The “crisis” in out of hours primary care1 2 and availability of new development funding3 have prompted new service arrangements, primarily general practice cooperatives and primary care emergency centres. Nurse telephone triage is an adjunct to cooperatives and primary care emergency centres in which trained nurses receive, assess, and manage calls by giving advice or by referral to the general practitioner or ambulance service.4 These services are established elsewhere but are an innovation in the United Kingdom. This paper reports a pilot study of a United Kingdom based nurse telephone triage service.
Subjects, methods, and results
The pilot was run in two practices in Salisbury (combined practice population 10 000) as 18 four hour sessions–14 in the evenings and four at weekends. Incoming calls to the practice were diverted to an experienced practice nurse, who was aided by the Telephone Advice System, a computer based primary care call management system.5 A printed summary of each assessment provided by the Telephone Advice System was faxed to the general practitioner. Callers received follow up questionnaires asking about their satisfaction with the service.
No logistic problems were encountered. Overall, 56 calls were received from 54 callers. There were no deaths, no hospital admissions, and no ambulance calls relating to any of the calls. Twenty one calls (38%; 95% confidence interval 25% to 51%) were handled by the nurse alone (table 1)). Of the 35 calls referred to a doctor, the nurse provided interim advice in 22 (39%; 27% to 53%). Two callers called twice about the same episode of illness. Both were dealt with by the nurse alone. Twenty two calls concerned children aged under 16, six being under 1 year. Practice policy dictated that these patients should automatically be referred to the doctor. Overall, 17 of 22 children were referred to the doctor.
No triage decision was changed by the general practitioner because of the faxed record. In 12 of the 35 referred calls the general practitioner gave telephone advice only. In five cases the patient had received the same advice from the nurse. In the first nine sessions the nurse managed seven of 29 calls alone (24%; 10% to 44%). In the second nine sessions this proportion increased to 14 of 27 (52%; 32% to 71% (χ2 test for difference in proportions=4.58; P=0.03, df=1)). This difference could not be explained by differences in the urgency of calls.
A postal follow up questionnaire was sent to 44 callers. The remaining 10 callers were excluded from receiving a questionnaire because they were acutely mentally ill, or distressed, or elderly and frail, or under 16 years of age, or were merely requesting a routine appointment. Replies were received from 30 (68%) of callers. Twenty six respondents (87%; 69% to 96%) were satisfied or highly satisfied with the advice they received from the nurse. The remainder failed to complete this question. Nineteen respondents had spoken to the nurse only and were asked whether they would prefer to have spoken directly to a doctor. Fourteen (74%; 49% to 91%) said “no.”
Nurse telephone triage was feasible in this setting, and most patients found the service acceptable. But what benefits does the service bring? The answer is likely to be both a reduction in general practitioners' workload and an economic gain. Over one third of calls in this study were handled by the nurse alone, and in the second half of the study this proportion increased to half. A message handling service alone would have referred many calls to the general practitioner unnecessarily. In such circumstances a cooperative currently employing two or more general practitioners on call might find it possible to replace one of the doctors with a telephone triage nurse.
We are conducting a randomised controlled trial of nurse telephone triage in a larger population over one year. This will permit better judgment of the safety and cost implications of the widespread institution of nurse telephone triage within the United Kingdom.
Members of the group are listed at the end of this report.
Members of the South Wiltshire Out of Hours Project (SWOOP) Group were: Mrs Val Lattimer, Dr Steve George, and Mrs Eileen Thomas (Wessex Institute for Health Research and Development, University of Southampton); Dr Helen Smith, Dr Michael Moore, and Mrs Felicity Thompson (Wessex Primary Care Research Network); and Professor Alan Glasper (School of Nursing, University of Southampton).
We thank general practitioners Dr Hugh Bond, Dr Richard Barnsley, and Dr Dougal Jeffries for help and support; the Royal College of Nursing for support; and Dr Jeremy Dale and Mr Robert Crouch, of King's College Hospital, London, and Mr Mike Bennett, of Plain Software, for help and advice throughout.
Funding: British Telecom and the NHS Executive South and West.
Conflict of interest: None.