Discussion

The death of a previously well 13-month-old infant in 2006 shortly after his mother contacted the Queensland nurse led telephone triage call centre ‘13Health’ for advice is the first Australian death associated with telephone triage. This death was followed by a ‘near miss incident’ in 2007 in another Australian State. In this incident an adult female contacted the service for advice because of fever, myalgia and arthralgia. She was advised to take paracetamol to lower her temperature and go to bed. She called the service again because of increasing pain and was told to take a bath with two tablespoons of bicarbonate of soda for 20 min. After the bath she called an ambulance and was transported to hospital where she was successfully treated for her meningococcal infection.1

Australia is in the process of developing a national telephone triage call centre network by July 2011. This network is based upon the British NHS Direct nurse led telephone triage call centres which were established in 1998. The available literature on telephone triage call centres is confusing as there are several models of care that are either described, or indexed in the medical literature, as ‘telephone triage’. These include nurse led telephone triage call centres using computer prompted protocols, GP supervised nurse staffed call centres and afterhours call centres for either individual or groups of medical practitioners.

In addition there is no distinction made between giving health information by telephone, versus telephone advice as to whether or not to seek medical attention. The risks associated these separate functions are not equivalent as demonstrated by this case. Telephone triage assessments can be further hindered by the normal variations in English language skills and syntax in the community which can impact upon how individual's expresses their symptoms, and their responses to medical questioning. Several life threatening emergency medical conditions in adults and children may initially have vague or non-specific symptoms.2

Telephone triage ignores the important role of visual cues in assigning a triage priority to a patient's symptoms in the emergency department. The correlation between nurses performing telephone versus in-person triage in non-critically ill patients presenting to the emergency department is only 43.1%.3 Even when triage certified nurses used structured triage protocols combined with knowledge of a patient's vital signs the correlation between telephone versus in-person triage was still only 48.8%.3

All available evidence indicates that telephone triage call centres do not decrease, and may even increase emergency department presentations4 in the UK and New Zealand.5

Experience from Australia is that up to 36.4% of calls are advised to see a doctor immediately with 9.1% requiring emergency ambulance transport.6 In addition 5% of callers ignore the call centre advice and subsequently present to the emergency department despite being advised otherwise.7 Problems with telephone triage can arise because patients can be confused about when they need to call for an ambulance directly rather than call a telephone triage call centre.8 Call centre screening introduces avoidable delays for individuals with potentially time critical emergencies which would not exist if patients called for an ambulance directly.9 Delays in the treatment of time critical emergency can result in either potentially preventable deaths or unnecessarily complicate their medical treatment and hospital stay.2 9

Telephone triage call centres are beneficial by providing a single point of contact for health information for members of the community 24 h a day. In addition telephone triage call centres can help direct members of the community to a GP afterhours and allow GPs manage their afterhour's workload. For those hospitals that do not prohibit staff providing telephone advice, telephone triage call centres can provide a standardised advice service that relieves emergency department staff in these hospitals. Improved indexing of medical literature on telephone triage call centres is required to be able to ascertain what impacts telephone triage call centres have on patient outcomes, which has to be an integral consideration of any evaluation of these services.