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Nurse (Telephone) Triage: The Wrong Skill Mix?
- timothy peter airey (25 November 2002)
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Telephone Triage - simple idea, complex communication skill
- Michael A Innes (28 November 2002)
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Nurse Telephone Triage - Risks and Costs: a reply to Innes
- David Arthur Richards (29 November 2002)
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timothy peter airey, gp principal gade surgery, 99b uxbridge road, rickmansworth, herts wd3 2dj
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The GP spends a long time in training,honing his medical skills. As arguably one of the most difficult parts of General Practice is rapidly assessing patients acutely presenting, it seems at odds to delegate this to nurses. It would be much more sensible to use our nurse resource to manage other areas of General Practice, for instance chronic disease management in its entirety. Following protocols this would include prescribing, referring etc. This would relieve a huge workload off GP's and let them get on with what they were really trained to do.
Telephone triage as a last resort Telephone diagnosis of acute illness is very dificult and often requires the need to see the patient face to face. Telephone triage takes five minutes and then a further five minutes if the patient needs to be seen. The best use of a scarce resource is to offer every patient who requests to be seen that day a five minutes appointment and only engage the patient on the telephone if they so wish, or if requesting a home visit. In my experience of running such a system it is possible to keep to time, and always having the patient face to face gives the added peace of mind on having made the correct diagnosis that one cannot get from telephone triage. Competing interests: None declared |
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Michael A Innes, NHS R&D Primary Care Researcher Development Fellow Department of PRimary Care and General Practice, The University of Birmingham. B15 2TT
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The paper by Richards et al. provides a large amount of new information about nurse triage in primary care:(1) daytime nurse triage can save general practitioner’s time at the expense of nurses’ time, A&E time and patient time (repeat visits to the surgery). Whilst it is no criticism of the study, I still feel unclear about the use of nurse triage in these circumstances. I have two observations and one question. The authors record that there is an overall increase in attendance up to one month after triage of 11% compared with standard care and, most importantly, that when telephone advice only is given compared with an appointment, this figure is 32%. The authors have not discussed this further. I believe that this is a very important point in that the major difference that triage introduces is the potential for a telephone consultation alone - triage has become a somewhat misleading term. This telephone advice may be against the wishes of the patient who phoned to book to see someone, but who may also feel powerless to object to advice alone. In this circumstance, reattendance might be a proxy measure for dissatisfaction with telephone advice or an indication of less good health education. I believe this needs consideration and that the process of communiction needs much more research before we adopt a new way of working. One possibility in this study would be to look at the difference in return rates for those who were triaged and those who were not triaged because the call was direct to the practitioner. Regarding safety and efficacy of nurse triage, there is one other small study by Marklund.(2) This preceded most other work by a number of years and showed that nurse consultations on the phone provided similar care to those face to face either with a nurse, or with a general pratitioner. It is limited by its size and the fact that is was only conducted in one practice, thereby opening it to bias. Whilst the full version of the paper provides some detail, the status of the cases that made no further contact is not clear. These could represent the most cost saving group of patients. Despite the numbers being small, the fact that cost differences are generally small makes this group an important group to consider when looking at overall cost. Can the authors provide more clarification about this group? Yours faithfully, Michael Innes
1. Richards D, Meakins J, Tawfik J, Godfrey L, Dutton E, Richardson G, Russell D. Nurse telephone triage for same day appointments in general practice: multiple interuppted time series trial of effect on workload and costs. BMJ 2002;352:1214-1217. 2. Marklund B, Koritz P, Bjoorkander E, Bengtsson C. How well do nurse- run telephone consultations and consultations in the surgery agree? Experience in Swedish primary health care. BJGP. 1991;41:462-465. Competing interests: I hold a NHS R&D Primary Care Researcher Development Fellowship to develop a method of assessing telephone consultations |
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David Arthur Richards, Senior Lecturer University of Manchester
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Michael Innes asks us for clarification on a number of points in our recent paper, Richards et al, 2002 (1). 1. Innes is not correct to state that triage increases attendance up to one month by 11% and telephone advice increases it to 32%. Relative risks are not raw percentage increases but reflect the increased risk of return over the baseline risk rate. In our case baseline return rates were nearly 50%. In comparison, the actual numbers of patients returning up to one month was 53.3% in the triage group. Rates of return for telephone advice versus appointments were 61.9% and 47.1% respectively, a difference of 14.8% not 32%. 2. We agree that these increased return rates warrant further explanation. We know that the increase in those that did return was for one main reason. We measured rates of return for same and different problems and for same day or routine appointments. The only group to show an increased rate of return, baseline versus triage, were those patients diverted by the nurse triage system from same day to routine appointments for consultation on the same presenting problem. This is an effect of the intervention not patient dissatisfaction. As we point out in the paper, this is indeed the intention of triage systems – to smooth out the peaks and troughs of demand and direct patients to have their needs met more appropriately. 3. Our study was intended to address workload and economic outcomes, not safety, an issue already addressed by Lattimer and her colleagues (2) and to some extent by the Swedish study of Marklund (3), although this latter study used a methodology extremely burdensome to patients and one that could not have addressed the health service research questions we investigated. Patients’ perspectives on triage must be considered. For example, it is not appropriate for health workers to ask patients to visit a surgery site for consultation on a minor illness that could be managed by patients themselves at home through brief telephone advice. Nonetheless, our protocols ensured that nurses never refused patients an appointment if the patient felt the telephone advice given was insufficient. We did indeed conduct a satisfaction survey but our resources did not permit us to achieve questionnaire return rates suitable for reporting alongside the trial. However, we detected no evidence of dissatisfaction from this survey or from clinical governance monitoring of complaints. 4. As we demonstrated in table 5 of the unabridged version of our paper, the costs of triage are a complex balance of same day and follow up costs. Changes in the proportions of patients achieving different outcomes affect this balance. If every patient were to be triaged into a general practitioner appointment, a triage system would be more expensive and futile. Conversely, more telephone advice only with no return to surgery would tip the balance in favour of cost savings. We found that these proportions were balanced and overall cost differences were insignificant, a result that stood up to considerable sensitivity analysis. Triage is cost neutral and can, therefore, be considered cost effective in terms of the workload outcomes we set out to investigate. 5. Cases that make no further contact are indeed the least costly group. Although we have not conducted in depth sub analyses of this group we do know that the mean number of presenting problems for patients given an appointment was significantly greater than those receiving telephone advice alone and the mean age of patients receiving appointments was younger than those receiving telephone care. This demonstrates the risk averse, conservative nature of nurses undertaking telephone triage, an effect noted by other studies (4). 1. Richards D, Meakins J, Tawfik J, Godfrey L, Dutton E, Richardson G, Russell D. Nurse telephone triage for same day appointments in general practice: multiple interuppted time series trial of effect on workload and costs. BMJ 2002;352:1214-1217. 2. Lattimer V, George S, Thompson F, Thomas E, Mullee M, Turnbull J, Smith H, Moore M, Bond H, Glasper A. Safety and effectiveness of nurse telephone consultation in out of hours primary care: a randomised controlled trial. BMJ 1998;317:1054-1059. 3. Marklund B, Koritz P, Bjoorkander E, Bengtsson C. How well do nurse- run telephone consultations and consultations in the surgery agree? Experience in Swedish primary health care. BJGP. 1991;41:462-465. 4. Leprohon J. Patel VL. Decision-making strategies for telephone triage in emergency medical services. Medical Decision Making 1995;15, 240 -253. Competing interests: None declared |
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