NHS Direct: consistency of triage outcomes

Abstract

Objectives: To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct. Methods: 119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System. Results: The overall level of agreement between the nurses using the four systems was "fair" rather than "moderate" or "good" (κ=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services. Conclusions: There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved.

Prehospital triage, discrepancy in priority-setting between emergency medical dispatch centre and ambulance crews

“…In our study, the difference between EMDC and ACR in priority-setting varied between 70% in P1 and 1% in P4. Although the national expert panel on field triage in the USA has reported a normal rate of under-and over-triage of 1-5 and 25-50%, respectively, the goal must be to improve the selection 3 AL 14 4 2 0 0 0 2 1 1 0 0 1 3 14 ANL 340 24 44 2 5 21 63 42 31 51 6 26 25 340 NOA 2,686 76 426 25 28 140 478 311 167 387 130 97 421 2,686 Sum 3,040 104 472 27 33 161 543 354 199 438 136 124 [17,18]. An improved system should also enable transport of patients directly from the scene to different healthcare centers based on their needs (''short tracks'').…”

The work, workforce, technology and organisational implications of the ‘111’ single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study

“…Previous research suggests that the CDSS is often oversensitive (it does not miss sick patients and therefore it is safe) but that it tends to 'over-triage' (it identifies 'too many' false positives because it is not specific enough). 47,48 Such studies acknowledge that it is difficult to devise a CDSS that has both high sensitivity and high specificity, and in a CDSS that has been designed for use by non-clinicians it is necessary -and somewhat inevitable -that NHS Pathways has high DISCUSSION AND CONCLUSIONS sensitivity. It is possible that NHS Pathways 13,15 may 'over-triage', particularly to ambulance services; however, more work is required to clearly understand this.…”

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…Of the 15 other studies, 72,89,100,101,[115][116][117][118][119]124,131,135,[138][139][140] four studies looked at the appropriateness of ED referrals. In terms of referral sources, no difference was found between telephone and self-referred patients, 118 but doctor-referred patients were the most appropriate referrals.…”