Telephone triage is not the answer to ED overcrowding

Health call centres using decision support information technology have been introduced in a number of countries ostensibly to provide standardized advice to patients in an attempt to assist in managing demand for health-care services and facilitate equity of access.1 A National Health Call Centre Network (healthdirect Australia), announced in February 2006,2 has evolved as an initiative of the Council of Australian Governments. This budget initiative of $176.4m over 5 years has been implemented by the Australian Federal Government amidst a continuing publicity blitz3–6 and is a free 24 h, 7 days a week, national telephone triage service, which gives callers advice from registered nurses according to structured algorithms with disposition options ranging from ‘call an ambulance immediately’ to ‘medical care not required’. A similar service, Healthline, also commenced in New Zealand in 2001.7 On 1 July 2011, the Australian Government extended the healthdirect Australia service by adding general practitioner support to the nurse-led telephone triage service, as a new after-hours GP helpline,8 at an additional cost of $50m over 3 years. A frequently stated benefit of the healthdirect Australia National Health Call Centre Network is to ‘act as a filter to direct people to appropriate sources of care, helping to ease demand on emergency wards and general practice’,5 particularly by diverting non-urgent, low-acuity patients from attending EDs.9,10 There is no evidence to support these claims – in fact, the evidence is to the contrary. Attendances at Australian EDs are increasing at rates faster than population growth, a phenomenon that many nations with highly developed health-care systems are experiencing.11 ED attendances between 2005–2006 and 2010–2011 grew by 25.8%, whereas the population only grew by 9.3%. A number of interrelated factors are postulated to drive this growth in demand and cause increased ED overcrowding.12 Unfortunately, an enduring myth is that EDs are overrun with patients who could have received care in a general practice setting,12–15 and policies have been made based on this invalid assumption. Such policy initiatives have included stand-alone GP casualties, co-located GP clinics with EDs, GP Super Clinics and nurse walk-in-centres co-located with an ED.16–20 Formal studies to determine the effects of such initiatives are rare, although a recent review found that there was no evidence that they reduced ED demand.21 The GP casualty model has been clearly disproven as an alternative to properly set up EDs.22 An analysis by Richardson23 showed that the introduction of a Canberra nurse walk-in-centre led to an increase in patient attendances at the co-located ED. After a year of operation, still no decrease was seen in ED attendances.24 The latest healthdirect Australia quarterly report card shows the service only advised 22% of patients to stay at home, whereas over 67% were advised to seek medical care in 24 h or less.25 The recent media release from the Federal Health Minister's Office stated that ‘because of the clinical advice which the GPs on the helpline can provide, thepercentage of people who were then referred on to EDs or after hours medical services was reduced from 62% to 35% – a reduction of 27% or more than 20 000 people since it was introduced in July 2011’.9 This represents less than 0.6% of total ED presentations, based on 2010–2011 Australian hospital statistics.26 Furthermore, the only conclusion that can be drawn from the Minister's statement is that the nurse-led telephone advice line was seriously over-referring patients for emergency and urgent care. No public study has been undertaken to determine the influence of healthdirect Australia on Australian ED attendances, although there are many reports on the effect of health call centres from a range of Australian states and internationally. A study by Sprivulis et al. in 2004 showed that the implementation of the healthdirect telephone triage service in Western Australia had limited capacity to influence ED use or workload.27 Ng et al. came to the same conclusion in their Western Australian study.28 Interestingly, Ng et al. showed that self-presenting ED patients had a very similar profile to healthdirect-referred patients. This may imply that patients realize when they need emergency care and call the telephone advice line to confirm this belief, a conclusion also suggested by Ström et al.29 A study of the New Zealand Healthline showed no effect on ED attendances.30 De Coster et al. showed that only 52% of patients advised to present to an ED by the Nurse Telephone Advice line in Calgary, Canada actually presented to an ED.31 Even fewer who were advised to see a doctor within 24 h did (43%). Munro et al. found no effect on NHS immediate care services following the introduction of NHS Direct telephone and digitally delivered health services.32 A Cochrane review in 200433 identified seven studies examining the effect of telephone triage on ED visits. Six studies showed no effect and one study showed an increase in presentations to the ED. No study demonstrated a decrease in ED visits. Advice prepared for Australian Health Ministers before the introduction of healthdirect Australia stated that ‘direct evidence that call centres have reduced unnecessary demands on emergency departments, along with the costs and possibly the effectiveness of treatment of those cases where emergency treatment is appropriate, is weak and patchy’.34 Despite the Government's own advice that there is no good evidence that call centres reduce ED demand, the Government continues to misrepresent this in publicity of the after-hours GP helpline. Low-acuity patients are not the major problem for most EDs. As has been pointed out previously,12 it is difficult to quantify the true number of low acuity/low complexity patients who attend EDs, but the figure in most metropolitan EDs is low. Furthermore, these patients suffer uncomplicated conditions that are quick, easy and cheap to treat in EDs,35 particularly if the EDs use fast-track streaming36,37 approaches. Such patients account for a small fraction of the total ED workload and less than 5% of avoidable total costs of providing emergency services in Australia.15 Access block, not low-acuity patients, is the key driver of ED overcrowding, staff stress, patient distress and increased mortality and morbidity.12,13,35 Access block occurs when patients who have received their emergency care and need a hospital bed remain in the ED because no beds are available in the hospital.38 Low-acuity patients do not contribute to access block as generally they require only a small amount of time to be examined and treated in the ED and are rarely admitted. Therefore, telephone advice lines, even if they did reduce the number of people presenting to EDs (and the evidence quoted above suggests that this doesn't occur), are unlikely to reduce ED pressures. Addressing access block by providing funding for an increase in hospital beds along with innovative ways of managing patients needing domiciliary care, and better support for these patients in community setting will have the greatest positive effect on EDs and patient outcomes. The Rural Doctors’ Association has calculated that it costs the taxpayer approximately $1000 for each person the after-hours GP helpline tells not to attend an ED.39 This is a very large amount, well above the marginal cost of providing treatment to these patients in the ED.35 It is very likely to be more effective and cost-efficient to allow this small number of patients to attend the ED rather than spend over $200m to ineffectively attempt to divert these patients to alternative care with a strategy that has not worked anywhere else in the world.30,32–34 There is no strong evidence that telephone triage improves clinical outcomes,33,34 so when the patient's problem is not resolved by the telephone triage, they are likely to attend multiple agencies, including the ED, in an attempt to solve their health problem. The evidence quoted above shows that it is likely that these patients would have presented to an ED regardless of the availability of a telephone triage service. Although health call centres are popular with consumers and healthdirect Australia reports indicate a high level of customer satisfaction with the service,40 before committing to significant ongoing expenditure of taxpayer's money on continuing the after-hours GP helpline, a comprehensive evaluation of this service must be conducted. We believe that a detailed research study is required looking at the effects of the healthdirect Australia and the after-hours GP helpline on EDs and after-hours general practices. With appropriate cooperation, such a study would be relatively easy to conduct. The Government must stop misleading the public about the effect of healthdirect Australia and the after-hours GP helpline on ED pressures. If the Government is truly concerned about the pressures facing EDs, they should tackle the real issue – overcrowding caused by lack of capacity in the hospital system – and ensure that funding and policies are directed towards solving overcrowding. DM is the Overcrowding Subcommittee Chair for ACEM.

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