Cellphone system for assessing chest troubles is unsafe and unreliable

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Phone system for assessing chest troubles is unsafe and unreliable

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A semi-automated phone triage system that helps people with breast discomfort outside of business hours is unsafe and unreliable, according to a study published in Open Heart magazine.

The severity of more than a quarter (27%) of patients with severe heart disease was underestimated by the phone system and required input from nurses to ensure better patient assessment, researchers from the Netherlands found.

Appropriate triage followed by early detection is critical for patients with acute chest discomfort who may have acute coronary syndrome (ACS) such as a heart attack or other life-threatening events such as pulmonary embolism (a blood clot in the lungs).

Telephone triage of such patients is sometimes done outside of business hours or in emergency care, but it can be challenging as it is difficult to distinguish acute coronary syndrome and other life-threatening events from other causes of chest pain.

Most western countries use a semi-automated computer triage system to aid telephone decision-making, in which triage nurses fill out a standard list of priority-ranked questions that is displayed after selecting the patient's main complaint in the computer system and the computer automatically generated a recommended urgency.

Since 2011, most outpatient basic services outside of business hours in the Netherlands and half of the emergency services have been using the Dutch triage system (NTS), which aims to ensure efficient and safe care.

The NTS appears to be safe with a very low serious adverse event rate, but the accuracy of the semi-automated assisted telephone triage with the Dutch system in primary care after business hours has never been validated from clinical outcomes.

Therefore, a team of researchers from the Julius Center for Health Sciences and Primary Care in Utrecht set out to evaluate the accuracy of phone triage on patients with breast problems who called the service.

Both the accuracy of the NTS tool and the "ultimate" urgency, including override by the triage nurses, were assessed.

They conducted a cross-sectional study of telephone calls with 2,023 patients with acute chest discomfort (pain, pressure, tension or discomfort) who used services outside of business hours for basic care between 2014 and 2016.

Any diagnoses were taken from the medical records of the patients in general medicine, including the discharge letters from the hospital specialists.

Analysis of the results revealed that of the 2,023 patients who called, 227 (11.2%) had acute coronary syndrome (men 14.9%, women 8.2%) and 58 (2.9%) had another life-threatening syndrome Event (men 3.6%, women 2.3%).

The researchers found that the safety and efficiency of the NTS decision support tool for phone triage was poor in patients with acute chest discomfort.

The tool underestimated the urgency in 27% of patients with acute coronary syndrome and other life-threatening events.

In 13.2% of the calls, the triage nurse overridden the NTS urgency, mostly through upscaling (11%).

When the tool was overridden by nurses it improved safety, but there were still 14% of people with these severe cardiac situations who were assigned too little urgency while efficiency remained poor.

The researchers recognized that a low urgency distribution did not necessarily mean that the acute coronary syndrome was overlooked, but that it posed an undesirable risk to patient safety, with the potential for life-threatening ventricular arrhythmias and sudden death from severe heart failure for those who have had a heart attack to have.

They concluded, "Semi-automated assisted telephone triage in primary care for patients with breast disorders is not safe or efficient.

"The 'human factor' contributes to security in the current telephone triage process. Nonetheless, the potential for improvement should be explored, both for the decision support tool itself by developing better rules for diagnostic prediction and by improving it its use by triage nurses and management. "Blind trust" in decision support systems should be replaced by critical use. "

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More information:
Accuracy of Telephone Triage in Primary Care Patients with Breast Discomfort: A Cross-sectional Study, Open Heart, DOI: 10.1136 / openhrt-2020-001376

Provided by
British Medical Journal

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