A mixed-methods evaluation of telephone based digital triage used in urgent care within the United Kingdom

Background Telephone-based urgent care in England typically involves an initial ‘primary’ triage conducted by a non-clinician in the NHS 111 telephone service. Approximately 50% of these patients are subsequently referred for ‘secondary’ clinician-led triage. This ‘two-step’ model contrasts with other parts of the UK and other countries, where patients typically undergo a single clinician-led triage. Digital triage is widely used in these services by call takers to support the provision of referral and/or self-care advice, based on the patient’s symptoms. Despite wide adoption, there is limited evaluation of patterns of triage outcomes and patient experience, particularly in the context of England’s two-step triage. Methods Convergent mixed methods, including analyses of routine data from four urgent care providers in England to evaluate patterns of triage outcomes, including clinicians’ overriding (decision to upgrade or downgrade the urgency level) from: 1)primary triage outcome and 2)digitally recommended triage outcome generated by the clinician in secondary triage. Semi-structured interviews and thematic analysis were used to explore callers’ experiences of ‘two-step triage’ and ‘direct clinician triage’ in England and Northern Ireland respectively. Results Non-clinician triage was risk averse, with over 70% of calls being subsequently downgraded in urgency following secondary triage. However, urgency appeared to be underestimated in primary triage in some calls. In secondary triage, there was variation between services and clinicians in how likely they were to upgrade/downgrade calls. Complexity and delays in two-step triage, and variation in call takers conduct of triage was evident in patients’ experiences. Discussion This research indicates inefficiency in two-step triage. Well-resourced secondary triage may help promote the efficient use of urgent and emergency care by patients following triage. Further research is required to investigate variation in triage outcomes between secondary triage providers and individual clinicians. Service providers should monitor calls where variation between call takers is most evident

An evaluation of service user experience, clinical outcomes and service use associated with urgent care services that utilise telephone-based digital triage : a systematic review protocol

Background: Telephone-based digital triage is widely used by services that provide urgent care. This involves a call handler or clinician using a digital triage tool to generate algorithm-based care advice, based on a patient’s symptoms. Advice typically takes the form of signposting within defined levels of urgency to specific services or self-care advice. Despite wide adoption, there is limited evaluation of its impact on service user experience, service use and clinical outcomes; no previous systematic reviews have focussed on services that utilise digital triage, and its impact on these outcome areas within urgent care. This review aims to address this need, particularly now that telephone-based digital triage is well established in healthcare delivery. Methods: Studies assessing the impact of telephone-based digital triage on service user experience, health care service use and clinical outcomes will be identified through searches conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus. Search terms using words relating to digital triage and urgent care settings (excluding in-hours general practice) will be used. The review will include all original study types including qualitative, quantitative and mixed methods studies; studies published in the last 20 years and studies published in English. Quality assessment of studies will be conducted using the Mixed Methods Appraisal Tool (MMAT); a narrative synthesis approach will be used to analyse and summarise findings. Discussion: This is the first systematic review to evaluate service user experience, service use and clinical outcomes related to the use of telephone-based digital triage in urgent care settings. It will evaluate evidence from studies of wide-ranging designs. The narrative synthesis approach will enable the integration of findings to provide new insights on service delivery. Models of urgent care continue to evolve rapidly, with the emergence of self-triage tools and national help lines. Findings from this review will be presented in a practical format that can feed into the design of digital triage tools, future service design and healthcare policy. Systematic review registration: This systematic review is registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO 2020 CRD42020178500)

Service use, clinical outcomes and user experience associated with urgent care services that utilise telephone based digital triage : a systematic review

Objective To evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care. Design Systematic review and narrative synthesis. Data sources Medline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020. Eligibility criteria for selecting studies Studies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care. Data extraction and synthesis Two reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings. Results Thirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients’ adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions. Conclusions Further research is needed into patient level service use, including patients’ adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery

Clinician-led secondary triage in England's urgent care delivery : a cross-sectional study

Clinician-led secondary triage, following primary triage by the NHS 111 phone line, is central to England's urgent care system. However, little is known about how secondary triage influences the urgency attributed to patients' needs. To describe patterns of secondary triage outcomes and call-related factors (such as call length and time of call) associated with upgrading/downgrading of primary triage outcomes. Cross-sectional analysis of secondary triage call records from four urgent care providers in England using the same digital triage system to support clinicians' decision making. Statistical analyses (mixed-effects regression) of approximately 200 000 secondary triage call records were undertaken. Following secondary triage, 12% of calls were upgraded (including 2% becoming classified as emergencies) from the primary triage urgency. The highest odds of upgrade related to chest pain (odds ratio [OR] 2.68, 95% confidence interval [CI] = 2.34 to 3.07) and breathlessness (OR 1.62, 95% CI = 1.42 to 1.85; reference: abdominal pain) presentations. However, 74% of calls were downgraded; notably, 92% ( = 33 394) of calls classified at primary triage as needing clinical attention within 1 h were downgraded. Secondary triage outcomes were associated with operational factors (day/time of call), and most substantially with the clinician conducting triage. Non-clinician primary triage has significant limitations, highlighting the importance of secondary triage in the English urgent care system. It may miss key symptoms that are subsequently triaged as requiring immediate care, while also being too risk averse for most calls leading to downgrading of urgency. There is unexplained inconsistency between clinicians, despite all using the same digital triage system. Further research is needed to improve the consistency and safety of urgent care triage

Service use, clinical outcomes and user experience associated with urgent care services that utilise telephone based digital triage: a systematic review

Objective: to evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care.Design: systematic review and narrative synthesis.Data sources: Medline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020.Eligibility criteria for selecting studies: studies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care.Data extraction and synthesis: two reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings.Results: thirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients' adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions.Conclusions: further research is needed into patient level service use, including patients' adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery

Abstracts of the 3rd Annual Graduate Entry Research in Medicine Conference

This book contains the abstracts of the papers presented at The 3rd Annual Graduate Entry Research in Medicine Conference (GERMCON 2020) Organized by Warwick Medical School, University of Warwick in collaboration with Swansea University Medical School, Swansea University, Wales, UK held on 12–18 October 2020. This was especially important for Graduate Entry Medical (GEM) students, who have less opportunity and time to engage in research due to their accelerated medical degree. Conference Title: 3rd Annual Graduate Entry Research in Medicine ConferenceConference Acronym: GERMCON 2020Conference Date: 12–18 October 2020Conference Location: Online (Virtual Mode)Conference Organizer: Warwick Medical School, University of Warwick, UKCo-organizer: Swansea University Medical School, Swansea University, Wales, UK Other Abstract Book of GERMCON: Abstracts of the 4th Annual Graduate Entry Research in Medicine Conferenc