VOL: 96, ISSUE: 49, PAGE NO: 42
Beverley Griffiths, RGN, SCM, MA, is A&E clinical nurse manager, Rochdale Infirmary, Lancashire
Hadrian Collier is audit manager, NHS Direct, Greater ManchesterBeverley Griffiths, RGN, SCM, MA, is A&E clinical nurse manager, Rochdale Infirmary, Lancashire
Historically, telephone triage or advice has always been given by A&E nurses, although the quality and appropriateness of such a service is difficult to evaluate.
Generally, A&E departments receive numerous calls from the public seeking advice on a variety of conditions or concerns. Calls are taken at all times of the day but tend to peak after 5pm and at weekends, when access to other health care providers is more difficult. But these are also the times when many departments are at their busiest and calls are often handled in an ad hoc way.
Staff at the A&E department at Rochdale Infirmary, Lancashire, were usually too busy to complete forms recording the calls and the advice given over the telephone, and the service was rarely audited.
The department's policy was that only staff with at least one year's experience in A&E should give advice. This was difficult to implement and the quality of advice varied depending on which member of staff was giving it and how busy the department was.
Previous audits revealed that nurses often spent up to 20 minutes on advice calls, especially those relating to drug overdoses. After talking to the nurses it became clear that many felt compromised by having to give reassuring, accurate advice to callers while dealing with patients in the department. All these pressures led to a suggestion that the department use the services of NHS Direct.
Collaboration with NHS Direct
NHS Direct provides a 24-hour confidential helpline staffed by nurses who offer advice and reassurance on all aspects of health, including illness and accidents. Nurses assess callers with the help of a computer programme. If a call is deemed an emergency, the nurse adviser transfers it to the paramedic emergency control department which will immediately dispatch an ambulance.
One advantage of NHS Direct is the use of protocol-driven advice and information, which provides a secure risk-management process.
After discussions in April 1999, Rochdale's A&E advice callers were diverted to NHS Direct for a three-month trial period. This was done by the switchboard operator asking callers if they were telephoning in connection with treatment they were receiving at the infirmary. If so, the caller was put through to the relevant ward or department. If not, he or she was offered the NHS Direct telephone number.
NHS Direct Manchester used a triage system when identifying callers referred from Rochdale Healthcare NHS Trust. Demographic information and caller outcomes were collated to assess the extent of the project. All calls taken by NHS Direct are subject to audit to ensure that clinical standards are met.
A total of 979 callers contacted NHS Direct as a result of the project and 574 (59%) of them were given health information, with no further health care input required.
More than 400 callers needed symptom assessment and further health care intervention. Graph 1 shows that almost three-quarters of these (72%) were advised to see other health care professionals. More than a quarter of all callers (27%) received advice on self-care and most (43%) were advised to contact or visit their GP either urgently (within four hours), less urgently (within 24 hours) or not urgently (more than 24 hours). Only 1% (six cases) had an ambulance sent directly as a 999 emergency.
Just over half the callers who required triage were female (54%) and the largest age group in need of advice was children of 16 and under (43%).
Graph 2 suggests that the increasing number of callers to NHS Direct are parents contacting the service about a child's health.
Over the project period, the summer months were the busiest. Graph 3 shows a breakdown of the triage dispositions given by NHS Direct in July, August and September 1999.
The collaboration with NHS Direct has significantly reduced the number of callers seeking advice from Rochdale Infirmary's A&E department. This has enabled nurses to spend more time caring for the patients in the department.
It is not possible to determine whether the new arrangement, in comparison with telephone advice being given by A&E staff, has resulted in any significant change in A&E attendance rates. However, 72% of callers whose symptoms were assessed by NHS Direct were advised to seek other health care interventions rather than attending A&E.
This project illustrates the role NHS Direct can play in integrating care providers. There are plans to extend the scheme across Greater Manchester and a direct call-transfer system, from the hospital switchboard to NHS Direct, is being investigated.