Supporting clinical decisions for better triage

Most of us understand the need to keep healthcare costs low. On the other hand, when we become patients, we’re not keen to see savings made at the price of increased risk. When it comes to avoiding the avoidable in healthcare, we like to think that costs are unavoidable if they ’re incurred ensuring our safety.

The Netherlands have an out-of-hours service patients can call when their GP practice is shut. The aim is to reduce visits to emergency departments in lieu of family practitioners. Nurses take callers through guidelines, asking a series of questions to establish what care the patient needs and with what urgency.

An out-of-hours call centre at work

A 2007 study set out to find out how well the service was performing. The results were disturbing. In 19% of cases, nurses underestimated the urgency of the patient’s condition. The study’s authors conclude that the service was “possibly not safe,” which feels like an understatement.

Denmark’s out-of-hours service gives evidence of the opposite effect: excessive caution by nurses. The Danish service is principally staffed by GPs, but there’s pressure to use nurses as an economy measure. However, a 2013 investigation found that nurses might be too inclined to refer a case for a GP to see instead of taking a decision themselves. The result? On top of the cost of employing the extra nurses needed, the service, far from reducing calls on GP time, might increase them. Costs could rise instead of falling.

What’s the answer? How can we reduce expenditure by having nurses or, even better, non-medical staff, take responsibility for triage, without either increasing risk to patients or incurring higher costs?

The 2007 Dutch study came up with one answer: it found that the more training nurses had received in the use of the call centre guidelines, the less frequently severity was underestimated. Certainly, telephone triage isn’t simply another application of already acquired skills. It’s a legitimate healthcare service in its own right, needing its own knowledge and expertise.

There is, however, another way in to  improve services. That’s the field in which I’m currently spending much of my time: clinical decision support.

What we’re talking about here is software that helps nurses or non-clinical call handlers work their way through guidelines. At the most trivial level, such software can ensure that nothing’s forgotten. A question might be mandatory, so the handler simply can’t move on until it’s asked. That would ensure essential information isn’t missed. Even with optional questions, their mere appearance on a screen would at least prompt the handler to ask them and might trigger a new line of enquiry.

That, however, is far from enough. There has been research (not enough, yet, but what there has been is telling) into the impact of clinical decision software. A revealing article showed that a call handler might be pushed down the wrong line by the software itself. It cites the example of a handler, a nurse, who had begun to explore what the software offered on the subject of nausea, while the caller had moved on to talk about back pain. With one line of questions already under way, the call handler failed to pick up the second symptom, however important it may have been.

Again, on some occasions, the lack of an appropriate response to certain questions led to a distorting effect: the patient was saying that she felt sick each time she ate, but the software hadn’t allowed for that reply, imposing instead quantitative entries – once a day, three times a day, and so on.

That’s what makes the search for effective software design such an interesting challenge. It’s not enough just to list all possible questions, in a fixed order. It’s vital to take all the information concerning any particular patient into account, without deciding too soon that one item has overriding importance or letting the software itself drive the direction of the investigation. In fact, the system has to:

1. take into account all the information about the patient, entered in whatever order. In other words, as in a real, face-to-face medical consultation, the patient should be able to describe all his or her symptoms without making a judgement about which is the most important 
2. suggest questions to the call handler based on all the symptoms, not just one of them 
3. drop irrelevant questions but propose all the others 
4. handle unquantified information, such as “I feel sick each time I eat”

That would be the kind of clinical decision support software that can really make a difference, because it emulates what happens in a medical consultation: the patient describes symptoms as they come to mind, not in an orderly or pre-filtered way. Alongside the kind of comprehensive training we’ve already seen is needed, such support software could bring us closer to the goal we seek: a triage service that delivers a reduction in costs without an increase in risk.

In fact, it would be valuable for far more than triage. It can make a major contribution to managing medical pathways in general. But that’s the subject of my next post.

Triage: one way of avoiding the avoidable

Just because something’s avoidable, it isn’t necessarily easy to avoid.

That’s certainly true of avoiding unnecessary hospital admissions. When we’re ill, we want to feel better, as quickly as possible. Indeed, if we’re in pain or great discomfort, we want our care to start immediately – to us at least, our condition is urgent. If we can’t see a professional in one of the relatively inexpensive settings, such as a GP practice – perhaps because we can’t get an appointment soon enough, or because our condition arose out of hours – we might be inclined to head straight for a hospital. Why, we might even call an ambulance to get us there.

When we need one, we really need one
When we don’t, we really don’t

A while later, we would be standing in our local Emergency Department and explaining how ill we are. It’s possible that the person we’re talking to is a relatively junior member of medical staff or nurse, inclined to be risk-averse: that is, they would prefer to err on the side of caution, offering more treatment than we really need rather than too little.

The next thing we know is that we’ve been admitted as an emergency inpatient to the hospital. Now, if that’s what we really needed, then that’s fine. If it wasn’t, then the system has failed us. From its own point of view, it will have behaved wastefully – as I argued last time, it may have spent twenty times as much on our case than it ought to have done.

But unlike a good meal or a good holiday, where spending more generally gives greater quality, in healthcare that’s not necessarily the case. In hospital, we’re surrounded by sick people. There’s a serious chance we might pick up a disease from some of them, and actually find ourselves becoming less well rather than better from our hospitalisation. It was clearly avoidable, and avoiding it would have been desirable for both sides.

The process that would have avoided it is called triage. From the French word for sorting, triage was first extensively used in the First World War, to identify three classes of injured soldiers: those who it would be a waste to treat as they were beyond rescue, those who could wait because they weren’t that seriously hurt, and the intermediate group on whom to focus.

Today, it’s come to mean a process by which the medical condition of a patient is assessed before a decision is taken on treatment. Triage can take place in a number of ways. For instance, a GP in effect carries out triage in deciding whether a patient needs hospital care or not. But we tend to think of triage more as the kind of service a patient might phone for advice before taking off for the hospital, or that an ambulance call handler provides when we dial an emergency number.

A conversation takes place between the caller – who may or may not be the patient – and someone able to advise on treatment options.

That sounds simple enough and provides an obvious way to avoid an unnecessary hospital visit. Unfortunately, it’s not as straightforward as it sounds. Triage is a skilled task, and there are two traps, at opposite ends of the scale, that have to be avoided.

• Excessive caution: to ensure a patient doesn’t miss out on treatment that might be necessary, the call handler decides on a referral to an urgent service when one isn’t necessary. A paramedic I once dealt with told me that the triage service locally had simply become “another way of calling an ambulance.” Far from reducing highly expensive but unnecessary care, the triage service might well increase it.
• Under treatment: the call handler fails to spot a condition that does need urgent care, and the patient suffers as a result. In January this year, the Guardian published the horror story of a doctor who needed urgent treatment but might have been left blind by a triager failing to spot the real problem.

The impact of good triage was shown by a study carried out by the journal Acute Medicine in 2015. It showed that when triage was carried out by senior hospital physicians, 28.5% of admissions were avoided – a huge success rate. But do we really want triage carried out by senior physicians who should be treating patients?

The elusive solution would be a way of increasing the quality of decisions by call handlers who are experts in triage as such, rather than medical specialists. That’s a matter of training, though of course it can also helped by providing better support.

Another study, in BMC Medical Informatics and Decision Making in 2014, suggests that providing a clinical decision support system can help. Since that’s my own field, it’ll be the subject of the next post in this series.

The central challenge for healthcare: avoiding the avoidable

One of the key questions facing health services today can be summed up in three words: avoiding the avoidable.

This is an international problem. I’ve been working around the healthcare sector, mostly in England but also in France, Germany, Switzerland and Spain since the mid-1980s. Much of the time, I was working for American companies through which I also gained some knowledge of the US system.

The graph below shows how expenditure on healthcare has grown, decade by decade, in those countries over that period (based on figures compiled by the OECD). The rate of growth is not the same in all of them, and the starting and end points are different, but they all show the same inexorable climb. Nor, despite all the moves to reduce expenditure – the NHS in England is on a five-year plan to save £20bn – there’s no sign of the upward pressure ending any time soon.

Notice that back in the 1980s, the US was spending a little under 10% of its income on healthcare. Today, it’s one dollar in every six.

The inexorable upward pressure on healthcare expenditure
(source OECD)

The reasons for that pressure are not hard to find. It is becoming possible to treat a constantly increasing range of diseases, which is wonderful for the patient seeking relief. Financially, however, it is far more problematic, as all those treatments have to be paid for, and many are expensive.

At the same time, life expectancy continues to grow in the advanced economies, so far higher numbers are reaching the period in life when there’s a much-increased chance of acquiring long-term diseases such as arthritis, heart disease, diabetes and so on. Many of these conditions are also influenced by lifestyle: this is the case of obesity and heart disease, for instance.

More to the point, many of our ageing population find themselves suffering from more than one long-term condition (LTCs as they’re commonly called, in a field that just loves three-letter abbreviations or LTAs). Take obesity: as well as being a dangerous LTC itself, it can also lead to coronary heart disease (CHD, of course) and type 2 diabetes. The patient may have arthritis too and perhaps the beginnings of dementia. Suddenly, as well as being a human enjoying a longer life than used to be possible in previous centuries, he or she is also a mass of conditions each of which needs treating.

Thereby hangs another tale. Western medicine has grown up in specialties. But how do you handle a patient with a heart, endocrine and rheumatic condition simultaneously? We need new models of care, based on multi-disciplinary cooperation.

When talking about new models of care, however, one that has to be right at the top of the list is a model that focuses on keeping patients out of hospital where possible. Hospital care is the most expensive form. Where in the past it was perhaps not a major issue for a patient to show up at a hospital because they were worried and no GP was available, today with the system creaking under the strain, that’s really no longer viable.

Here’s how it works. In England, to visit a General Practitioner incurs a cost of roughly £80. If that patient went to an Emergency Department instead, the cost would be nearer £150. Now imagine the situation where in that Emergency Department, the patient, an old man running a high temperature and coughing uninterruptedly, is being seen by a relatively junior doctor on call late at night. Will he have the courage to issue some medications and tell the patient to go home and see his GP in the morning? Or will he admit him, just in case?

If he does admit him and the patient ends up staying over two nights, we’re talking about a cost in the region of £1500.

That’s what I mean about avoiding the avoidable. If the patient doesn’t really need the hospital care, you’re talking about saving 80-90% of the cost of the treatment if you can avoid the admission.

In the next in this series, I’m going to talk about some of the ways in which that can be achieved.