Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7165.1054 (Published 17 October 1998) Cite this as: BMJ 1998;317:1054All rapid responses
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Dr Lee Casey
Oakleaf Medical Practice
The Health Centre
Great James Street
Derry
BT48 7DH
12th February 2008
Editor,
The study by Lattimer et al (ref 1) is often quoted as providing
valuable evidence for the effectiveness of decision assisted software for
triage nurses working in an out of hours setting. I feel the design of
this trial is seriously flawed and that the results should be interpreted
with caution.
Tanna (BMJ rapid response), quite rightly points out that ‘during the
intervention period 50.2% of the calls were assessed twice, once by an
experienced and specially trained nurse using a systematic assessment,
with the aid of decision support software and then by the general
practitioner in attendance’. I feel there is another importance difference
between the two groups that makes any comparison between them flawed.
During the intervention period of the study ‘calls about children under 1
year old, and second calls about a patient on the same day, were always
referred to a doctor’.
In addition to this ‘patients and callers wishing to speak directly
to a doctor were always able to do so’. I feel that callers in these
categories are more likely to require home visits or base consultations
and so a comparison between doctor triaged and computer assisted nurse
triage groups should not be made.
It is also worth pointing out that of the 49.2% of calls handled by
triage nurses during the intervention period a further 15% were passed
onto the doctor for advice.
Therefore during the intervention period only 35% of the total number
of calls received were managed by triage nurses advice. This figure is
disappointing and certainly does not suggest that nurses using decision
support software produce 69% reduction in telephone advice from a GP which
I think is a misleading claim made by the authors.
Interest Declared.
LC is a manager for an out of hours organisation
________________
Dr Lee Casey
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Lattimer et al have provided some valuable evidence for the
effectiveness of nurse telephone consultations as part of the NHS Direct
service due to be implemented by the year 2000 (1).
We would like to comment on the equivalence limits chosen for
analysis of the outcome measure of death within 7 days of call. The
equivalence limits of 80-125% chosen by the authors seem rather arbitrary.
We question whether a tolerance level of 25% excess of deaths is
acceptable for an intended nationwide scheme.
A more reasonable approach might be to estimate the difference in
rates of death between the two arms of the study. This would allow readers
to make their own decisions about acceptable limits.
Kate Blackmore
Louise Dodd
Samantha Twist
4th Year Medical Students
Department of Epidemiology and Public Health
Newcastle University Medical School
NE2 4HH
Competing interests: No competing interests
As an Expatriate Doctor I am working in rural Queensland and am on
call 24 hrs a day for 28 days at a stretch. I have followed the debate on
out of hours advice as a qualified outside observer with interest and some
concern.
Lattimer et.al. seem to suggest that nurses could quite adequately
handle out of hours calls 50% of the time. This surely suggests that 50%
of the time they can't and the deaths of several children in Ayrshire
would appear to demonstrate this.
The basic requirements of a competent medical assessment have not
changed over the last 3000 yrs as far as I'm aware. We as doctors are
still required to LISTEN, LOOK and TOUCH to reach a safe and satisfactory
diagnosis and the telephone does not meet these requirements no matter how
convienient it may be.
Competing interests: No competing interests
Clarendon Medical Centre, Clarendon Street, Hyde. SK14-2AQ
EDITOR,
Lattimer et al report a randomised controlled trial to demonstrate
the safety and effectiveness of nurse telephone consultations in out of
hours primary care (1). I accept that the trial results show reduced GP
workload by nurse intervention, probably at an increased cost. I am less
certain whether the results demonstrate safety, for methodological
reasons.
The authors report that during ‘intervention periods’ 49.8% of the
calls could be managed by the nurse alone, without referral to a doctor.
This implies that 50.2% of the calls were assessed twice : once by ‘an
experienced and specially trained nurse’ using a ‘systematic assessment
with the aid of decision support software’, and then by the GP in
attendance. I would expect that the improved diagnosis/management in this
second subgroup would lead to much better clinical outcomes than in the
control group with only one assessment by the GP. This improved outcome
could mask the potentially poorer outcomes in the 49.8% calls handled by
the nurse alone. By combining the outcomes for essentially two
interventions (‘nurse alone’ and ‘nurse plus GP’) into a single
‘intervention group’, the issue has been clouded. I therefore question the
conclusion that ‘nurse telephone consultation is at least as safe as
existing out of hours care’.
To convince a sceptic of the safety of nurse telephone consultations,
the outcomes for patients managed by the ‘nurse alone’ should be compared
with the outcomes for matched patients in the ‘control’ group. I wonder
whether the authors can extract this information from their data. It may
be that the trial would have to run for longer than one year to fulfil
sample size criteria for such a comparison.
Dr Vikram Tanna
General Practitioner, Clarendon Medical Centre, Clarendon Street, Hyde.
SK14-2AQ
20/10/98
(1) Lattimer V et al : Safety and effectiveness of nurse telephone
consultation in out of hours primary care : randomised controlled trial :
BMJ 1998 : 317 : 1054-9.
Competing interests: No competing interests
Debate required
Dr Lee Casey
Oakleaf Medical Practice
The Health Centre
Great James Street
Derry
BT48 7DH
12th February 2008
Dear Editor,
I think it would be timely for the B.M.J to consider commissioning a
review article on the effectiveness of decision support software in a
primary care out of hours setting. Recently there has been a rush by Out
of Hours organisations to embrace this software and introduce it without a
critical review of the literature supposedly supporting its use.
I have recently reviewed the literature for a decision support software
product and found the evidence base for its use in an Out of Hours setting
to be almost non-existent. Only one publication for the product was quoted
(suggesting that only one exists!) This paper was seriously flawed and the
outcomes which are often quoted are misleading. I feel that there are
inherent dangers in the rush towards using decision assisted software.
It undoubtedly deskills clinicians who use it. Clinicians who use this
software are trained to ask the required computer generated questions and
this results in disjointed telephone consultations.
I feel this also will result in low morale if highly experienced
clinicians are forced to use decision assisting software.
It has been often claimed that decision assisting software is safer but I
feel this claim is not evidence based.
Yours sincerely,
_______________
Dr Lee Casey
Competing interests:
None declared
Competing interests: No competing interests