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Rapid Responses: Rapid Responses published:
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Telephone Triage
- David J Mendel, David J Mendel (27 September 2008)
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Re: Telephone Triage
- Hay Derkx, Jan-Joost E Rethans, Arno M Muijtjens, Bas H Maiburg, Ron Winkens, Harrie G van Rooij, and J André Knottnerus (2 October 2008)
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David J Mendel, General Practitioner Harmoni Ltd WD3 1RE, David J Mendel
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Derkx et al (2008) potentially call into question the quality of much OOH care delivered in the UK. We would suggest that there is a fundamental difficulty with the methodology employed. The study is, in effect, a construct whereby triage quality is judged by comparing the questions asked in standardised cases against the views of an expert panel. The “triagists” in the study were a mixture of GPs, nurses, and non clinical call handlers and we would argue that different considerations apply to these groups. Within Harmoni (2007), a large UK OOH Care provider, non-clinical call handlers and nurses triage using protocols embedded in decision support software supplied and validated by Adastra (2008) and TAS Odyssey (Plain Healthcare 2008), whilst doctors use clinical acumen without formal protocols. We encourage doctors to use techniques derived from widely accepted consultation skill models to conduct telephone triage (Neighbour 2005; Pendleton 1984; Silverman J, Kurtz S, & Draper J 2004) in which “open” questions are asked at the start of the consultation with the intention of establishing rapport and understanding the callers ideas, concerns and expectations. We encourage doctors to use a “cone” in which initial open questions are following by direct questions to establish important clinical details so that both the biomedical “disease” and the patient narrative “illness” components of the consultation are developed (Silverman J, Kurtz S, & Draper J 2004). We would argue that the author’s use of standardised incognito patients, who are briefed not to volunteer information unless directly asked, does not effectively model real life consultations. For example, an open question to the parent with a child with fever, such as “tell me about it, take me back to the start”, is highly likely to elicit information about the child’s behaviour, and it is most unlikely that an alarming symptom, such as a fit, would not be mentioned. The doctor, having heard the patient’s story, can then focus on the direct questions which add value to their decision making. Where triage by a nurse using TAS Odyssey decision support software is being undertaken, an open style of questioning at the start of a consultation will often elicit useful information which can reduce the subsequent need for direct questions, whilst still enabling the question set required by the protocol to be completed. The authors only appear to have recorded whether the questions regarded as obligatory by their expert panel were asked – not whether the information was obtained – and this is presumably because their incognito patients would not give up this information without direct questions. We suggest that triage is reduced by this approach to a mechanistic tick-box exercise and does not accurately reflect the real world of professional practice. We would acknowledge, however, that non-clinical triagists, such as call-handlers, should be using set algorithms and basing decisions and advice on protocol-driven direct questions. Our approach to quality control and education for triage within Harmoni has been to assess the quality of calls using the RCGP toolkit (Royal College of General Practitioners 2007). This has the advantage of utilising actual consultations and allowing an assessor to rate the quality of the communication, decision making, advice given and safety netting in real practice, rather than within a simulation. Neither approach is designed to measure the actual outcomes for patients, which we would argue is the key challenge. References Adastra Sofware Ltd. Adastra. Information for care. Everywhere. http://www.adastra.com/ 2008 (Available online) Accessed 22nd July 2008 Derkx, H. P., Rethans, J. J., 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, vol. 337, no. sep12_1, p. a1264. Harmoni. Harmoni - Better care by design. http://www.harmoni.co.uk/content/default.asp?ParamReload=true&PageId=7 2007. (Available online) Accessed 11th July 2008 Neighbour, R. 2005, The Inner Consultation: how to develop an effective and intuitive consulting style, 2nd edn, Radcliffe Publishing, Oxford. Pendleton, D. 1984, The Consultation: An Approach to Learning and Teaching Oxford University Press, Oxford. Plain Healthcare. TAS Odyssey: Much more than nurse triage. http://64.233.183.104/search?q=cache:FxugjcwD3DsJ:www.plainhealthcare.net/PDF/TAS2.pdf+TAS+triage&hl=en&ct=clnk&cd=1&gl=uk 2008 (Available online) Accessed 26th September 2008 Royal College of General Practitioners 2007, Out of Hours Clinical Audit Toolkit, Royal College of General Practitioners/DH, London. Silverman J, Kurtz S, & Draper J 2004, Skills for communicating with patients, 2nd edn, Radcliffe Publishing, Oxford Competing interests: Employed by Harmoni HS as Educational Lead |
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Hay Derkx, Dr. Tilburg, The Netherlands, Jan-Joost E Rethans, Arno M Muijtjens, Bas H Maiburg, Ron Winkens, Harrie G van Rooij, and J André Knottnerus
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Dear colleague Mendel 1: We do agree with your remark that in real life some patients might inform the triagist spontaneously with a lot of information, but we also know that some patients are hesitant about doing so. Furthermore, patients often do not know the kind of information that the triagist needs to hear and so may not volunteer it, even in response to an appropriate open question. Hence, the triagist needs to ask relevant questions and in order to complete the history, and specifically ask questions that might lead to information that challenges the most obvious explication for the problem presented. 2: We do agree with remarks concerning quality of communication. Therefore we also investigated this quality for all calls by using the RICE rating list (1). With this instrument we also assess the quality of the first phase of the telephone consultation in which patients’ complaint, expectation and personal situation are explored. The results of this assessment will be published soon (Hay P Derkx, Jan-Joost E Rethans, Bas H Maiburg, Ron A Winkens, Arno M Muijtjens, Harrie G van Rooij, J André Knottnerus. Quality of communication during telephone triage at Dutch out- of hours centres. Patient Education and Counseling in press). 3: In the Netherlands health care assistants work at OOH centres as triagists. In our study GPs only came on the phone to advise by making a return call on request of the triagist. 4: In order to undertake a comparative quality study we decided to use standardised patients as without standardised calls it is difficult to compare the quality between different out of hours centres. We also studied the reliability and the quality of performance of the standardised incognito patients and these results too will be published soon (Hay Derkx, Jan Joost Rethans, Bas Maiburg , Ron Winkens, Andre Knottnerus. New methodology for using incognito standardised patients for telephone consultation in primary care. Medical Education in press). 5: We did not only record questions asked but we also recorded the answers given by the standardised patients as we needed to know the amount of clinical information available to a triagist before giving an advice. Every kind of available information was recorded. 6: We fully agree with your remark on the use of computerised decision support systems with validated protocols. However, our study showed that GPs as well as triagists miss questions or do not register answers which could be indicative of a more serious problem, and hence we believe they may also be need of such support. 7. Finally, we believe our methodology with using standardised incognito patients should be used as the basis for testing the quality of out of hours services, and that services should be required to demonstrate their safety against a standardised benchmark. It may be that in the UK services are safer than those in the Netherlands, but this should not be assumed. (1): Derkx HP, Rethans J-J E, Knottnerus JA, Ram P. Assessing communication skills of clinical call handlers working at an out of hours centre. The development of the RICE rating scale. Br J Gen Pract. 2007 May; 57 (538):383-7 Tilburg/ Maastricht, The Netherlands 01-10-08 Competing interests: None declared |
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