Nurse telephone triage in Dutch out-of-hours primary care: the relation between history taking and urgency estimation

Objective In the Netherlands, a patient's first contact with a general practitioner cooperative, an out-of-hours primary-care center, is usually with a triage nurse. Previous research has shown that nurses sometimes underestimate the level of urgency, which may be caused by incomplete history taking. The aim of this study was to examine the relation between comprehensiveness of history taking and appropriateness of urgency estimation. Methods Simulated patients, presenting 20 standardized vignettes, called four general practitioner cooperatives in different regions in the Netherlands that used the national telephone guidelines. We assessed the questions triage nurses asked in 304 audio-taped contacts, distinguishing between discriminating and general recommended questions. Discriminating questions help to confirm or reject a specific urgency level, whereas general questions are used to collect additional information regarding context. We calculated the percentage of recommended questions asked and made plots of the patterns of questions asked for chest pain and dyspnea. Results Mean numbers of discriminating and general questions per telephone contact were 4.4 and 3.2, respectively. There were no differences between the number of discriminating questions asked for contacts with correctly estimated urgency and contacts with underestimated urgency. We identified clusters of frequently asked questions, which were similar for contacts with correctly estimated and contacts with underestimated urgency. Conclusion Incomplete asking of recommended questions through telephone triage was not associated with underestimation of urgency. Pattern recognition may be more important for identification of urgent health problems by nurses than asking all crucial questions during history taking. European Journal of Emergency Medicine 19:309-315 (c) 2012 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.