title: Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?
abstract: BACKGROUND
  In recent years, there has been a growth in the use of triage nurses to decrease general practitioner (GP) workloads and increase the efficiency of telephone triage. The actual safety of decisions made by triage nurses has not yet been assessed.
  
  
  OBJECTIVE
  To investigate whether triage nurses accurately estimate the urgency level of health complaints when using the national telephone guidelines, and to examine the relationship between the performance of triage nurses and their education and training.
  
  
  METHODS
  A cross-sectional, multicentre, observational study employing five mystery (simulated) patients who telephoned triage nurses in four GP cooperatives. The mystery patients played standardised roles. Each role had one of four urgency levels as determined by experts. The triage nurses called were asked to estimate the level of urgency after the contact. This level of urgency was compared with a gold standard.
  
  
  RESULTS
  Triage nurses estimated the level of urgency of 69% of the 352 contacts correctly and underestimated the level of urgency of 19% of the contacts. The sensitivity and specificity of the urgency estimates provided by the triage nurses were found to be 0.76 and 0.95, respectively. The positive and negative predictive values of the urgency estimates were 0.83 and 0.93, respectively. A significant correlation was found between correct estimation of urgency and specific training on the use of the guidelines. The educational background (primary or secondary care) of the nurses had no significant relationship with the rate of underestimation.
  
  
  CONCLUSIONS
  Telephone triage by triage nurses is efficient but possibly not safe, with potentially severe consequences for the patient. An educational programme for triage nurses is recommended. Also, a direct second safety check of all cases by a specially trained GP telephone doctor is advisable.
authors.affiliation: Centre for Quality of Care Research, Radboud University Nijmegen, Nijmegen, The Netherlands. p.giesen@voha.umcn.nl
authors.forename: Paul
authors.initials: P
authors.lastname: Giesen
authors.forename: Rosa
authors.initials: R
authors.lastname: Ferwerda
authors.forename: Roelie
authors.initials: R
authors.lastname: Tijssen
authors.forename: Henk
authors.initials: H
authors.lastname: Mokkink
authors.forename: Roeland
authors.initials: R
authors.lastname: Drijver
authors.forename: Wil
authors.initials: W
authors.lastname: van den Bosch
authors.forename: Richard
authors.initials: R
authors.lastname: Grol
mesh_terms: D039602:After-Hours Care / Q000458:organization & administration / Q000592:standards*; D003299:Cooperative Behavior; D003430:Cross-Sectional Studies; D004630:Emergencies / Q000145:classification*; D005194:Family Practice / Q000458:organization & administration / Q000592:standards*; D006123:Group Practice; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D015277:Hotlines / Q000592:standards; D006801:Humans; D007600:Judgment; D009426:Netherlands; D009731:Nursing Audit; D009733:Nursing Diagnosis; D009740:Nursing Staff / Q000193:education / Q000592:standards*; D016544:Patient Simulation; D011320:Primary Health Care; D019114:Remote Consultation / Q000458:organization & administration / Q000592:standards*; D012449:Safety; D014218:Triage / Q000145:classification / Q000592:standards*