This study assessed the appropriateness of advice given by teletriage nurses to patients in northern Ontario. Assessments used audiotapes and printed records of 73 calls, selected from approximately 350 calls based on sound quality, completeness, and consent of caller and teletriage nurse. Audits were conducted independently by one family physician, one nurse practitioner, and one registered nurse with teletriage experience. In 56% of the 73 calls, all three auditors judged the nurse's advice as "appropriate." In 92% of the 73 calls, at least two of the three auditors judged the teletriage nurse's advice as "appropriate." All calls were rated as "appropriate" by at least one auditor. If not "appropriate," then auditors were three times more likely to rate the advice as "overly-cautious" rather than "insufficient." The percentage of calls with the same rating varied from 62% to 86% with an outlier of 33%. Nurse practitioners tended to rate the appropriateness of the advice slightly, but significantly lower than the rating given by family physicians or registered nurses. Interestingly, nurse practitioners tended to rate aspects of the nurse-caller interaction advice as slightly and significantly better than the rating chosen by family physicians or registered nurses. The teletriage service was providing appropriate advice, but the generalizability of these results may be limited because of the selection of calls.
There is a critical shortage of specialty rheumatology services in Canada. The impact is felt more in rural and northern regions than on urban areas of the country. In response to the need, this study was conducted to compare the satisfaction of referring physicians with rheumatology services through conventional visiting specialty clinics; email consults and regularly scheduled videoconference.
Three rural communities of similar size and availability of physician services were assigned to one of the following means of providing outreach rheumatology services: visiting rheumatologist clinics, email access to rheumatologist and scheduled videoconference consults. A case based pre/post test, and post satisfaction questionnaire were administered to the primary care physicians in these communities. Patient outcomes, and physician ability and confidence in managing specific arthritis problems, were measured.
Physicians responded positively to all methods of rheumatology service provision. The videoconference group were the most positive. The reasons were: immediate feedback to referring physician and patient, effective case based learning and transfer of knowledge, and improved accessibility.
Videoconference is preferred to visiting clinics and email as a method for rheumatology services to rural/northern communities. It is cost effective and there is knowledge transfer between the rheumatologist and the referring physicians.
We investigated the effect of daily real-time teleconsultations for one week between hospital-based nurses specialised in respiratory diseases and patients with severe COPD discharged after acute exacerbation. Patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at two hospitals were recruited at hospital discharge. They were randomly assigned to intervention or control. The telemedicine equipment consisted of a briefcase with built-in computer including a web camera, microphone and measurement equipment. The primary outcome was the mean number of total hospital readmissions within 26 weeks of discharge. A total of 266 patients (mean age 72 years) were allocated to either intervention (n?=?132) or control (n?=?134). There was no significant difference in the unconditional total mean number of hospital readmissions after 26 weeks: mean 1.4 (SD 2.1) in the intervention group and 1.6 (SD 2.4) in the control group. In a secondary analysis, there was no significant difference between the two groups in mortality, time to readmission, mean number of total hospital readmissions, mean number of readmissions with AECOPD, mean number of total hospital readmission days or mean number of readmission days with AECOPD calculated at 4, 8, 12 and 26 weeks. Thus the addition of one week of teleconsultations between hospital-based nurses and patients with severe COPD discharged after hospitalisation did not significantly reduce readmissions or affect mortality.
A prospective study was carried out to evaluate the effect of teleradiology on the diagnosis, treatment and prognosis of patients in primary care. A university hospital was sent 685 plain film examinations via an ISDN connection from a primary care centre, for a radiological report. The study was conducted in two phases: during phase 1 (446 cases) general practitioners (GPs) selected the examinations, and during phase 2 (239 cases) all consecutive examinations were transmitted. In phase 1, 40% of the examinations were of the chest and 24% were of the spine; the remaining 36% were mainly bone and sinus examinations. In phase 2, 28% of the examinations were of the chest and 19% were of the spine. The sensitivity and specificity of the GPs' interpretations (compared with the radiologists') were 0.85 and 0.62 respectively in the first phase, and 0.90 and 0.86 in the second. In at least one-third of all cases, teleradiology helped with the diagnosis, although completely new diagnoses were less common. An effect on treatment was noted in 15% of cases and on prognosis in 5%. However, an appropriate consultation level is required for these positive effects. Adequate accuracy and patient safety cannot be achieved if the examinations sent for radiological reporting are preselected by a GP.
We conducted a retrospective study of incident reports concerning the national, nurse-led telephone triage system in Sweden. The Swedish Health Care Direct organization (SHD) is staffed by registered nurses who act as telenurses and triage the callers' need for care, using a computerized decision support system. Data were collected during 2007 from all county councils that participated in the SHD and were analysed using content analysis. Incident reports were then compared concerning differences in reported categories and who reported the errors. The 426 incident reports included 452 errors. Of the analysed incident reports, 41% concerned accessibility problems, 25% incorrect assessment, 15% routines/guidelines, 13% technical problems and 6% information and communication. The most frequent outgoing incident reports (i.e. sent from SHD to other health-care providers) concerned accessibility problems and the most frequently incoming reports (i.e. sent to SHD from other health-care providers) concerned incorrect assessment. There was a significant difference (P
We analysed the characteristics of all malpractice claims arising out of telephone calls to Swedish Healthcare Direct (SHD) during 2003-2010 (n = 33). The National Board of Health and Welfare's (NBHW) investigations describing the causes of the malpractice claims and the healthcare providers' reported measures were analysed using Qualitative Content Analysis. The original telephone calls themselves, which had been recorded, were analysed using the Roter Interaction Analysis System (RIAS). Among the 33 cases, 13 patients died and 12 were admitted to intensive care. Failure to listen to the caller (n = 12) was the most common reason for malpractice claims, and work-group discussion (n = 13) was the most common measure taken to prevent future re-occurrence. Male patients (n = 19) were in the majority, and females (n = 24) were the most common callers. The most common symptoms were abdominal (n = 11) and chest pain (n = 6). Telenurses followed up on caller understanding in six calls, and mainly used closed-ended questions. Despite the severity of these malpractice claims, the measures taken mainly addressed active failure, rather than the latent conditions. Third-party communication should be regarded as a risk. When callers make repeated contacts, telenurses need to re-evaluate their need for care.
The aim of the present study was to elucidate both the interaction between a doctor and five registered nurses and the problems or tasks dealt with in teleconsultations between a university clinic for geriatric medicine and a nursing home for the elderly in northern Sweden. The interaction and problems or tasks were studied through analyses of video-recorded teleconsultations and through open interviews with the participating staff. The results indicated that teleconsultations between a geriatrician and the nurses at a nursing home for the elderly can be a useful tool for providing medical services. Teleconsultations alter both the 'power-control' and 'practice spheres' for the doctor and the nurses, and must be based on mutual trust. The use of teleconsultations gives the nurse a larger role as the presenter of medical problems, and gives the doctor the role of remote consultant.
Since 2000, routine tele-ophthalmology services have been provided by St Erik's Eye Hospital to three large urban primary care centres in Stockholm. Diagnostic support from the specialist eye hospital to primary care centres uses video slit-lamps and realtime videoconferencing. After the initial introduction period at the primary care centres, the number of teleconsultations stabilized at a very low level. Despite this, the general practitioners learned to handle more diagnostic conditions by themselves and to identify what diagnostic situations should be referred to a specialist without having to consult the specialist beforehand via telemedicine. The availability of instant eye expertise via telemedicine therefore proved to be an excellent on-the-job training tool to develop and maintain the diagnostic competence of general practitioners. Patient satisfaction was high.
BACKGROUND: A cluster randomized trial of tailored interventions to support the implementation of guidelines for sore throat and urinary tract infection found little or no change in the main outcomes, which were antibiotic prescriptions, use of laboratory tests and use of telephone consultations. There was great variation between the practices in the change in these outcomes. OBJECTIVES: Our aim was to evaluate how the interventions were received and to understand why practices did or did not change. METHODS: The trial was conducted in general practices in Norway. Data for this process evaluation were collected from the 120 practices that completed the trial. Multiple methods were used: observations, semi-structured telephone interviews, a postal survey and data extracted from electronic medical records. We investigated factors that might explain a lack of change, including: agreement with the guidelines; communication within each practice; degree of participation in the project; taking time to discuss the guidelines and their implementation; use of the components of the interventions; and routines for telephone consultations. Possible explanatory factors were explored in relation to variation in change and the overall extent of change in rates of use of antibiotics, laboratory tests and telephone consultations. RESULTS: Sixty-three per cent of practices agreed with the guidelines. Only 35% reported having regular meetings, and 33% discussed the project before its start, although 75% reported agreement about participating within the practice. Only 33% reported meeting to discuss the guidelines. Use of the components of the interventions ranged from 11% for the increased fee for telephone consultations to 48% for the computerized decision support. Forty-four per cent reported problems with telephone routines. No single factor explained the observed variation in the extent of change across practices. CONCLUSIONS: Inadequate time, resources and support were the most salient factors that might explain a lack of change. Problems with internal communication and telephone routines were important contributing factors in many practices.