Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national studyBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1264 (Published 12 September 2008) Cite this as: BMJ 2008;337:a1264
All rapid responses
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
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
(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: No competing interests
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
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
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.
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.
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,
Pendleton, D. 1984, The Consultation: An Approach to Learning and
Teaching Oxford University Press, Oxford.
Plain Healthcare. TAS Odyssey: Much more than nurse triage.
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
Employed by Harmoni HS as Educational Lead
Competing interests: No competing interests