outbreak substantially.

Effective and sustainable advice line promotes safe vaccine practices.

The SHOT LINE Telephone Assistance Resource provides consistent and timely education to healthcare providers ensuring safe delivery of immunizations. A local health district created and implemented an advice line to assist healthcare personnel with immunization storage or administration questions. Healthcare workers with varying levels of education call with requests for information including vaccine administration, storage and handling, scheduling, contraindications, and timing. Ten years of call data to the SHOT LINE were analyzed through categorizing type of calls, personnel calling, facility type, information needed, and education provided. There were 3032 calls received from various job types. The most frequent inquiries were vaccine-specific calls, timing, and vaccine schedules. Medical assistants from family medicine clinics called the most. Five percent of the calls included reports of immunization errors. Healthcare personnel reported errors and self-disclosed making errors; 7% of all calls were errors in the first 2 years, but decreased to 5.4% in the last 8 years. The SHOT LINE telephone assistance provides timely education to healthcare personnel whose primary responsibilities are immunization practice management, administration, and handling. The findings reveal a significant need for timely advice in immunization practice management. Error reporting was an unexpected outcome of this advice line. Call categories of vaccine-specific information, vaccine timing, and schedules were similar across all groups of callers. The advice line has grown to include parents, school nurses, childcare providers, and emergency personnel. In summary, the SHOT LINE prevents errors, increases accuracy of vaccine management, and provides 'just in time' education.

Specialist advice for primary care: an evaluation of a gastroenterology email advice service

Communication between primary and secondary care -physicians is often unreliable and one sided in the form of clinic letters. Alternatively, general practitioners (GPs) may have difficulty contacting an on-call specialist via outdated hospital paging services. At Imperial College Healthcare NHS Trust, a gastroenterology email advice line was set up to promote dialogue and potentially help GPs deal with issues within their practices. The service has been evaluated both objectively through analysis of enquiries and subjectively through a -survey of GPs' views. Analysis showed a very high level of satisfaction among users of the service. There is also good evidence to suggest that the service has helped to streamline patient management and led to the avoidance of some outpatient appointments.