Emergency Department Attendance after Telephone Triage: A Population-Based Data Linkage Study.

OBJECTIVE: To investigate compliance with telephone helpline advice to attend an emergency department (ED) and the acuity of patients who presented to ED following a call. DATA SOURCES/COLLECTION METHODS: In New South Wales (NSW), Australia, 2009-2012, all (1.04 million) calls to a telephone triage service, ED presentations, hospital admissions and death registrations, linked using probabilistic data linkage. STUDY DESIGN: Population-based, observational cohort study measuring ED presentations within 24 hours of a call in patients (1) with dispositions to attend ED (compliance) and (2) low-urgency dispositions (self-referral), triage categories on ED presentation. PRINCIPAL FINDINGS: A total of 66.5 percent of patients were compliant with dispositions to attend an ED. A total of 6.2 percent of patients with low-urgency dispositions self-referred to the ED within 24 hours. After age adjustment, healthdirect compliant patients were significantly less likely (7.8 percent) to receive the least urgent ED triage category compared to the general NSW ED population (16.9 percent). CONCLUSIONS: This large population-based data linkage study provides precise estimates of ED attendance following calls to a telephone triage service and details the predictors of ED attendance. Patients who attend an ED compliant with a healthdirect helpline disposition are significantly less likely than the general ED population to receive the lowest urgency triage category on arrival.

The quality, safety and governance of telephone triage and advice services - an overview of evidence from systematic reviews.

BACKGROUND: Telephone triage and advice services (TTAS) are increasingly being implemented around the world. These services allow people to speak to a nurse or general practitioner over the telephone and receive assessment and healthcare advice. There is an existing body of research on the topic of TTAS, however the diffuseness of the evidence base makes it difficult to identify key lessons that are consistent across the literature. Systematic reviews represent the highest level of evidence synthesis. We aimed to undertake an overview of such reviews to determine the scope, consistency and generalisability of findings in relation to the governance, safety and quality of TTAS. METHODS: We searched PubMed, MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library for English language systematic reviews focused on key governance, quality and safety findings related to telephone based triage and advice services, published since 1990. The search was undertaken by three researchers who reached consensus on all included systematic reviews. An appraisal of the methodological quality of the systematic reviews was independently undertaken by two researchers using A Measurement Tool to Assess Systematic Reviews. RESULTS: Ten systematic reviews from a potential 291 results were selected for inclusion. TTAS was examined either alone, or as part of a primary care service model or intervention designed to improve primary care. Evidence of TTAS performance was reported across nine key indicators - access, appropriateness, compliance, patient satisfaction, cost, safety, health service utilisation, physician workload and clinical outcomes. Patient satisfaction with TTAS was generally high and there is some consistency of evidence of the ability of TTAS to reduce clinical workload. Measures of the safety of TTAS tended to show that there is no major difference between TTAS and traditional care. CONCLUSIONS: Taken as a whole, current evidence does not provide definitive answers to questions about the quality of care provided, access and equity of the service, its costs and outcomes. The available evidence also suggests that there are many interactional factors (e.g., relationship with other health service providers) which can impact on measures of performance, and also affect the external validity of the research findings.

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study.

BACKGROUND: Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call. METHODS: Records of calls to the Australian healthdirect helpline (July 2008-December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice "Attend ED immediately"; "See a doctor (immediately, within 4 hours, or within 24 hours)"; "Self-care"; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics. RESULTS: This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices "Attend ED immediately", "See a doctor" and "Self-care" were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice "Attend ED immediately" was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice "See a doctor" was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient's behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice "Self-care". The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED. CONCLUSIONS: Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance.

Service provider perceptions of transitioning from audio to video capability in a telehealth system: a qualitative evaluation.

BACKGROUND: Telephone consultation and triage services are increasingly being used to deliver health advice. Availability of high speed internet services in remote areas allows healthcare providers to move from telephone to video telehealth services. Current approaches for assessing video services have limitations. This study aimed to identify the challenges for service providers associated with transitioning from audio to video technology. METHODS: Using a mixed-method, qualitative approach, we observed training of service providers who were required to switch from telephone to video, and conducted pre- and post-training interviews with 15 service providers and their trainers on the challenges associated with transitioning to video. Two full days of simulation training were observed. Data were transcribed and analysed using an inductive approach; a modified constant comparative method was employed to identify common themes. RESULTS: We found three broad categories of issues likely to affect implementation of the video service: social, professional, and technical. Within these categories, eight sub-themes were identified; they were: enhanced delivery of the health service, improved health advice for people living in remote areas, safety concerns, professional risks, poor uptake of video service, system design issues, use of simulation for system testing, and use of simulation for system training. CONCLUSIONS: This study identified a number of unexpected potential barriers to successful transition from telephone to the video system. Most prominent were technical and training issues, and personal safety concerns about transitioning from telephone to video media. Addressing identified issues prior to implementation of a new video telehealth system is likely to improve effectiveness and uptake.

Medication-related calls received by a national telenursing triage and advice service in Australia: a retrospective cohort study.

BACKGROUND: Telenursing triage and advice services are increasingly being used to deliver health advice. Medication-related queries are common, however little research has explored the medication-related calls made to these services. The aim of this study was to examine the profile of medication-related calls to a national telenursing triage and advice service and the medications involved. METHODS: This was a retrospective cohort study of medication-related calls received by Australia's national helpline (healthdirect helpline) in 2014, which provides free advice from registered nurses. We examined the volume of medication-related calls over time, user profiles for patients and callers, and call characteristics and we also investigated medications involved in the calls by their generic names and therapeutic classes. RESULTS: Of 675,774 calls, 3.8% (n = 25,744) were medication-related, which was the largest category of calls. The average call length was 10 min. Over half of callers (55.4%) were advised to deliver self-care. Of 7,459 calls where the callers reported they did not know what to do prior to calling, 56.8% were advised to self-care and 3.5% were transferred to the Poisons Information Centre immediately. Of 1,277 calls where callers reported that they had originally intended to call an ambulance or attend an emergency department (ED), none were advised to do so. Advice most frequently requested was about analgesics and antipyretics, followed by non-steroidal anti-inflammatory agents. CONCLUSION: The telenursing triage and advice helpline offered quick and easily accessible advice, and provided reassurance to patients and callers with medication-related queries. The service also potentially diverted some patients from attending an ED unnecessarily.

Medication-related queries received for 'after hours GP helpline' - Comparison of callers' intentions with GPs' advice.

BACKGROUND: Limited studies have explored the actual usage of the 'after hours GP helpline' (AGPH). OBJECTIVE: The objectives of the article are to describe medication-related calls to the AGPH and compare callers' original intentions versus the advice provided by the general practitioner (GP). METHODS: We performed a detailed descriptive statistical analysis of medication-related queries received by the AGPH in 2014. RESULTS: In 2014, 13,600 medication-related calls were made to the national AGPH. For 86.56% of calls, GPs advised callers to either self-care only, or self-care overnight and see their GP during business hours. Of the 1442 calls where the caller had originally intended to visit the emergency department (ED), 76.70% were advised by GPs to self-care, and only 5.48% were advised to call 000 or visit an ED. Overall, less than 2.26% of callers were directed to the ED, despite 10.60% of people originally calling with this intention. DISCUSSION: The availability of an after-hours service potentially prevented 1363 people from unnecessarily attending an ED and directed 228 people who had originally underestimated the seriousness of their condition to an ED.

Healthdirect's After Hours GP Helpline - A Survey of Patient Satisfaction with the Service and Compliance with Advice.

The after hours GP helpline (AGPH), one of the key services provided by Healthdirect, is an extension of the existing healthdirect telephone nurse triage and advice service. It provides access to telephone health advice by GPs after hours to patients/callers who are triaged by the telephone nurse as needing to see a GP immediately, within four hours or within 24 hours. The aims of this study were to assess patient satisfaction with the AGPH service and compliance with the GP advice; and to investigate factors associated with patients' compliance. This study included 2486 patients/callers who used the AGPH and participated in a survey between February and September 2013. Over 97.1% of patients/callers were either satisfied or very satisfied with the AGPH service. Compliance was measured in two ways: i) self-reported compliance to advice provided; and ii) matching of self-reported actions with actual GP advice given: 94.0% of patients reported they followed the advice given to them by GPs and for 86.8% of patients their reported actions following consultations matched the recommended advice documented by GPs in the healthdirect database. Patients' compliance with recommended advice were associated with patient overall satisfaction with the service, the type of AGPH advice received, and the estimated severity level of the conditions. Improving patient satisfaction with the service along with patient understanding of the advice can lead to an increased compliance rate.

Evaluation of Web-Based Consumer Medication Information: Content and Usability of 4 Australian Websites.

BACKGROUND: Medication is the most common intervention in health care, and written medication information can affect consumers' medication-related behavior. Research has shown that a large proportion of Australians search for medication information on the Internet. OBJECTIVE: To evaluate the medication information content, based on consumer medication information needs, and usability of 4 Australian health websites: Better Health Channel, myDr, healthdirect, and NPS MedicineWise . METHODS: To assess website content, the most common consumer medication information needs were identified using (1) medication queries to the healthdirect helpline (a telephone helpline available across most of Australia) and (2) the most frequently used medications in Australia. The most frequently used medications were extracted from Australian government statistics on use of subsidized medicines in the community and the National Census of Medicines Use. Each website was assessed to determine whether it covered or partially covered information and advice about these medications. To assess website usability, 16 consumers participated in user testing wherein they were required to locate 2 pieces of medication information on each website. Brief semistructured interviews were also conducted with participants to gauge their opinions of the websites. RESULTS: Information on prescription medication was more comprehensively covered on all websites (3 of 4 websites covered 100% of information) than nonprescription medication (websites covered 0%-67% of information). Most websites relied on consumer medicines information leaflets to convey prescription medication information to consumers. Information about prescription medication classes was less comprehensive, with no website providing all information examined about antibiotics and antidepressants. Participants (n=16) were able to locate medication information on websites in most cases (accuracy ranged from 84% to 91%). However, a number of usability issues relating to website navigation and information display were identified. For example, websites not allowing combinations of search terms to be entered in search boxes and continuous blocks of text without subheadings. CONCLUSIONS: Of the 4 Australian health information websites tested, none provided consumers with comprehensive medication information on both prescription and nonprescription medications in a user-friendly way. Using data on consumer information needs and user testing to guide medication information content and website design is a useful approach to inform consumer website development.

Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.

INTRODUCTION: Methods for improving patient safety are predicated on cooperation between healthcare groups, but are the views of health professionals involved in promoting safety shared by other healthcare workforce staff and managers? AIM: To compare patient-safety suggestions from health workforce managerial and staff groups with those of patient-safety specialists. METHOD: Samples of managers (424) and staff (1214) in the South Australian state health system and 131 Australian patient-safety specialists were asked to write suggestions for improving patient safety. Group responses were content analysed and compared. RESULTS: Patient-safety specialists (83.2%) were more likely to make suggestions than were workforce managers (57.8%) or staff (44.1%). Workforce members from clinical professions were more likely than non-clinicians to tender suggestions. No relationship existed between the importance specialists and managers (ρ = -0.062, p = 0.880) and specialists and staff (ρ = -0.046, p = 0.912) attached to nine categories of suggestions. There was a high correlation between the importance that managers and non-managers attached to safety strategies (ρ = 0.817, p = 0.011). Among those who made suggestions, specialists were more likely to suggest implementing reviews and guidelines, and incident reporting. Workforce groups were more likely to recommend increased and improved staffing and staffing conditions, and better equipment and infrastructure. There were no significant differences in the proportions of group members recommending: improving management and leadership; increasing staff safety education and supervision; communication and teamwork; improved patient focus; or tackling specific safety projects. IMPLICATIONS: Differences between safety specialists' and workforce groups' beliefs about how to improve patient safety may impede the successful implementation of patient-safety programmes.

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study.

BACKGROUND: Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. OBJECTIVE: To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. DESIGN: Independent blinded assessment of these variables in a random, stratified sample of health service organisations. SETTINGS: Acute care: large, medium and small health-service organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. MAIN MEASURES: Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377). CONCLUSIONS: Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

Distributed leadership to mobilise capacity for accreditation research.

PURPOSE: Inquiries into healthcare organisations have highlighted organisational or system failure, attributed to poor responses to early warning signs. One response, and challenge, is for professionals and academics to build capacity for quality and safety research to provide evidence for improved systems. However, such collaborations and capacity building do not occur easily as there are many stakeholders. Leadership is necessary to unite differences into a common goal. The lessons learned and principles arising from the experience of providing distributed leadership to mobilise capacity for quality and safety research when researching health care accreditation in Australia are presented. DESIGN/METHODOLOGY/APPROACH: A case study structured by temporal bracketing that presents a narrative account of multi-stakeholder perspectives. Data are collected using in-depth informal interviews with key informants and ethno-document analysis. FINDINGS: Distributed leadership enabled a collaborative research partnership to be realised. The leadership harnessed the relative strengths of partners and accounted for, and balanced, the interests of stakeholder participants involved. Across three phases, leadership and the research partnership was enacted: identifying partnerships, bottom-up engagement and enacting the research collaboration. PRACTICAL IMPLICATIONS: Two principles to maximise opportunities to mobilise capacity for quality and safety research have been identified. First, successful collaborations, particularly multi-faceted inter-related partnerships, require distributed leadership. Second, the leadership-stakeholder enactment can promote reciprocity so that the collaboration becomes mutually reinforcing and beneficial to partners. ORIGINALITY/VALUE: The paper addresses the need to understand the practice and challenges of distributed leadership and how to replicate positive practices to implement patient safety research.

A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737].

BACKGROUND: Accreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted. METHODS/DESIGN: To understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multi-level, multi-disciplinary approach to assess the validity, impact and value of accreditation. DISCUSSION: The accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it.

Decentralised management structures - the physiotherapy experience at John Hunter Hospital.

In response to the increasingly competitive and demanding health environment, many Australian hospitals have implemented, or are considering, the implementation of organisational forms and management practices which call for the decentralisation of allied health services. From its early development, the John Hunter Hospital in Newcastle was planned to have a decentralised structure. In response to inquiries from many allied health professionals in New South Wales, Victoria and Western Australia, this paper discusses the difficulties experienced by physiotherapists working in this decentralised management structure and the rationale behind the decision to withdraw from such a structure and to form a centralised professional department.