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.     

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.     

Review of a computer based telephone Helpline in an A&E department.

OBJECTIVE: An audit of use of the telephone Helpline in the accident and emergency (A&E) department was conducted to establish the type of call, time, by whom the calls were made, appropriateness of advice given, and whether callers attended or not as advised, and also to obtain feedback from callers as to the degree of satisfaction with the advice given. METHODS: All calls over a four week period were included in the study. The information logged comprised name, age, telephone number, date and time of call, nature of query, advice given, and name of advisor. Callers whose telephone number had been noted were contacted for feedback. RESULTS: There were 300 calls over the four week period, and 150 callers were available for feedback. Most calls were received between 12.00 and 20.00 hours. The majority of callers were parent or self, 52% of calls were for problems concerning adults, and 40% for children; no age was recorded in 8%. Nursing staff answered 90.7% of the calls. Queries were wide ranging but commonly involved open and closed wounds and head injuries, with 29.3% being advised to attend A&E, 32.3% to ring or see their GP, and 38.4% were reassured or given other advice; 4% of callers attended A&E despite being advised otherwise, 97% were judged to have received appropriate advice, and 91.3% of callers were satisfied with the advice given. CONCLUSION: The Helpline has proved of benefit to the public. It is necessary and important to have protocols for common problems and to document all details carefully. It is also necessary that nursing staff are trained in handling the telephone queries and using the protocols. The use of a PC based system has improved data collection and also allows immediate access to protocols.     

Role of the short stay observation ward in accident and emergency departments in the United Kingdom.

OBJECTIVE: To define the role of the accident and emergency (A&E) short stay ward by a survey of departments in the United Kingdom and review of published reports. METHODS: A postal questionnaire with telephone follow up to all major A&E departments with short stay beds. RESULTS: 95 departments were found to have short stay beds. These units received between 19000 and 121000 new patients per year (mean 51000, median 50500) and had access to between two and 20 beds (mean 7.5, median 6). The level of provision varied from one bed per 2440 new attendances to one bed per 27250 new attendances (mean 8380, median 6625). Where data on admission rates were available the departments admitted between 0.1% and 13.3% of their new attendances (mean 2.62%, median 1.9%). Cover was typically provided by an A&E senior house officer with frequent senior ward rounds. While the casemix usually included minor head injuries and alcohol intoxicated patients, there was considerable variation in the cases admitted. CONCLUSIONS: Short stay provision is highly variable in the United Kingdom. While there are many reports of well run short stay units, consistent evidence of clinical value and cost-effectiveness compared to other methods of care is lacking. Further comparative studies are required to define the role of the A&E short stay ward.     

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.     

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES: A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service. METHODS: A questionnaire was sent to all 560 departments providing A&E services in the UK. RESULTS: Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents. CONCLUSION: The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.     

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.

     

Characteristics of self referred patients attending minor injury units.

OBJECTIVE: To examine the characteristics, expectations, and use of health services of patients who self refer to minor injury units (MIUs). DESIGN: Preconsultation questionnaire administered to self referred patients attending with new problems. SETTING: Two MIUs in south Kent. MAIN RESULTS: Of 312 self referred patients, 265 (84.9%) presented with minor injuries and 47 (15.1%) with illnesses. In most cases the illness/injury was of recent origin: 119 (38.1%) said it was of less than six hours' duration and 115 (27.6%) between 6 and 24 hours' duration. Most (214; 68.6%) came from home, and for 268 (85.9%) it took 10 min or less to get to the MIU. 79 patients (25.3%) had used the MIU on on e to two occasions in the previous year, and 21 (6.7%) had used it on three or more occasions. In the same period, 44 (14.1%) had attended on accident and emergency (A&E) department on one to two occasions, and 17 (5.4%) has used A&E on three or more occasions, while 108 (34.6%) had been to a general practitioner on one to two occasions, and 144 (46.1%) on three or more occasions. If there had been no MIU available, 151 patients (48.4%) said they would have attended an A&E department, and 91 (29.4%) said they would have attended their general practitioner. The remainder would have self treated or were unsure. CONCLUSIONS: While the availability of an intermediate tier of care appears to result in greater overall workload for the health service, this must be balanced against the clinical and social costs involved in different patterns of service provision. The cost-effectiveness of these services need further study.     

Accident and emergency services for children within Trent region

Objectives—To investigate the provision of accident and emergency (A&E) services for children within Trent region, and to compare these with published recommendations.

Methods—A postal questionnaire was sent to all A&E and minor injury units within Trent region providing services for children. Findings were compared with published recommendations including those of the Multidisciplinary Working Party into Accident and Emergency Services for Children.

Results—Thirty six units provided A&E services for children within Trent: 17 mixed units, 17 minor injury units and two children's units. Within mixed A&E units complete audio-visual separation from adult patients was provided by six units (35%), inpatient paediatric facilities were available at 11 units (65%) and a minimum of one registered children's nurse was always on duty in three units (18%).

Conclusions—Few A&E units within Trent region currently meet the recommendations of the Multidisciplinary Working Party. The most common shortfall identified was in the provision of registered children's nurses.

     

A profile of sports hand injuries in an accident and emergency department.

OBJECTIVE: To establish a profile of sports hand injuries requiring treatment in an urban accident and emergency (A&E) department, and to determine the extent to which these injuries resulted in morbidity. METHODS: A one year prospective observational study at the Royal Victoria Infirmary, Newcastle upon Tyne. All patients presenting to the A&E department between 29 July 1995 and 28 July 1996 with a hand injury sustained during sporting activity and who received follow up by A&E or plastic surgery units were enrolled. Patients were contacted by telephone or post at median of four months after injury (range two to 13) for their assessment of the outcome. RESULTS: 262 cases were enrolled into the study. The median age for males was 21 years (range 7 to 55) and for females 16 (range 9 to 40). Follow up data were obtained by telephone in 206 (79%), and by letter in a further 26 (10%). Fractures were the commonest injury (68%), followed by soft tissue injuries (20%) and dislocations (11%). The thumb was the site affected most commonly overall, and in 10 of 17 ski related injuries; next most frequent sites were little and ring fingers. Males sustained 79% of the injuries, and 54% of these occurred during football. Netball/basketball caused 63% of female injuries. Follow up indicated that mild impairment in terms of pain, stiffness, or deformity was common (45%), while the incidence of moderate pain or serious problems was 11%. CONCLUSIONS: Sporting injuries to the hand commonly require treatment in the A&E department. Telephone/postal follow up of such injuries indicates that significant short term and longer term impairment of function may result. Suitable target areas for injury prevention are secondary schools, football (in males), and netball/basketball.     

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.     

Role of the accident and emergency review clinic in UK service provision

Objectives: Selected patients attending accident and emergency (A&E) are seen again in the A&E review clinic for planned follow up. Despite the large number of patients being seen in these clinics, this area of A&E service provision has rarely been studied. The aim of this study was to determine the current provision of review clinic services in UK A&E departments, their organisation, and their perceived role in current practice.

Methods: Postal survey of all major UK adult and paediatric A&E units.

Results: Almost all major UK A&E departments have a review clinic service and almost three quarters see less than 10% as reviews in line with current guidance. Many departments feel their clinics are well run and fulfil their objectives. Others are under pressure from external sources to see more patients. Over a third of departments have no written policies or protocols guiding referral to these clinics.

Conclusion: Review clinics are an important part of the A&E service in the UK and minimum standards need to be set in the provision of these services. Further audit and research needs to be carried out on the review clinic service to guide its future development.

     

Management of eye emergencies in the accident and emergency department by senior house officers: a national survey.

OBJECTIVE: To assess the training that accident and emergency (A&E) senior house officers (SHOs) receive in dealing with eye emergencies, their own perceived level of confidence and competence in managing such cases, and the availability of appropriate equipment in their departments. METHODS: Prospective telephone survey using a standardised structured questionnaire. One SHO from each United Kingdom A&E department listed in the BAEM directory of 1993 was chosen at random and interviewed. RESULTS: 226 A&E departments were contacted and 192 SHOs were successfully interviewed (response rate 84.9%); 26.0% received no training in the management of eye emergencies, 68.8% had only a little or no confidence in dealing with these cases, and 42.2% worked in A&E departments which had no slit lamp. CONCLUSIONS: There is a lack of adequate basic ophthalmic training for A&E SHOs, leading to a lack of confidence on their part in the management of eye emergencies. In just over 40% of A&E departments in the United Kingdom, the management of these cases may be less than optimal because of the absence of a slit lamp.     

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.     

Questionnaire survey of interpreter use in accident and emergency departments in the UK.

OBJECTIVE: To determine the support for a national telephone interpreter service from accident and emergency (A&E) departments across the UK, and the factors that may influence that support. To determine the nature of interpreter needs for these departments. METHODS: Postal questionnaire survey of 255 A&E departments in the UK. RESULTS: A total of 197 replies were received, a response rate of 77.3%. Altogether 186 respondents answered the question on support for a national telephone interpreter service and 124 (66.7%) would support one. Those departments in favour were no more likely to have required an interpreter in the last seven days (chi 2 = 0.16, df = 1, p = 0.69), be in the inner city (Fisher's exact test, two sided probability, p = 1), have predominantly local population needs compared with tourist needs (chi 2 = 0.65, df = 1, p = 0.42), or be current users of a telephone interpreter service (chi 2 = 0.01, df = 1, p = 0.93). Seventy-nine of 180 (42.9%) departments had used some form of interpreter in the seven days preceding completion of the survey. Seventy-six of 86 (88.4%) of those departments using face to face interpreters had experienced difficulty obtaining an interpreter out of hours. Nationally, the following proportion of all A&E departments listed the named language as occurring among the three most common languages requiring interpretation: French 0.46 (95% confidence interval 0.42 to 0.50), Urdu 0.30 (0.26 to 0.34), and German 0.24 (0.21 to 0.27). CONCLUSIONS: There is widespread need and support for a national telephone interpreter service that would match the requirements of 24 hour emergency health care provision.     

An analysis of calls referred to the emergency 999 service by NHS Direct

Methods—The study was carried out in three accident and emergency (A&E) departments in West Yorkshire, between 1 April 1999 and 21 August 1999. NHS Direct generated 999 calls were identified. The comparison group was selected at random from a list of all other 999 cases attending the three departments. The study involved retrieving basic demographic data, as well as duration of symptoms before dialling 999, triage category on arrival in A&E and disposal of patient. Ethical approval and statistical advice were obtained.

Results—91 NHS Direct generated 999 calls were identified. Of the comparison group (260 cases), 28 were excluded from the study. There were no differences in the triage categories assigned to the two groups on arrival in A&E. There were notable differences in presenting complaint between the two groups and in particular, trauma was less common among the NHS Direct patients (6.6%) compared with those who had self dialled (37.5%). Patients who had first called NHS Direct were younger (p=0.033) and had endured their symptoms for longer (p<0.001); they were less likely to be admitted, and if discharged, were less likely to have follow up arranged (p=0.014).

Conclusions—Both groups received similar triage categories suggesting that severity of illness is equally well assessed by self as by NHS Direct. There are large differences in case mix between the two groups studied and these almost certainly explain the differences in outcome.

     

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.

     

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.

     

Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews

Methods: Ambulance crews in two services were asked to transport appropriate patients to MIU during randomly selected weeks of one year. During all other weeks they were to treat such patients according to normal practice. Patients were followed up through ambulance service, hospital and/or MIU records, and by postal questionnaire. Semi-structured interviews were undertaken with crews (n = 15). Cases transferred from MIU to accident and emergency (A&E) were reviewed.

Results: 41 intervention cluster patients attended MIU, 303 attended A&E, 65 were not conveyed. Thirty seven control cluster patients attended MIU, 327 attended A&E, 61 stayed at scene. Because of low study design compliance, outcomes of patients taken to MIU were compared with those taken to A&E, adjusted for case mix. MIU patients were 7.2 times as likely to rate their care as excellent (95% CI 1.99 to 25.8). Ambulance service job-cycle time and time in unit were shorter for MIU patients (-7.8, 95% CI -11.5 to -4.1); (-222.7, 95%CI -331.9 to -123.5). Crews cited patient and operational factors as inhibiting MIU use; and location, service, patient choice, job-cycle time, and handover as encouraging their use. Of seven patients transferred by ambulance from MIU to A&E, medical reviewers judged that three had not met the protocol for conveyance to MIU. No patients were judged to have suffered adverse consequences.

Conclusions: MIUs were only used for a small proportion of eligible patients. When they were used, patients and the ambulance service benefited.