Diabetes and risk of acute coronary syndrome in callers with chest discomfort: Cross-sectional study in out-of-hours primary care.

AIMS: We investigated the differences in prevalence of acute coronary syndrome (ACS) by presence versus absence of diabetes in males and females with chest discomfort who called out-of-hours primary care (OHS-PC). METHODS: A cross-sectional study performed in the Netherlands. Patients who called the OHS-PC in the Utrecht region, the Netherlands between 2014 and 2017 with acute chest discomfort were included. We compared those with diabetes with those without diabetes. Multivariable logistic regression was used to determine the relation between diabetes and (i) high urgency allocation and (ii) ACS. RESULTS: Of the 2,195 callers with acute chest discomfort, 180 (8.2%) reported having diabetes. ACS was present in 15.3% of males (22.0% in those with diabetes) and 8.4% of females (18.8% in those with diabetes). Callers with diabetes did not receive a high urgency more frequently (74.4% vs. 67.8% (OR: 1.38; 95% CI 0.98-1.96). However, such callers had a higher odds for ACS (OR: 2.17; 95% CI 1.47-3.19). These differences were similar for females and males. CONCLUSIONS: Diabetes holds promise as diagnostic factor in callers to OHS-PC with chest discomfort. It might help triage in this setting given the increased risk of ACS in those with diabetes.

Accuracy of urgency allocation in patients with shortness of breath calling out-of-hours primary care: a cross-sectional study.

BACKGROUND: In out-of-hours primary care (OHS-PC), semi-automatic decision support tools are often used during telephone triage. In the Netherlands, the Netherlands Triage Standard (NTS) is used. The NTS is mainly expert-based and evidence on the diagnostic accuracy of the NTS' urgency allocation against clinically relevant outcomes for patients calling with shortness of breath (SOB) is lacking. METHODS: We included data from adults (≥18 years) who contacted two large Dutch OHS-PC centres for SOB between 1 September 2020 and 31 August 2021 and whose follow-up data about final diagnosis could be retrieved from their own general practitioner (GP). The diagnostic accuracy (sensitivity and specificity with corresponding 95% confidence intervals (CI)) of the NTS' urgency levels (high (U1/U2) versus low (U3/U4/U5) and 'final' urgency levels (including overruling of the urgency by triage nurses or supervising general practitioners (GPs)) was determined with life-threatening events (LTEs) as the reference. LTEs included, amongst others, acute coronary syndrome, pulmonary embolism, acute heart failure and severe pneumonia. RESULTS: Out of 2012 eligible triage calls, we could include 1833 adults with SOB who called the OHS-PC, mean age 53.3 (SD 21.5) years, 55.5% female, and 16.6% showed to have had a LTE. Most often severe COVID-19 infection (6.0%), acute heart failure (2.6%), severe COPD exacerbation (2.1%) or severe pneumonia (1.9%). The NTS urgency level had a sensitivity of 0.56 (95% CI 0.50-0.61) and specificity of 0.61 (95% CI 0.58-0.63). Overruling of the NTS' urgency allocation by triage nurses and/or supervising GPs did not impact sensitivity (0.56 vs. 0.54, p = 0.458) but slightly improved specificity (0.61 vs. 0.65, p < 0.001). CONCLUSIONS: The semi-automatic decision support tool NTS performs poorly with respect to safety (sensitivity) and efficiency (specificity) of urgency allocation in adults calling Dutch OHS-PC with SOB. There is room for improvement of telephone triage in patients calling OHS-PC with SOB. TRIAL REGISTRATION: The Netherlands Trial Register, number: NL9682 .

Shortness of breath as a diagnostic factor for acute coronary syndrome in male and female callers to out-of-hours primary care.

OBJECTIVE: Chest discomfort and shortness of breath (SOB) are key symptoms in patients with acute coronary syndrome (ACS). It is, however, unknown whether SOB is valuable for recognising ACS during telephone triage in the out-of-hours primary care (OHS-PC) setting. METHODS: A cross-sectional study performed in the Netherlands. Telephone triage conversations were analysed of callers with chest discomfort who contacted the OHS-PC between 2014 and 2017, comparing patients with SOB with those who did not report SOB. We determine the relation between SOB and (1) High urgency allocation, (2) ACS and (3) ACS or other life-threatening diseases. RESULTS: Of the 2195 callers with chest discomfort, 1096 (49.9%) reported SOB (43.7% men, 56.3% women). In total, 15.3% men (13.2% in those with SOB) and 8.4% women (9.2% in those with SOB) appeared to have ACS. SOB compared with no SOB was associated with high urgency allocation (75.9% vs 60.8%, OR: 2.03; 95% CI 1.69 to 2.44, multivariable OR (mOR): 2.03; 95% CI 1.69 to 2.44), but not with ACS (10.9% vs 12.0%; OR: 0.90; 95% CI 0.69 to 1.17, mOR: 0.91; 95% CI 0.70 to 1.19) or 'ACS or other life-threatening diseases' (15.0% vs 14.1%; OR: 1.07; 95% CI 0.85 to 1.36, mOR: 1.09; 95% CI 0.86 to 1.38). For women the relation with ACS was 9.2% vs 7.5%, OR: 1.25; 95% CI 0.83 to 1.88, and for men 13.2% vs 17.4%, OR: 0.72; 95% CI 0.51 to 1.02. For 'ACS or other life-threatening diseases', this was 13.0% vs 8.5%, OR: 1.60; 95% CI 1.10 to 2.32 for women, and 7.5% vs 20.8%, OR: 0.81; 95% CI 0.59 to 1.12 for men. CONCLUSIONS: Men and women with chest discomfort and SOB who contact the OHS-PC more often receive high urgency than those without SOB. This seems to be adequate in women, but not in men when considering the risk of ACS or other life-threatening diseases.

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study.

OBJECTIVE: To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC). DESIGN: Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects. SETTING: Seven OHS-PC in the Netherlands. PARTICIPANTS: 2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed. PRIMARY AND SECONDARY OUTCOMES MEASURES: Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses. RESULTS: Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration. CONCLUSION: The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC. TRIAL REGISTRATION NUMBER: NTR7331.

Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care: Lessons From A Case-Control Study.

OBJECTIVES: Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hindsight bias. This study compared the recorded triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS. METHODS: A case-control study with data from 2013 to 2017 of 9 OHS-PC in the Netherlands. The cases were matched 1:8 with controls based on age and sex. Clinical, patient, and call characteristics were univariably assessed, and general practitioner experts evaluated the triage while blinded to the final diagnosis or the case-control status. RESULTS: Fifteen missed ACS calls and 120 matched control calls were included. Cases used less cardiovascular medication (38.5% versus 64.1%, P = 0.05) and more often experienced pain other than retrosternal chest pain (63.3% versus 24.7%, P = 0.02) compared with controls. Consultation of the supervising general practitioner (86.7% versus 49.2%, P = 0.02) occurred more often in cases than in controls. Experts rated the triage of cases more often as "poor" (33.3% versus 10.9%, P = 0.001) and "unsafe" (73.3% versus 22.5%, P < 0.001) compared with controls. CONCLUSIONS: To facilitate learning from serious adverse events in the future, these should also be bundled and carefully assessed without hindsight bias and within the context of "normal" clinical practice.

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study.

OBJECTIVES: To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men. DESIGN: Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS. SETTING: Nine OHS-PC in the Netherlands. PARTICIPANTS: 993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016. PRIMARY OUTCOME MEASURE: Diagnosis of ACS retrieved from the patient's medical record in general practice, including hospital specialists' discharge letters. RESULTS: Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%). CONCLUSION: Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses. TRIAL REGISTRATION NUMBER: NTR7331.

Interactional implications of either/or-questions during telephone triage of callers with chest discomfort in out-of-hours primary care: A conversation analysis.

OBJECTIVE: To explore the interactional implications of either/or-questions on the interaction between people who call out-of-hours services in primary care (OHS-PC) and triage nurses who use a decision support tool called the 'Netherlands Triage Standard' (NTS) during telephone triage. METHODS: A qualitative study of 68 triage conversations at six Dutch OHS-PC. Patients called the OHS-PC with symptoms, e.g. chest discomfort, suggestive of acute coronary syndrome. Using conversation analysis, we identified two categories of multiple-choice either/or-questions that indicated interactional difficulties, shown in hesitation markers within callers' responses. RESULTS: Our analysis shows that interactional difficulties mainly arise when (i) questions are poorly designed by the triage nurse; or (ii) when the caller's complaints are ambiguously presented reflecting patient's difficulties to verbalize them (e.g. "not feeling well"). CONCLUSION: The way NTS displays key diagnostic options encourages triage nurses to use multiple-choice either/or-questions. More awareness among triage nurses is needed on undesirable implications of either/or-questions on the interaction. PRACTICE IMPLICATIONS: We recommend changing the NTS display of diagnostic options and to use questions with fewer options in order to decrease the chance of formulating ambiguous questions soliciting unclear responses. Furthermore, asking content questions when complaints are ambiguously formulated may specify the presentation of complaints.

Accuracy of telephone triage in patients suspected of transient ischaemic attack or stroke: a cross-sectional study.

BACKGROUND: The Netherlands Triage Standard (NTS) is a widely used decision support tool for telephone triage at Dutch out-of-hours primary care services (OHS-PC), which, however, has never been validated against clinical outcomes. We aimed to determine the accuracy of the NTS urgency allocation for patients with neurological symptoms suggestive of a transient ischaemic attack (TIA) or stroke, with the clinical outcomes TIA, stroke, and other (neurologic) life-threatening events (LTEs) as the reference. METHOD: A cross-sectional study of telephone triage recordings of patients with neurological symptoms calling the OHS-PC between 2014 and 2016.The allocated NTS urgencies were derived from the electronic medical records of the OHS-PC. The clinical outcomes were retrieved from the electronic medical records of the patients' own general practitioners. The accuracy of a high NTS urgency allocation (medical help within 3 h) was calculated in terms of sensitivity, specificity, positive and negative predictive values (PPV and NPV) with the clinical outcomes TIA/stroke/other LTEs as the reference. RESULTS: Of 1269 patients, 635 (50.0%) received the diagnosis TIA/stroke (34.2% TIA/minor stroke, 15.8% major ischaemic or haemorrhagic stroke), and 4.8% other LTEs. For TIA/stroke/other LTEs, the sensitivity and specificity of the NTS urgency allocation were 0.72 (95%CI 0.68-0.75) and 0.48 (95%CI 0.43-0.52), and the PPV and NPV were 0.62 (95%CI 0.60-0.64) and 0.58 (95%CI 0.54-0.62). CONCLUSIONS: The NTS decision support tool used in Dutch OHS-PC performed poor to moderately regarding safety (sensitivity) and efficiency (specificity) in allocating adequate urgencies to patients with and without TIA/stroke/other LTEs. TRIAL REGISTRATION: The Netherlands National Trial Register, identification number NTR7331 /Trial NL7134 .

Limited reliability of experts' assessment of telephone triage in primary care patients with chest discomfort.

OBJECTIVE: Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability. STUDY DESIGN AND SETTING: This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation. RESULTS: In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32). CONCLUSIONS: Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations.

BACKGROUND: During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful. OBJECTIVE: To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk. METHODS: Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient's general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age. RESULTS: The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39-2.34, P < 0.001): 2.33 (1.68-3.22, P < 0.001) for men and 1.29 (0.83-1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07-3.10, P = 0.039). CONCLUSIONS: Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more 'straightaway' could be considered for these patients with chest discomfort. TRIAL NUMBER: NTR7331.

Tinkering and overruling the computer decision support system: Working strategies of telephone triage nurses who assess the urgency of callers suspected of having an acute cardiac event.

AIMS AND OBJECTIVES: To understand clinical reasoning and decision-making of triage nurses during telephone conversations with callers suspected of having acute cardiac events, and support from a computer decision support system (CDSS) herewith. BACKGROUND: In telephone triage, nurses assess the urgency of callers' conditions with clinical reasoning, often supported by CDSS. The use of CDSS may trigger interactional workability dilemmas. DESIGN: Qualitative study using principles of a grounded theory approach following COREQ criteria for qualitative research. METHODS: Audio-stimulated recall interviews were conducted amongst twenty-four telephone triage nurses at nine out-of-hours primary care centres (OHS-PC). RESULTS: Telephone triage nurses use clinical reasoning elements for urgency assessment. Typically in telephone triage, they interpret the vocal-but not worded-elements in communication (paralanguage) such as tone of voice and shortness of breath and create a mental image to compensate for lack of visual information. We confirmed that interactional workability dilemmas occur. Congruence, established when the CDSS supports the triage nurses' decision-making, is essential for the CDSS' value. If congruence is absent, triage nurses may apply four working strategies: (a) tinker to make CDSS final recommendation align with their own assessment, (b) overrule the CDSS recommendation, (c) comply with the CDSS recommendation or (d) transfer responsibility to the GP. CONCLUSION: Triage nurses who assess urgency may experience absence of congruence between the CDSS and their decision-making. Awareness of how triage nurses reason and make decisions about urgency and what aspects influence their working strategies can help in achieving optimal triage of callers suspected of acute cardiac events at OHS-PC. RELEVANCE TO CLINICAL PRACTICE: Triage nurses' reasoning and their working strategies are vital for outcome of triage decisions. Understanding these processes is essential for CDSS developers and OHS-PC managers, who should value how triage nurses interact with the CDSS, while they have the benefit of callers in mind.

Pilot study on identification of incidents in healthcare transitions and concordance between medical records and patient interview data.

OBJECTIVE: To investigate whether transitional incidents can be identified from the medical records of the general practitioners and the hospital and to assess the concordance of transitional incidents between medical records and patient interviews. DESIGN: A pilot study. SETTING: The study was conducted in 2 regions in the Netherlands: a rural and an urban region. PARTICIPANTS: A purposeful sample of patients who experienced a transitional incident or are at high risk of experiencing transitional incidents. MAIN OUTCOME MEASURES: Transitional incidents were identified from both the interviews with patients and medical records and concordance was assessed. We also classified the transitional incidents according to type, severity, estimated cause and preventability. RESULTS: We identified 28 transitional incidents within 78 transitions of which 3 could not be found in the medical records and another 5 could have been missed without the patient as information source. To summarise, 8 (29%) incidents could have been missed using solely medical records, and 7 (25%) using the patients' information exclusively. Concordance in transitional incidents between patient interviews and medical records was 64% (18/28). The majority of the transitional incidents were unsafe situations; however, 43% (12/28) of the incidents reached the patient and 18% (5/28) caused temporary patient harm. Over half of the incidents were potentially preventable. CONCLUSIONS: This pilot study suggests that the majority of transitional incidents can be identified from medical records of the general practitioner and hospital. With this information, we aim to develop a measurement tool for transitional incidents in the medical record of general practitioner and hospital.