Quality monitoring of nurse telephone triage: pilot study

Background.  Nurse telephone triage is a popular way of managing workload in primary care and has been shown to be as safe as general practitioner (GP)-delivered alternatives. No studies have tested a routine method of assessing the quality of decision-making by triage nurses in primary care. Aims.  The aim of this paper is to describe a study to evaluate accuracy and utility of audiotaping telephone consultations to assess the quality of decisions made by practice nurses triaging same day appointment requests in routine practice. Method.  An observational study was carried out using external assessment by GPs and nurse practitioners of triage quality in 218 audiotaped nurse telephone triage consultations. Results.  There were high levels of agreement between triage nurses and assessors on identifying the presenting problem. However, there were only moderate levels of agreement between GPs and nurse assessors both on level of information sought (kappa = 0·434) and appropriateness of outcome (kappa = 0·614). Assessors rated information-gathering as poor in 19·3% of calls (95% confidence interval 14·6 to 25·0), and seven (3·2%) consultations were rated as potentially dangerous (95% confidence interval 1·6 to 6·5). A 1% sample of all consultations would have a probability of 0·48 of identifying unsafe consultations and 0·99 probability of identifying consultations with poor information-gathering. Conclusions.  External assessment of triage quality may be of only moderate accuracy and reliability. Nonetheless, considerable information can be gleaned from assessing audiotapes to assess consultation quality. Even where nurses are generally highly skilled and competent, a 1% review of triage consultations would be sufficient to identify their information-gathering learning needs in relation to patients’ presenting problems. Audio-taped consultations could be an important part of clinical governance strategies.