NHS Direct: consistency of triage outcomes.
OBJECTIVE
To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct.


METHODS
119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System.


RESULTS
The overall level of agreement between the nurses using the four systems was "fair" rather than "moderate" or "good" (kappa=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services.


CONCLUSIONS
There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved.
Medical Care Research Unit, University of Sheffield, Sheffield, UK. a.ocathain@sheffield.ac.uk
A
A
O'Cathain
E
E
Webber
J
J
Nicholl
J
J
Munro
E
E
Knowles
D000328:Adult; D001291:Attitude of Health Personnel; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical / Q000592:standards*; D003936:Diagnosis, Computer-Assisted / Q000592:standards*; D004631:Emergency Medical Service Communication Systems; D004636:Emergency Service, Hospital; D005260:Female; D015277:Hotlines / Q000592:standards*; D006801:Humans; D009740:Nursing Staff / Q000523:psychology*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000592:standards; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012984:Software; D013222:State Medicine; D014218:Triage / Q000379:methods / Q000592:standards*; D006113:United Kingdom