Optimizing telephone triage of patients calling for acute shortness of breath in primary care (Opticall)

Telephone triage during out-of-hours primary care (OHS-PC) is notoriously difficult. At Dutch OHS-PCs, triage is performed by triage nurses under supervision of GPs. Triage nurses use the Nederlandse Triage Standaard (NTS), a decision support tool that, as a ‘forced function’, helps them to focus on the patient’s symptoms with yes/no questions in a digitally guided protocol. However, the NTS has never been validated against the patients’ final diagnoses, and recent studies indicated that the tool sometimes may hinder instead of facilitate telephone conversations with patients, notably in case of urgent symptoms, e.g. chest pain or shortness of breath. If NTS would hamper adequate telephone triage in such circumstances, it may even jeopardize an adequate balance between safe and efficient care in a substantial number of calls. Evidently, research on the validity, practical use and potential improvements of NTS is needed, specifically in the aforementioned domains in which patients may have critical underlying diseases. We consider adults calling with acute shortness of breath (SOB) as such a crucial domain in which adequate triage is key. SOB in adults is the most common reason for home visits in Dutch out-of-hours primary care. Moreover, triaging SOB is very challenging because multiple disorders may cause acute SOB, and different organ structures may be involved, most often the lungs and the heart, but also fear for such disorders. Urgent diagnoses that may underlie SOB, such as pulmonary embolism (PE), pneumonia, severe lung attacks of asthma, allergies or chronic obstructive pulmonary disease (COPD), acute coronary syndrome (ACS) or acute heart failure (AHF) should not be missed. But also SOB due to anxiety disorders or in palliative patients with life-limiting diseases warrants special attention and is often reason for urgent care. Finally, patients with SOB use an array of different wordings to express their complaints and its severity, which in turn may be aggravated by emotions of fear and anxiety, further complicating the conversation and the subsequent urgency allocation decision by the triage nurse. Thus, analyzing current practice of triaging of SOB at OHS-PC is crucial for safe and efficient primary care telephone triage. Over- and underestimation of urgency both have critical impact on patients and health resources, and there is high potential for gains in both safety and efficiency of SOB triage. We need to know how the current NTS diagnostic algorithm for SOB performs when taking into account the patients’ final diagnosis, whether the algorithm can be improved by adding new or removing redundant items, and how triage in actual OHS-PC practice could be further improved for SOB patients. For this, we designed an observational mixed methods study, in which we will conduct (i) diagnostic cross-sectional and case-control studies and (ii) action research comprising qualitative studies with interviews and practice observations. Our aim is to optimize the triage of primary care patients calling the OHS-PC with acute shortness of breath (SOB). In collaboration with three large OHS-PC organizations, patient representatives and the two national stakeholders, e.g. the NTS editorial board and the Association of Dutch OHS-PCs, we will assess how the triage of adult patients with SOB at OHS-PC is currently performed. Subsequently, we will validate the NTS urgency categories for adults with SOB against clinically relevant outcomes, and build diagnostic algorithms based on triage call characteristics of patients with SOB for the different clinical relevant medical outcomes. Finally, we will test and/or implement our findings in both the education of GP trainees and triage nurses, as well as in current clinical OHS-PC practice. We will do so in close collaboration with patients and professionals from the OHS-PC work floor as well as with the GP specialty training and triage nurse educators and with representatives of the NTS editorial board and the Association of Dutch OHS-PCs.