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

Abstract

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.

Box plots (distributions) of percentage obligatory questions asked versus standard and percentage home management and safety advice provided versus standard. Left panel shows distribution for all calls (n=357), middle panel shows distributions per case (51 calls per box plot), and right panel shows distributions per out of hours centre (21 calls per box plot). Each box plot shows mean value (solid line), 25th and 75th centiles (lower and higher boundaries of grey box) indicating central part, and 10th and the 90th centiles (grey “whiskers” outside box) indicating outer parts of distribution