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

Abstract

Background: 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.

Aim: 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.

Design and setting: 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.

Method: Statistical analyses (mixed-effects regression) of approximately 200 000 secondary triage call records were undertaken.

Results: 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% (n = 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.

Conclusion: 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.

Keywords: National Health Service, British; cross-sectional studies; digital triage; emergencies; primary health care; urgent care.

Figure 1.

Referral routes for patients triaged by NHS 111; approximate percentages provided. Blue referral route represents patients referred to secondary, digitally supported, clinician-led triage, which is the patient population for this study. ED = emergency department.

Figure 2.

Sankey visualisation: change in triage outcomes between primary and secondary triage for calls where primary and secondary triage outcome urgencies were available.