Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study

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

doi:10.1136/bmjopen-2018-027477

Cited by 20 publications

(25 citation statements)

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“…The study design and data collection have been published in our study design paper. 14 In short, we performed a cross-sectional study in 2023 patients who contacted one of nine OHS-PCs in the Netherlands with acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016. We selected calls on the basis of the International Classification of Primary Care (ICPC; a WHO worldwide code system for primary care) codes (K01, K02, K03, K24, K74, K75, K76, K77, K93, L04, P74, R02, R98) and keywords (thoracic pain, chest pain, myocardial infarction, heart attack and their common abbreviations).…”

Section: Methodsmentioning

confidence: 99%

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

Wouters¹,

Rutten²,

Erkelens³

et al. 2020

Open Heart

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ObjectiveTo assess the accuracy of semi-automatic assisted telephone triage in patients with acute chest discomfort against the diagnosis of acute coronary syndrome (ACS) or other life-threatening events (LTEs).MethodsA cross-sectional study was performed of telephone conversations with 2023 patients with acute chest discomfort (pain, pressure, tightness or discomfort) who called out-of-hours services for primary care (OHS-PC) between 2014 and 2016. Sensitivity, specificity, positive and negative predicted values were calculated for a high urgency (patient seen within one hour) against the diagnoses of ACS and other LTEs. Diagnoses were retrieved from the patients' medical records in general practice, including hospital specialists' discharge letters.ResultsOf 2023 patients who called because of chest discomfort, 227 (11.2%) had an ACS (men 14.9%, women 8.2%) and 58 (2.9%) had another LTE (men 3.6%, women 2.3%). The sensitivity and specificity of a high Netherlands Triage System (NTS) urgency allocation against ACS/other LTEs were 0.73 (95% CI 0.68 to 0.78) and 0.43 (95% CI 0.40 to 0.45), respectively. In 13.2% of the calls the triage nurse overruled the NTS urgency, mostly by upscaling (11.0%). The sensitivity and specificity of the final urgency allocation were 0.86 (95% CI 0.81 to 0.90) and 0.34 (95% CI 0.32 to 0.37). The positive and negative predictive values of the final urgency were 0.18 (95% CI 0.17 to 0.19) and 0.94 (95% CI 0.92 to 0.95), respectively.ConclusionsThe semi-automatic triage NTS tool underestimated the urgency in 27% of patients with ACS/other LTEs. Overruling by triage nurses improved safety, but still 14% of men and women with ACS/other LTEs received too low urgency, while efficiency remained poor.Trial registration numberNTR7331.

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Section: Methodsmentioning

confidence: 99%

“…Sample size was calculated using Harrell’s rule of thumb, which can be found in our study design paper. 14 All data analyses were performed using SPSS statistical software programme Version 25.0.…”

Section: Methodsmentioning

confidence: 99%

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

Wouters¹,

Rutten²,

Erkelens³

et al. 2020

Open Heart

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“…The study design and data collection are published before in our study design paper ( 15 ). In short, we performed a cross-sectional study with a random sample of 1655 calls of people calling the OHS-PC for chest discomfort between 2014 and 2016.…”

Section: Methodsmentioning

confidence: 99%

“…In the second place came respiratory tract symptoms with just 8.1% ambulances dispatched ( 7 ). The Dutch triage system is overall safe with only 0.006% calamities a year, but this incidence is higher with around 0.03% in the domain of chest discomfort ( 14 , 15 ). Besides safety, also efficiency could very likely be improved in the domain chest discomfort because only 1 out of 10 of the referred patients actually has an ACS ( 5–7 , 14 ).…”

Section: Introductionmentioning

confidence: 99%

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations

et al. 2020

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Background During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful. Objective To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk. Methods Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient’s general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age. Results The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39–2.34, P < 0.001): 2.33 (1.68–3.22, P < 0.001) for men and 1.29 (0.83–1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07–3.10, P = 0.039). Conclusions Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more ‘straightaway’ could be considered for these patients with chest discomfort. Trial number NTR7331.

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“…(35) A detailed description of the ICPC codes, medical keywords, inclusion and exclusion criteria has been published elsewhere. (36) We selected and relistened a random sample of 2,209 calls. Patient and call characteristics, and assigned NTS urgencies were collected.…”

Section: Data Collectionmentioning

confidence: 99%

Accuracy of telephone triage in suspected transient ischaemic attack or stroke: A cross-sectional study

Erkelens

Rutten

Wouters

et al. 2020

Preprint

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BackgroundThe 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.MethodA 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 three hours) 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.ResultsOf 1,269 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).ConclusionsThe 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.Trial registration: the Netherlands National Trial Register, identification number NTR7331.

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Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study

Cited by 20 publications

References 36 publications

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

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

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations

Accuracy of telephone triage in suspected transient ischaemic attack or stroke: A cross-sectional study

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