Do callers to NHS Direct follow the advice to attend an accident and emergency department?

Methods: A representative three week period in May 2000 was investigated. During this period there were no health scares, major health campaigns, or bank holidays that may have affected the call rate. NHS Direct callers who were advised to attend A&E were identified. Data from the four A&E departments for the same three week period and two additional days were searched and matched to NHS Direct data by surname, date of birth, and post code. This process created three groups: (1) callers triaged to A&E who attended, (2) callers triaged to A&E who did not attend, (3) callers with different triage outcome who attended A&E. The age, sex, relationship of caller, time of call, and distance to nearest A&E were compared for groups (1) and (2).

Results: Just less than two third of callers triaged to A&E attended with the same presenting complaint. There were no statistically significant differences between group (1) and (2) in terms of age, sex, relationship of caller, time of call, and distance to A&E. A small number of callers (2.4%) were identified as being given other advice and attending A&E for the same presenting complaint. This group took significantly longer to attend A&E than group (1) (χ² =139.01, df=7, p<0.001).

Conclusions: Assessing levels of compliance is difficult. These findings suggest that NHS Direct may have comparatively high levels of compliance compared with other similar services. However, using the single triage outcome as the means of identifying the advice given may oversimplify the range of possible advice given. The delay in attending A&E for the group of callers who were given other advice may indicate they had tried other actions. Further larger studies are needed to assess the appropriateness of referrals through investigation of clinical outcomes.

     

Patients telephoning A&E for advice: a comparison of expectations and outcomes.

OBJECTIVE: To investigate the expectations of patients when they phone the accident and emergency (A&E) department, how this relates to the advice they receive, the action they subsequently take, and their satisfaction with the service. SETTING: The study was undertaken at an inner city hospital in south east London. METHODS: 597 calls to the department were documented during the study period, and callers for whom a phone number had been recorded were followed up by structured interviews carried out by a trained interviewer within 72 h of the call. Up to three attempts were made to contact each patient. The interviews were conducted at various times of the day to avoid excluding people with different work or social patterns. RESULTS: The interviewer was able to contact 203 patients within 72 h of their call to the A&E department. Of these 197 (97%) agreed to participate. Almost two thirds stated that when they phoned A&E they anticipated receiving self care advice; 11% expected to be advised to see or contact their general practitioner. Only a quarter of callers stated that they had expected to be told to attend A&E. There was disagreement between the advice that nurses documented as having been given, the advice the caller recalled receiving, and the action the patient subsequently took. Even so, 107 (55%) callers were very satisfied and 62 (32%) were satisfied, while 11 (6%) were dissatisfied with the telephone consultation; 15 (8%) were unsure. In all, 170 (87%) thought the advice they received was helpful. CONCLUSIONS: Understanding the reasons why patients phone A&E departments and their expectations should contribute to developing more responsive and effective services.     

Audit of telephone advice in a paediatric accident and emergency department.

This paper audits the telephone requests for advice to a paediatric accident and emergency (A&E) Department over a 4-week period. All calls were answered by senior nurses. Most calls were received in the early evenings when the A&E department was busy. Parents were the most frequent callers and the majority of calls were for children under 5 years of age. The problems presented were wide ranging but advice over the telephone meant that many unnecessary visits to hospital were prevented. The public use the A&E department as a primary source for health advice and very few of the calls resulted in admissions. This telephone advice service is effective and helpful to the public but time consuming for A&E nursing staff at peak workload periods in their own department.     

Telephone advice in the accident and emergency department: a survey of current practice.

The objective of this study was to assess the standard of advice given by telephone by accident and emergency (A&E) departments following patients' enquiries. In order to do this patient enquiries were simulated and a telephone questionnaire was carried out. The study was carried out in 18 major and 16 minor A&E departments in Wales. Results achieved were that overall, correct telephone advice was given to 72 of 97 simulated patients (74%). Sixty calls were dealt with by the nursing staff (62%) who gave correct advice on 41 (68%) occasions. No A&E department had a formal policy nor provided staff training for handling patients' enquiries by telephone. It is concluded that A&E departments should train designated members of staff, preferably the triage nurse, who would formally deal with telephone enquiries requiring medical advice. There should be formal documentation of the enquiry and advice proffered as part of a departmental policy.     

Provision of telephone advice from accident and emergency departments: a national survey.

This study sought to gain a national picture of the provision of telephone advice using a postal survey of senior nurses from accident and emergency (A&E) and minor injury units (MIUs). In all, 268/313 (85%) of hospitals/units responded. The average number of calls reported as received per day was 15.5 (median 12; quartiles 6, 20) for weekdays and 21.0 (median 17; quartiles 10, 29) for weekends. Most (89%) viewed the provision of telephone advice as an important component of their work, but few units offered staff training for this role or had implemented protocols or guidelines. Only 5.4% units included the number of calls received in their department in their workload figures, but 91.9% felt that they should be. Extrapolation of the data from this study to all 313 A&E and MIUs in the UK suggests that just under two million calls for telephone advice are currently made to units each year. Recognition and formalization of this aspect of work is likely to be of increasing importance given the constraints on services and the need to manage demand effectively. Future integration of A&E telephone advice calls with NHS Direct should be considered as a means of managing demand and avoiding duplication of service provision.     

The effect of the introduction of NHS Direct on requests for telephone advice from an accident and emergency department

Methods—Review of departmental telephone advice logbook before and after the introduction of NHS Direct together with recording of the number of calls redirected to NHS Direct by the hospital switchboard and the A&E department.

Results—The number of advice calls responded to within the department fell by 72.6% (84 in October 1998, 23 in October 1999). The number of calls redirected to NHS Direct was 242. The total number of calls to the hospital seeking advice thus increased by 315%.

Conclusion—The introduction of NHS Direct has allowed for a mechanism to be put in place reducing the number of calls for advice being dealt with by the A&E department clinical staff with a concomitant time saving. At the same time the number of calls for advice made by the public to the hospital has dramatically increased.

     

Patient compliance with medical advice given by telephone

Data on compliance with medical advice given by telephone consultation services are currently lacking. The aim of this study was to assess patient compliance with medical advice given by a call center. A cross-sectional telephone survey was carried out on a random sample of 463 callers 72 hours after contacting the Grenoble Dial 15 center in France. Four hundred nine subjects (88.3%) participated in the study. Of these, 286 callers (69.9%) complied with the medical advice given. Compliance was 61.4% among patients who were advised to treat themselves, 83.9% among patients who were advised to consult a general practitioner during business hours, and 64.0% among patients who were advised to go to an accident and ED (P <.01). The survey pointed out adverse events resulting from the service. Assessing patient compliance can be an important source of information for improving aspects of patient management provided by telephone consultation services.     

Provision of telephone advice from accident and emergency departments: a national survey

This study sought to gain a national picture of the provision of telephone advice using a postal survey of senior nurses from accident and emergency (A&E) and minor injury units (MIUs). In all, 268/313 (85%) of hospitals/units responded. The average number of calls reported as received per day was 15.5 (median 12; quartiles 6, 20) for weekdays and 21.0 (median 17; quartiles 10, 29) for weekends. Most (89%) viewed the provision of telephone advice as an important component of their work, but few units offered staff training for this role or had implemented protocols or guidelines. Only 5.4% units included the number of calls received in their department in their workload figures, but 91.9% felt that they should be. Extrapolation of the data from this study to all 313 A&E and MIUs in the UK suggests that just under two million calls for telephone advice are currently made to units each year. Recognition and formalization of this aspect of work is likely to be of increasing importance given the constraints on services and the need to manage demand effectively. Future integration of A&E telephone advice calls with NHS Direct should be considered as a means of managing demand and avoiding duplication of service provision.     

Compliance with Poisons Center Referral Advice and Implications for Toxicovigilance

Background: When Poisons Information, or Poisons Control Centers (PCC) give directive advice in response to general public calls it is usually assumed that the advice will be followed, but it is difficult to measure the actual compliance of callers to a PCC. Epidemiological data regarding the incidence of poisoning incidents (Toxicovigilance) often utilizes reports of calls to a PCC. Methods: Retrospective review of advice given to all callers to the New Zealand National Poisons Centre (NZNPC) from a defined area for the calendar year 2001. Callers to the NZNPC telephone hotlines who were advised to attend or not to attend the hospital Emergency Department (ED) were subsequently matched with actual ED visits. Results: The compliance rate for those advised to attend the ED was 76.1%, whereas those advised not to attend had a compliance rate of 98.7%. The overall compliance rate was 94.1%. Of the patients presenting to the ED with a potential poisoning, only 10.2% were referred by the PCC. The callers referred by PCC and direct ED visitors appeared to differ in some respects. Conclusions: Compliance with PCC telephone advice is similar to the compliance rates in many other health interventions. Comparisons between populations calling a PCC and those self‐presenting to an ED show that PCC data may not reflect the true burden of poisoning to health care systems.     

Misuse of the London ambulance service: How much and why?

OBJECTIVES: To assess the degree of inappropriate use of the London Ambulance Service and analyse the reasons for misuse. DESIGN: An immediate assessment of the appropriateness of the "999" call by the ambulanceperson and casualty senior house officer followed by a retrospective review of each case by the accident and emergency (A&E) consultant. SETTING: A busy inner London A&E department. METHODS: Three hundred consecutive emergency ambulance arrivals to the A&E department underwent assessment as to the appropriateness of the call. RESULTS: Overall 53.7% of patients were considered justified in their call, 15.7% of calls were inappropriate, and in 19.0% of cases a unanimous decision was not reached. Eleven per cent of all forms were incompletely filled. CONCLUSIONS: Almost 16% of emergency ambulance calls were considered unanimously to be inappropriate. This suggests that 75,000 emergency calls per year to the London Ambulance Service are not necessary. The commonest reason for inappropriately calling an ambulance was that the caller felt that they had a serious or life threatening condition. The need for public education and deterrents of ambulance abuse are discussed. The further introduction of a nursing led triage "hot line" to appropriately dispatch ambulances according to clinical needs of the patient, and other alternatives to this are discussed.     

Will alternative immediate care services reduce demands for non-urgent treatment at accident and emergency?

Methods—A questionnaire survey and notes review of 267 adults presenting to the A&E department of a large teaching hospital in Sheffield, England, triaged to the two lowest priority treatment streams, was conducted over seven weeks. Using defined criteria, patients were classified by the suitability of the presenting health problem to be managed by alternative immediate care services or only by A&E, and also by the likelihood, in similar circumstances, of patients presenting to other services given their reasons for seeking A&E care. Results—Full data were obtained for 96% of participants (255 of 267). Using objective criteria, it is estimated that 55% (95% CI 50%, 62%) of the health problems presented by a non-urgent population attending A&E are suitable for treatment in either general practice, or a minor injury unit, or a walk in centre or by self care after advice from NHS Direct. However, in almost one quarter (24%) of low priority patients who self referred, A&E was not the first contact with the health services for the presenting health problem. The reason for attending A&E cited most frequently by the patients was a belief that radiography was necessary. The reason given least often was seeking advice from a nurse practitioner. Taking into account the objective suitability of the health problem to be treated elsewhere, and the reasons for attending A&E given by the patients, it is estimated that, with similar health problems, as few as 7% (95% CI 3%, 10%) of the non-urgent A&E population may be expected to present to providers other than A&E in the future. Conclusions—The increasing availability of alternative services offering first contact care for non-urgent health problems, is likely to have little impact on the demand for A&E services.     

Telephone nursing: calls and caller satisfaction

To understand the function of telephone nursing, every call to the Medical Call Centre in Stockholm was recorded during one week (n = 2866). Every tenth caller (n = 203) was asked to answer a mailed questionnaire about consultation and satisfaction. The most common reason for calling was symptoms of infection. The predominant outcome was self-care advice (49%). In the mailed questionnaire 85% of respondents stated that they had followed the advice and 95% were satisfied with their consultation. Compared to earlier studies of calls to health-care centres and accident and emergency departments, a larger proportion of the callers were advised to see a physician. The Call Centre we examined proved to be more inclined to give self-care advice than other health-care settings.     

Next day telephone follow up of the elderly: a needs assessment and critical incident monitoring tool for the accident and emergency department

Background—Patients over the age of 75 years comprise an increasing proportion of accident and emergency (A&E) department attendances. Within this group there is a high incidence of comorbidity, which mandates effective discharge coordination from the A&E department.

Objectives—The aims of this study were to assess the needs of these patients the day after discharge, target patients for appropriate interventions and identify critical incidents.

Setting—The study was undertaken in a district general hospital A&E department that has 62 000 new patient attendances per year.

Inclusion criteria—Patients aged 75 years or over who were discharged from the A&E department.

Exclusion criteria—Nursing home patients. Patients without a telephone.

Study design—Pre-discharge information was collected from the medical notes. A community liaison nurse (CLN) then contacted patients by telephone. A semi-structured questionnaire was used to assess patients. Patients were risk stratified and appropriate interventions made. Interventions initiated by the CLN were scored from 1 to 6 based on the level of input required.

Results—551 patients or their carers were contacted by telephone. Existing home support was felt to be insufficient in 44 (8%) cases and in need of immediate intervention in a further 45 (8%) cases. Sixty five (11%) Category 1 patients required no intervention, 223 (42%) Category 2 patients required advice only, 107 (19%) Category 3 patients were referred to their GP, 127 (23%) Category 4 patients required a domicillary visit by a GP or a nurse, 26 (5%) Category 5 patients were at risk requiring urgent home assessment and three Category 6 patients had to re-attend A&E. Advice was given by the CLN on a broad range of issues and a wide range of health care services was accessed. Five hundred and fifty nine referrals were made by the CLN after telephone assessment.

Conclusions—Telephone follow up of patients over 75 attending our A&E department identified a number of areas where care could be improved before and after discharge. This low cost, high quality intervention has the potential for decreasing inappropriate return visits to the department by a vulnerable group of patients as well as improving overall quality of care.

     

Satisfaction with the accident and emergency department--a postal survey of general practitioners' views.

OBJECTIVE: To survey general practitioners' opinions of the quality of care offered by an urban accident and emergency (A&E) department. METHODS: A postal questionnaire was used. The questionnaire addressed issues of patient treatment, communications between hospital and GPs, and the GPs' perceptions of patient satisfaction. Questions required graded responses. Response rate was 57% (91 of 160 GPs mailed). RESULTS: 96% and 91% of responders respectively were satisfied with patient assessment and treatment, and 70% were satisfied with the explanation given to the patient. Problems were highlighted in communications between the department and GPs. 68% reported that adult patients always/usually gave their practice a hand written letter detailing their initial A&E attendance. Concerns were expressed about the content, illegibility, and inconvenience of this form. 42% of GPs reported never/rarely receiving a typed summary of patients discharged from the A&E review clinic. 28% of GPs would have appreciated a telephone call from the department on occasions. The areas of most patient dissatisfaction were perceived by GPs as: waiting time (67%), communication (19%), staff attitude (7%), and actual treatment (7%). CONCLUSIONS: A postal survey of local GPs can give valuable information about the quality of care provided by a hospital department. Overall GP satisfaction with the service was high, but there are concerns about aspects of written and telephone communications between the department and GPs, which can be addressed.     

Manipulation under sedation in the accident and emergency department.

The Royal College of Surgeons of England recently published guidelines for sedation by non-anaesthetists. The report emphasizes sedation for endoscopy and dental surgery, but the recommendations are equally relevant to accident and emergency (A&E) medicine. Current sedation practice for orthopaedic manipulations was determined by questionnaire in 58 A&E and orthopaedic junior staff in one teaching and one district general hospital. Of the 50 doctors who completed the questionnaire, 14 (28%) respondents made an inadequate pre-sedation assessment. Over half were unable to name the antagonist to benzodiazepine drugs. Eleven (22%) doctors administered supplemental oxygen to all their patients, 12 (24%) did not consider it necessary. Pulse oximetry was used for patient monitoring by one respondent (2%). None of the junior staff had received any formal training in sedation techniques. Thirty-one (62%) had attended a resuscitation refresher course within the last year. These results emphasize the need for training in sedation techniques for A&E and orthopaedic juniors and the importance of appropriate supervision.     

Epilepsy in the accident and emergency department--developing a code of safe practice for adult patients. South East and South West Thames Accident and Emergency Specialty Sub-committees.

OBJECTIVES: To benchmark current practice in the management of adult patients presenting with seizures to the accident and emergency (A&E) departments by performing a comparative interdepartmental audit. To assess the quality and degree of completeness of documentation in A&E records and to develop a proforma for the documentation of any case presenting with a seizure which would incorporate management guidelines for use by A&E doctors. METHODS: This was a retrospective, criterion based audit carried out in 12 A&E departments in the South Thames region. It involved 1200 adult patients who presented to A&E departments after a seizure. The degree of completeness of A&E records was assessed using criteria identified by A&E consultants and neurologists. Guidelines for use in the management of patients with seizures have been produced. RESULTS: Important aspects of the history and examination were frequently unrecorded in patients' notes. The recording of vital signs was particularly poor. A diversity of practice was shown between the departments that were audited and the number of investigations performed in each department varied considerably. Hospital admissions for patients with first seizures varied widely between departments, ranging from between 34.6% to 91.7% of cases. Documentation of advice given to patients about driving was evident in just 0.9% of cases. CONCLUSIONS: Wide interdepartmental variation exists in both the quality of information recorded in A&E records and in the management of patients. Deficiencies could be minimised and potential improvements in the quality of documentation might be achieved by the introduction of a structured proforma incorporating pre-defined management guidelines.     

Patients who attend two accident and emergency departments.

Forty-six patients were identified who attended an accident and emergency (A&E) department having previously attended a different A&E department in the same city for the same problem. Of these patients, 20% had been referred to the second department by the general practitioner (GP) or practice nurse. A diagnostic error had been made in 17.5% of patients at their first visit and some management errors were discovered. Eleven per cent of patients had an unnecessary second set of radiographs taken. A review of unplanned reattenders to an A&E department is an important opportunity for audit and normally an error will not be discovered if a patient attends a different department. We recommend that in cities where there is more than one A&E department a system should be set up whereby if a patient attends one department having previously attended another, the first department should be informed of the patients reattendance, especially if any diagnostic or management error has been discovered. Patients should be educated that if they have sought medical help for any problem and the condition does not improve, then they should return to see the same doctor or A&E department for continuity of care and avoidance of unnecessary duplication of investigations including exposure to X-rays.     

Primary care in London: an evaluation of general practitioners working in an inner city accident and emergency department.

OBJECTIVE: To determine the characteristics of primary care attenders to St Mary's Hospital accident and emergency (A&E) department, evaluate the effects of the introduction of general practitioners (GPs) on patient care in A&E, and make recommendations for the provision of GPs in appropriate A&E departments. DESIGN: Prospective survey over a six week period. METHODS: Data collected from the attendances of 970 consecutive patients triaged with "minor" primary care problems, whether seen by A&E doctors or by GPs working in A&E, were analysed. RESULTS: During the study period 1078 patients (16.6%) were triaged as suitable for primary care. The A&E GPs saw 58.4% of these patients. The majority of primary care patients were young British residents, 71.1% of whom were registered with a GP. Sixty per cent of patients lived within St Mary's catchment area. Of those registered patients asked why they attended A&E, 27.1% thought their problem inappropriate for their GP. A&E doctors were more likely to investigate patients and arrange hospital follow up than GPs, who arranged community follow up in 80% of patients needing further care. CONCLUSIONS: The demand for primary care at St Mary's necessitates the provision of a primary care service, albeit for the first visit only. This can be provided by GPs in A&E. The features of the patients using the service suggests that discouraging first attendance is unrealistic, but using the visit to educate patients and return them to the care of the community is not.     

Review of calls to NHS Direct related to attendance in the paediatric emergency department

Objective

To examine the outcomes of calls to NHS Direct (NHS‐D) in relation to attendance at the accident and emergency (A&E) department.

Design

A prospective collection of data about consecutive calls to NHS‐D North West Coast was matched with attendances at the A&E department over a period of 3 months.

Setting

NHS‐D Regional Trust and a large urban paediatric A&E department.

Patients

Children and young adults aged <16 years living in local postal code areas.

Main outcome measures

To examine (1) whether advice given by NHS‐D was followed and (2) the differences in disease severity and necessity of attendance of patients referred by NHS‐D and those referred by general practitioners and self‐presenters.

Results

The relationship between the advice given and subsequent action is complex. Only 70% of calls advised to attend the A&E department did so. A further 1% (176) were advised not to attend the A&E department did in fact attend the department. Patients referred by NHS‐D represented only 3.2% of department attendances. There was little difference in the triage categories of the presenting groups, but there were significantly less admissions (p<0.01) in the NHS‐D group.

Conclusions

Delivering telephone advice about illness severity in children is difficult as visual clues are so important. More collaborative prospective studies are needed, including with primary care, to understand families'' choices, and to refine and assess NHS‐D''s ability to discriminate those requiring further clinical assessment.NHS Direct (NHS‐D) seeks to provide telephone advice using call triage and assessment by qualified nurses underpinned by decision support software. NHS‐D is now the world''s largest provider of healthcare advice,¹ and 30–40% of calls are about children. A large amount of public money has been invested and efforts have been made to refine and improve the process and efficiency of handling calls. Although NHS‐D has been operating in several areas since 1998, there have been few attempts to follow the clinical outcome of calls systematically. A review of the service tends to concentrate on these aspects² rather than the clinical course, which relies on voluntary feedback from clinicians.Telephone advice about acute illness is challenging in cases where children are concerned; not only because a carer acts as a third party interpreting the patient''s symptoms but also because of the non‐specific nature of the symptoms of many childhood illnesses. This might result in a higher hospital referral rate for children who are less ill.Working in collaboration with the Medical Director of NHS‐D North West Coast we investigated the outcome of all calls regarding children to this service for a period of 3 months. The primary aim was to determine whether advice in relation to hospital attendance was followed and to examine the types of patients referred to the accident and emergency (A&E) department by NHS‐D. A secondary aim was to compare patients referred by NHS‐D with those referred by general practitioners and those who self‐presented to check whether there were differences in terms of disease severity and necessity of attendance.³