BMJ 1998;317:1054-1059 ( 17 October )

General Practice

Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial

Editorial by Pencheon

Val Lattimer, research student, ^a Steve George, director, ^a Felicity Thompson, project nurse, ^a Eileen Thomas, principal in public health and primary care nursing, ^a Mark Mullee, senior research fellow, ^c Joanne Turnbull, data manager, ^c Helen Smith, senior lecturer in primary medical care, ^b Michael Moore, general practitioner, ^b Hugh Bond, general practitioner, ^b Alan Glasper, professor of nursing, ^d (the South Wiltshire Out of Hours Project (SWOOP) Group).

^a Health Care Research Unit, Wessex Institute for Health Research and Development, ^b Primary Medical Care, ^c Medical Statistics and Computing, ^d School of Nursing

Correspondence to: Dr S George, University of Southampton Health Care Research Unit, Mailpoint 805, Level B, South Academic Block, Southampton General Hospital, Southampton SO16 6YD pluto{at}soton.ac.uk

Objective To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls.
Design Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention.
Setting One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire.
Subjects All patients contacting the out of hours service or about whom contact was made during specified times over the trial year.
Intervention A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 615 pm to 1115 pm from Monday to Friday, 1100 am to 1115 pm on Saturday, and 800 am to 1115 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software.
Main outcome measures Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial.
Results 14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments.
Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.

Key messages Telephone consultation is becoming an increasingly accepted approach to patient care and improves public access to medical information and advice This study found that nurse telephone consultation halved the number of cases dealt with by general practitioners and was at least as safe as existing out of hours services Nurse telephone consultation not only replaced telephone advice given by a doctor but led to reductions in both home visits and surgery attendances out of hours Further testing is required of variants to the system used in this trial, including the selection and training of nurses and the decision support software used There are clear opportunities for and potential benefits from integrating existing out of hours services with NHS Direct

---

© BMJ 1998
CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study

Hay P Derkx, Jan-Joost E Rethans, Arno M Muijtjens, Bas H Maiburg, Ron Winkens, Harrie G van Rooij, and J André Knottnerus
BMJ 2008 337: a1264. [Abstract] [Full Text] [PDF]

NHS Direct did not emerge from an evidence free void

Geoff H Royston
BMJ 2006 332: 305. [Extract] [Full Text]

Effect of introduction of integrated out of hours care in England: observational study

Val Lattimer, Joanne Turnbull, Abigail Burgess, Heidi Surridge, Karen Gerard, Judith Lathlean, Helen Smith, and Steve George
BMJ 2005 331: 81-84. [Abstract] [Full Text] [PDF]

Safety and effectiveness of nurse telephone consultation in out of hours primary care

Vikram Tanna, Kate Blackmore, Louise Dodd, Samantha Twist, Steve George, and Val Lattimer
BMJ 1999 318: 1137. [Extract] [Full Text]

Such things as values
BMJ 1998 317: 0. [Full Text] [PDF]

Nurses can safely manage half of out of hours calls in primary care
BMJ 1998 317: 0. [Full Text]

NHS Direct

David Pencheon
BMJ 1998 317: 1026-1027. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Derkx, H. P, Rethans, J.-J. E, Muijtjens, A. M, Maiburg, B. H, Winkens, R., van Rooij, H. G, Knottnerus, J A. (2008). Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study. BMJ 337: a1264-a1264 [Abstract] [Full text]  
• Thwaites, C., Ryan, S., Hassell, A. (2008). A survey of rheumatology nurse specialists providing telephone helpline advice within England and Wales. Rheumatology (Oxford) 47: 522-525 [Abstract] [Full text]  
• Richards, S H, Pound, P, Dickens, A, Greco, M, Campbell, J L (2007). Exploring users' experiences of accessing out-of-hours primary medical care services. Qual Saf Health Care 16: 469-477 [Abstract] [Full text]  
• Black, K. L. (2007). Standardization of Telephone Triage in Pediatric Oncology. Journal of Pediatric Oncology Nursing 24: 190-199 [Abstract]  
• Giesen, P., Ferwerda, R., Tijssen, R., Mokkink, H., Drijver, R., van den Bosch, W., Grol, R. (2007). Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?. Qual Saf Health Care 16: 181-184 [Abstract] [Full text]  
• Snooks, H, Nicholl, J (2007). Sorting patients: the weakest link in the emergency care system. Emerg. Med. J. 24: 74-74 [Full text]  
• Magin, P, Adams, J, Ireland, M, Joy, E, Heaney, S, Darab, S (2006). The response of general practitioners to the threat of violence in their practices: results from a qualitative study. Fam Pract 23: 273-278 [Abstract] [Full text]  
• Royston, G. H (2006). NHS Direct did not emerge from an evidence free void.. BMJ 332: 305-305 [Full text]  
• Wetta-Hall, R., Berg-Copas, G. M., Dismuke, S. E. (2005). Help on the Line: Telephone-Triage Use, Outcomes, and Satisfaction Within an Uninsured Population. Eval Health Prof 28: 414-427 [Abstract]  
• Lattimer, V., Turnbull, J., Burgess, A., Surridge, H., Gerard, K., Lathlean, J., Smith, H., George, S. (2005). Effect of introduction of integrated out of hours care in England: observational study. BMJ 331: 81-84 [Abstract] [Full text]  
• Xu, J., Schwartz, K., Monsur, J., Northrup, J., Neale, A. V. (2004). Patient-clinician agreement on signs and symptoms of 'strep throat': a MetroNet study. Fam Pract 21: 599-604 [Abstract] [Full text]  
• Richards, D. A, Godfrey, L., Tawfik, J., Ryan, M., Meakins, J., Dutton, E., Miles, J. (2004). NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial. BMJ 329: 774- [Abstract] [Full text]  
• Dale, J, Williams, S, Foster, T, Higgins, J, Snooks, H, Crouch, R, Hartley-Sharpe, C, Glucksman, E, George, S (2004). Safety of telephone consultation for "non-serious" emergency ambulance service patients. Qual Saf Health Care 13: 363-373 [Abstract] [Full text]  
• Laurant, M. G H, Hermens, R. P M G, Braspenning, J. C C, Sibbald, B., Grol, R. P T M (2004). Impact of nurse practitioners on workload of general practitioners: randomised controlled trial. BMJ 328: 927- [Abstract] [Full text]  
• Peile, E (2004). The future of primary care paediatrics and child health. Arch. Dis. Child. 89: 113-115 [Full text]  
• Leibowitz, R., Day, S., Dunt, D. (2003). A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction. Fam Pract 20: 311-317 [Abstract] [Full text]  
• Car, J., Sheikh, A. (2003). Telephone consultations. BMJ 326: 966-969 [Full text]  
• Pinnock, H., Bawden, R., Proctor, S., Wolfe, S., Scullion, J., Price, D., Sheikh, A. (2003). Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ 326: 477-479 [Abstract] [Full text]  
• Dale, J, Higgins, J, Williams, S, Foster, T, Snooks, H, Crouch, R, Hartley-Sharpe, C, Glucksman, E, Hooper, R, George, S (2003). Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch. Emerg. Med. J. 20: 178-183 [Abstract] [Full text]  
• Wright, P J, English, P J, Hungin, A P S, Marsden, S N E (2002). Managing acute renal colic across the primary-secondary care interface: a pathway of care based on evidence and consensus. BMJ 325: 1408-1412 [Full text]  
• Richards, D. A, Meakins, J., Tawfik, J., Godfrey, L., Dutton, E., Richardson, G., Russell, D. (2002). Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs. BMJ 325: 1214-1214 [Abstract] [Full text]  
• de Groot, R. A, de Haan, J., Bosveld, H. E., Nijland, A., Meyboom-de Jong, B. (2002). The implementation of a call-back system reduces the doctor's workload, and improves accessibility by telephone in general practice. Fam Pract 19: 516-519 [Abstract] [Full text]  
• Snooks, H., Williams, S., Crouch, R., Foster, T., Hartley-Sharpe, C., Dale, J. (2002). NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious. BMJ 325: 330-333 [Full text]  
• Sharples, L D, Edmunds, J, Bilton, D, Hollingworth, W, Caine, N, Keogan, M, Exley, A (2002). A randomised controlled crossover trial of nurse practitioner versus doctor led outpatient care in a bronchiectasis clinic. Thorax 57: 661-666 [Abstract] [Full text]  
• George, S. (2002). NHS Direct audited. BMJ 324: 558-559 [Full text]  
• Salisbury, C., Chalder, M., Scott, T. M., Pope, C., Moore, L. (2002). What is the role of walk-in centres in the NHS?. BMJ 324: 399-402 [Full text]  
• Boardman, J., Steele, C. (2002). NHS Direct -- a telephone helpline for England and Wales. Psychiatr. Bull. 26: 42-44 [Full text]  
• Coleman, P, Irons, R, Nicholl, J (2001). Will alternative immediate care services reduce demands for non-urgent treatment at accident and emergency?. Emerg. Med. J. 18: 482-487 [Abstract] [Full text]  
• Rushforth, H., Bliss, A., Burge, D., Glasper, E. A. (2000). A pilot randomised controlled trial of medical versus nurse clerking for minor surgery. Arch. Dis. Child. 83: 223-226 [Abstract] [Full text]  
• Salisbury, C. (2000). The demand for out-of-hours care from GPs: a review. Fam Pract 17: 340-347 [Abstract] [Full text]  
• Munro, J., Nicholl, J., O'Cathain, A., Knowles, E. (2000). Impact of NHS Direct on demand for immediate care: observational study. BMJ 321: 150-153 [Abstract] [Full text]  
• Lattimer, V., Sassi, F., George, S., Moore, M., Turnbull, J., Mullee, M., Smith, H. (2000). Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial. BMJ 320: 1053-1057 [Abstract] [Full text]  
• Thompson, F., George, S., Lattimer, V., Smith, H., Moore, M., Turnbull, J., Mullee, M., Thomas, E., Bond, H., Glasper, A. (1999). Overnight calls in primary care: randomised controlled trial of management using nurse telephone consultation. BMJ 319: 1408-1408 [Full text]  
• MCLELLAN, N. (1999). NHS Direct: here and now. Arch. Dis. Child. 81: 376-378 [Full text]  
• Tanna, V., Blackmore, K., Dodd, L., Twist, S., George, S., Lattimer, V. (1999). Safety and effectiveness of nurse telephone consultation in out of hours primary care. BMJ 318: 1137a-1137 [Full text]  
• (1999). Nurse Telephone Consultation Safely Cuts Physician Workload. JWatch Emergency Med. 1999: 24-24 [Full text]  
• (1998). Telephone Consultation with Nurses Cuts Physician Workload Safely. JWatch General 1998: 3-3 [Full text]  
• Pencheon, D. (1998). NHS Direct. BMJ 317: 1026-1027 [Full text]  

Rapid Responses:

Read all Rapid Responses

Untitled

V N M Tanna
bmj.com, 29 Oct 1998 [Full text]

Untitled

Daniel Pettersson
bmj.com, 11 Nov 1998 [Full text]

Tolerance Limits Too Wide

Kate Blackmore
bmj.com, 12 Nov 1998 [Full text]

nurse triaged and doctor triaged groups can not assumed to be equal

Lee Casey, et al.
bmj.com, 2 Mar 2008 [Full text]

Debate required

Lee Casey, et al.
bmj.com, 19 Mar 2008 [Full text]