The quality, safety and governance of telephone triage and advice services – an overview of evidence from systematic reviews

Abstract

BackgroundTelephone triage and advice services (TTAS) are increasingly being implemented around the world. These services allow people to speak to a nurse or general practitioner over the telephone and receive assessment and healthcare advice. There is an existing body of research on the topic of TTAS, however the diffuseness of the evidence base makes it difficult to identify key lessons that are consistent across the literature. Systematic reviews represent the highest level of evidence synthesis. We aimed to undertake an overview of such reviews to determine the scope, consistency and generalisability of findings in relation to the governance, safety and quality of TTAS.MethodsWe searched PubMed, MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library for English language systematic reviews focused on key governance, quality and safety findings related to telephone based triage and advice services, published since 1990. The search was undertaken by three researchers who reached consensus on all included systematic reviews. An appraisal of the methodological quality of the systematic reviews was independently undertaken by two researchers using A Measurement Tool to Assess Systematic Reviews.ResultsTen systematic reviews from a potential 291 results were selected for inclusion. TTAS was examined either alone, or as part of a primary care service model or intervention designed to improve primary care. Evidence of TTAS performance was reported across nine key indicators – access, appropriateness, compliance, patient satisfaction, cost, safety, health service utilisation, physician workload and clinical outcomes. Patient satisfaction with TTAS was generally high and there is some consistency of evidence of the ability of TTAS to reduce clinical workload. Measures of the safety of TTAS tended to show that there is no major difference between TTAS and traditional care.ConclusionsTaken as a whole, current evidence does not provide definitive answers to questions about the quality of care provided, access and equity of the service, its costs and outcomes. The available evidence also suggests that there are many interactional factors (e.g., relationship with other health service providers) which can impact on measures of performance, and also affect the external validity of the research findings.Electronic supplementary materialThe online version of this article (10.1186/s12913-017-2564-x) contains supplementary material, which is available to authorized users.

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

“…In most Western countries, computer decision support systems (CDSSs) are used to support telephone triage decision-making (Lake et al, 2017). Commonly used CDSSs are constructed as a list of questions, starting with questions that ask for an immediate medical response, and gradually questions come up about symptoms which allow for a longer response time (Kuriyama, Urushidani, & Nakayama, 2017).…”

Calling for confirmation, reassurance, and direction: Investigating patient compliance after accessing a telephone triage advice service

“…Strategies external to the ED include, various methods of hospital diversion and demand management, such as TTAS, stand‐alone GP services; and GP Super Clinics . The TTAS, providing advice to patients prior to accessing EDs or other primary care services, uses the avenue of external strategies to directly influence the functioning of ED and the health system more broadly …”

“…Questioning the effectiveness of a TTAS illuminates a “wicked problem” in health care, that of a complex challenge embedded within a multilayered context, involving a diverse range of stakeholders with divergent thinking on the issue. Unsurprisingly, a recent systematic review identified that TTAS involves the dynamics of at least nine key indicators‐access, appropriateness, compliance, patient satisfaction, cost, safety, health service utilization, clinician workload, and clinical outcome . TTAS stakeholders are telephone triage, primary care and ED clinicians, patients and their families, policy makers, and the community.…”

“…Even so, TTAS have been assessed as providing safe, effective triage decisions and are positively regarded by users and providers. TTAS referrals were found appropriate with low triage acuity outcomes recorded, and the consultations receive positive reports for patient satisfaction, management of workload of general practitioners, and patient‐doctor satisfaction . An outright decision on the appropriateness of TTAS decisions is, however difficult.…”

“…An outright decision on the appropriateness of TTAS decisions is, however difficult. The challenge is that the definition for “appropriateness” varies considerably and the reported rate for TTAS disposition appropriateness ranges between 44% and 98% …”