Intended for healthcare professionals


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

BMJ 2008; 337 doi: (Published 12 September 2008) Cite this as: BMJ 2008;337:a1264
  1. Hay P Derkx, researcher1,
  2. Jan-Joost E Rethans, associate professor2,
  3. Arno M Muijtjens, assistant professor 3,
  4. Bas H Maiburg, vocational trainer4,
  5. Ron Winkens, assistant professor5,
  6. Harrie G van Rooij, head of quality management 6,
  7. J André Knottnerus, professor of general practice and epidemiology1
  1. 1Department of General Practice, Maastricht University, Maastricht, Netherlands
  2. 2Skillslab, Maastricht University
  3. 3Department of Educational Development and Research, Maastricht University
  4. 4Department of General Practitioner Vocational Training, Maastricht University
  5. 5Centre for Quality of Care Research, Department of General Practice, Maastricht University
  6. 6Primary Care Out-of-hours Centre, Tilburg, Netherlands
  1. Correspondence to: H P Derkx hay.derkx{at}
  • Accepted 6 July 2008


Objective To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient’s clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres.

Design Cross sectional national study using telephone incognito standardised patients.

Setting The Netherlands.

Participants 17 out of hours centres.

Main outcome measures Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice.

Results The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls.

Conclusion In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.


  • We thank Ron Hoogenboom for helping with the statistical analysis of all data.

  • Contributors: Each author participated as a member of the research team during each stage of this study and in writing the article. J-JER is the guarantor.

  • Funding: A contribution was received from the Dutch Health Insurance Companies CZ (Tilburg) and VGZ (Nijmegen). The authors’ work was independent of the funders (the funding source had no involvement).

  • Competing interests: None declared.

  • Ethical approval: Not needed.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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