Télécharger le rapport (152 p.) - KCE
Télécharger le rapport (152 p.) - KCE
Télécharger le rapport (152 p.) - KCE
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>KCE</strong> reports vol. 19B Urgences 23<br />
Washington et al. 94 sought to develop and validate standardized clinical criteria to<br />
identify patients presenting to the emergency department whose care may be safely<br />
deferred to a later date in a nonemergency setting. In a prospective cohort design,<br />
emergency nurses at a tertiary care Veterans Administration Medical Centre screened<br />
1,187 consecutive ambulatory adult patients presenting with abdominal pain,<br />
musculoske<strong>le</strong>tal symptoms, or respiratory infection symptoms. Patients meeting<br />
deferred-care criteria were offered the option of an appointment within 1 week in the<br />
ambulatory care clinic at the study site; all other patients were offered same-day care.<br />
Two hundred twenty-six (19%) patients met screening criteria for deferred care.<br />
Patients meeting deferred-care criteria experienced zero (95% confidence interval, 0%<br />
to 1.2%) related none<strong>le</strong>ctive hospitalisations within 7 days of evaluation, and none died<br />
within 30 days. By contrast, 68 (7%) of 961 (95% confidence interval, 5.5% to 8.9%)<br />
patients who did not meet deferred-care criteria were hospitalised none<strong>le</strong>ctively for<br />
related conditions, and 5 (0.5%) died. The authors concluded that using hospitalisation<br />
and 30-day mortality as safety gauges, standardised clinical criteria can identify, at<br />
presentation, ED users who may be safely cared for at a later date in a nonemergency<br />
setting.<br />
Te<strong>le</strong>phone triage or consultation and te<strong>le</strong>medicine.<br />
Te<strong>le</strong>phone consultation is the process where calls are received, assessed and managed<br />
by giving advice or by referral to a more appropriate service. There has been a growth<br />
in te<strong>le</strong>phone consultation, in part, as a response to increased demand for General<br />
Practitioner (GP) and Accident and Emergency (A&E) department care. The te<strong>le</strong>phone<br />
consultation is established in the UK, USA, Canada, Scandinavia, Australia, The<br />
Netherlands and in Israël 89 .Te<strong>le</strong>phone consultation services work separately from<br />
emergency call centres receiving emergency calls via the emergency phone number.<br />
Te<strong>le</strong>medicine is delivery of health services via remote te<strong>le</strong>communications 89 and<br />
includes interactive consultative and diagnostic services. Te<strong>le</strong>medicine is proposed to<br />
have a real potential to reduce immediate medical workload 95 , and to reduce costs by<br />
saving consultations and visits 96 . Te<strong>le</strong>medicine has only been investigated so far as a tool<br />
for direct and interactive te<strong>le</strong>communication between physicians 97-99 or between<br />
prehospital services and ED 100 The ro<strong>le</strong> of te<strong>le</strong>medicine as a triage tool for patients in<br />
the prehospital phase has not yet been studied.<br />
Seven studies quoted in a systematic review on the effects of te<strong>le</strong>phone consultation<br />
out of the emergency department 101, 102, 95 looked at accident and emergency<br />
department visits; six showed no difference between the groups and one, of nurse<br />
te<strong>le</strong>phone consultation, found an increase in visits. Two studies reported deaths and<br />
found no difference between nurse te<strong>le</strong>phone triage and normal care. It was concluded<br />
that te<strong>le</strong>phone consultation appears to reduce the number of GP surgery contacts and<br />
out-of-hours visits by general practitioners. However, questions remain about its affect<br />
on emergency department service use and further rigorous evaluation is needed with<br />
emphasis on service use, safety, cost and patient satisfaction.<br />
Computerized algorithms have been developed to assess the patientÊs condition and the<br />
subsequent decision-making. In a recent RCT 103 , the use of computerized algorithms by<br />
a trained nurse integrated within a GP-cooperative was compared with standard care.<br />
Da<strong>le</strong> et al. assessed the safety of nurses and paramedics offering te<strong>le</strong>phone assessment,<br />
triage, and advice as an alternative to immediate ambulance dispatch for emergency<br />
ambulance service cal<strong>le</strong>rs. It was found that te<strong>le</strong>phone advice may be a safe method of<br />
managing many cal<strong>le</strong>rs to ambulance services with non-serious prob<strong>le</strong>ms. However, a<br />
clinical trial of the full imp<strong>le</strong>mentation of this intervention is needed, large enough to<br />
exclude the possibility of rare adverse events.<br />
An observational before and after study assessed the impact of NHS Direct , the<br />
national, nurse <strong>le</strong>d te<strong>le</strong>phone helpline, on the use of accident and emergency, ambulance,<br />
and general practitioner cooperative services 104 . Changes in use of accident and<br />
emergency departments and ambulance services after introduction of NHS Direct were<br />
small and non-significant. In its first year NHS Direct did not reduce the pressure on<br />
NHS immediate care services, although it may have restrained increasing demand on<br />
one important part-general practitioners' out of hours services.