Accuracy of telephone triage in primary care patients with chest discomfort: a cross-sectional study

Wouters, Loes; Rutten, Frans H.; Erkelens, Daphne Carmen; Groot, Esther de; Damoiseaux, Roger; Zwart, Dorien

doi:10.1136/openhrt-2020-001376

Cited by 17 publications

(20 citation statements)

References 30 publications

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“…23 A recent validation study showed that the diagnostic accuracy of the NTS for patients with chest discomfort was poor (sensitivity 0.73 (95% CI 0.68 to 0.78) and specificity 0.43 (95% CI 0.40 to 0.45)), as calculated on the outcome ACS or other life-threatening events (LTEs). 24 All telephone calls to the OHS-PC are routinely recorded and archived for 5 years for training and quality control purposes.…”

Section: Contextmentioning

confidence: 99%

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study

et al. 2021

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ObjectivesTo identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men.DesignCross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS.SettingNine OHS-PC in the Netherlands.Participants993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016.Primary outcome measureDiagnosis of ACS retrieved from the patient’s medical record in general practice, including hospital specialists’ discharge letters.ResultsAmong 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%).ConclusionOur results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses.Trial registration numberNTR7331.

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Section: Contextmentioning

confidence: 99%

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study

et al. 2021

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“…The NTS is based on the Manchester triage system developed in and for the emergency department setting,7 8 and it may be over-ruled by the triage nurse, with or without consulting the supervising GP 2 7 9. However, the accuracy of the NTS has solely, and only recently, been validated against clinically relevant outcomes in the domains’ chest discomfort and neurological deficit 9–12. So, for other domains, it is still unknown if the urgency allocation is in line with clinical outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, interviews with triage nurses revealed that the NTS may hinder triage, especially in very urgent calls where emotions of both triage nurses and patients are prominent during the telephone conversation 15. Previous studies from our research group showed that the accuracy of NTS was at the best moderate for patients with chest discomfort or suspected neurological deficits, and that both the NTS itself as working with the tool could be improved in these important domains 11 12 15 16. Thus, it is important to analyse the use of the NTS by triage nurses as well beside the NTS itself.…”

Section: Introductionmentioning

confidence: 99%

Optimising telephone triage of patients calling for acute shortness of breath during out-of-hours primary care: protocol of a multiple methods study (Opticall)

et al. 2022

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IntroductionCallers with acute shortness of breath (SOB) are a challenge for telephone triage at out-of-hours primary care (OHS-PC) as SOB could be the sign of a potentially life-threatening disease, yet mostly is a symptom of a broad range of self-limiting disorders. Current telephone triage practice is mainly expert based and clear evidence on accuracy, safety and efficiency of the use of the Netherlands Triage Standard (NTS) by triage nurses based on the eventual clinical outcome is lacking for this domain.Methods and data analysisMultiple methods study in five OHS-PC services in the Utrecht region, the Netherlands. Data will be collected from OHS-PC electronic health records (EHR) and backed up tapes of telephone triage conversations, which will be linked to routine primary care EHR data. In cross-sectional studies, we will (1) validate the NTS urgency classification for adults with SOB against final diagnoses and (2) develop diagnostic prediction models for urgent diagnoses (eg, composite endpoint of urgent diagnoses, pulmonary embolism, acute coronary syndrome, acute heart failure and pneumonia). We will develop improvement measures for the use of the NTS by triage nurses through practice observations and semistructured interviews with patients, triage nurses and general practitioners (GPs). In an action research approach, we will, in collaboration with these stakeholders, implement and evaluate our findings in both GP and triage nurse educational programmes as well as in OHS-PC services.Ethics and disseminationThe Medical Ethics Review Committee Utrecht, the Netherlands, approved the study protocol (protocol 21/361). We will take into account the ‘code of conduct for responsible research’ of the WHO, the EU General Data Protection Regulation and the ‘Dutch Medical Treatment Contracts Act’. Results will be disseminated in peer-reviewed publications and at (inter)national meetings.Trial registration numberNL9682.

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“… 12 13 The prevalence of ACS among patients with chest discomfort who call OHS-PC or EMS is about 10%–15%, and among those seen at the ED between 10% and 30%. 10 11 13 14 Only one prediction rule was developed in primary care for diagnosing ACS; the modified Grijseels prediction rule, which had moderate discriminative ability (c-statistic of 0.66) after external validation. 7 8 Five other primary care prediction rules were developed to predict CAD; for example, the Marburg Heart Score (MHS) and INTERCHEST prediction rule (International Working Group on Chest Pain in Primary Care).…”

Section: Introductionmentioning

confidence: 99%

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

et al. 2022

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ObjectiveTo develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC).DesignCross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects.SettingSeven OHS-PC in the Netherlands.Participants2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed.Primary and secondary outcomes measuresDiagnosis of ACS retrieved from the patient’s medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses.ResultsAmong the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration.ConclusionThe final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC.Trial registration numberNTR7331.

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Accuracy of telephone triage in primary care patients with chest discomfort: a cross-sectional study

Cited by 17 publications

References 30 publications

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study

Optimising telephone triage of patients calling for acute shortness of breath during out-of-hours primary care: protocol of a multiple methods study (Opticall)

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

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