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KCE reports vol. 19B Urgences 23
Washington et al. 94 sought to develop and validate standardized clinical criteria to
identify patients presenting to the emergency department whose care may be safely
deferred to a later date in a nonemergency setting. In a prospective cohort design,
emergency nurses at a tertiary care Veterans Administration Medical Centre screened
1,187 consecutive ambulatory adult patients presenting with abdominal pain,
musculoskeletal symptoms, or respiratory infection symptoms. Patients meeting
deferred-care criteria were offered the option of an appointment within 1 week in the
ambulatory care clinic at the study site; all other patients were offered same-day care.
Two hundred twenty-six (19%) patients met screening criteria for deferred care.
Patients meeting deferred-care criteria experienced zero (95% confidence interval, 0%
to 1.2%) related nonelective hospitalisations within 7 days of evaluation, and none died
within 30 days. By contrast, 68 (7%) of 961 (95% confidence interval, 5.5% to 8.9%)
patients who did not meet deferred-care criteria were hospitalised nonelectively for
related conditions, and 5 (0.5%) died. The authors concluded that using hospitalisation
and 30-day mortality as safety gauges, standardised clinical criteria can identify, at
presentation, ED users who may be safely cared for at a later date in a nonemergency
setting.
Telephone triage or consultation and telemedicine.
Telephone consultation is the process where calls are received, assessed and managed
by giving advice or by referral to a more appropriate service. There has been a growth
in telephone consultation, in part, as a response to increased demand for General
Practitioner (GP) and Accident and Emergency (A&E) department care. The telephone
consultation is established in the UK, USA, Canada, Scandinavia, Australia, The
Netherlands and in Israël 89 .Telephone consultation services work separately from
emergency call centres receiving emergency calls via the emergency phone number.
Telemedicine is delivery of health services via remote telecommunications 89 and
includes interactive consultative and diagnostic services. Telemedicine is proposed to
have a real potential to reduce immediate medical workload 95 , and to reduce costs by
saving consultations and visits 96 . Telemedicine has only been investigated so far as a tool
for direct and interactive telecommunication between physicians 97-99 or between
prehospital services and ED 100 The role of telemedicine as a triage tool for patients in
the prehospital phase has not yet been studied.
Seven studies quoted in a systematic review on the effects of telephone consultation
out of the emergency department 101, 102, 95 looked at accident and emergency
department visits; six showed no difference between the groups and one, of nurse
telephone consultation, found an increase in visits. Two studies reported deaths and
found no difference between nurse telephone triage and normal care. It was concluded
that telephone consultation appears to reduce the number of GP surgery contacts and
out-of-hours visits by general practitioners. However, questions remain about its affect
on emergency department service use and further rigorous evaluation is needed with
emphasis on service use, safety, cost and patient satisfaction.
Computerized algorithms have been developed to assess the patientÊs condition and the
subsequent decision-making. In a recent RCT 103 , the use of computerized algorithms by
a trained nurse integrated within a GP-cooperative was compared with standard care.
Dale et al. assessed the safety of nurses and paramedics offering telephone assessment,
triage, and advice as an alternative to immediate ambulance dispatch for emergency
ambulance service callers. It was found that telephone advice may be a safe method of
managing many callers to ambulance services with non-serious problems. However, a
clinical trial of the full implementation of this intervention is needed, large enough to
exclude the possibility of rare adverse events.
An observational before and after study assessed the impact of NHS Direct , the
national, nurse led telephone helpline, on the use of accident and emergency, ambulance,
and general practitioner cooperative services 104 . Changes in use of accident and
emergency departments and ambulance services after introduction of NHS Direct were
small and non-significant. In its first year NHS Direct did not reduce the pressure on
NHS immediate care services, although it may have restrained increasing demand on
one important part-general practitioners' out of hours services.