Overruling of the urgency allocation by triage nurses in males and females with symptoms suspected of transient ischemic attack or stroke in out-of-hours primary care

Abstract

Abstract: Background: During out-of-hours, primary care is provided by the out-of-hours service primary care (OHS-PC) in the Netherlands. For patients with symptoms suspected of transient ischemic attack (TIA) or stroke most often first the OHS-PC is contacted during out-of-hours, not directly 112. In the OHS-PC a semi-automatic decision tool, the Netherlands Triage Standard (NTS), is used to generate an urgency allocation which is linked to a time frame within which medical care should be delivered, all based on the estimated severity of symptoms by the triage nurse. However, a triage nurse can overrule the urgency level given by the NTS by upgrading or downgrading it. Aim: To identify the relation between overruling of the NTS urgency by the triage nurse and eventual diagnosis of TIA or stroke in males and females who call the OHS-PC for symptoms suspected of TIA or stroke.

Methods: This study was executed in nine OHS-PC locations around Utrecht, the Netherlands between 2014 and 2016. Information was collected on call characteristics and urgency allocation at the OHS-PC, and the general practitioner (GP) was asked to provide the final diagnosis. The direction and frequency was calculated of overrulement of the urgency level generated by the NTS. Accuracy of the NTS urgency and final urgency (including overruled cases) against the final outcome TIA or stroke was given by calculating the sensitivity, specificity, positive and negative predictive value. The association between overruling and (i) the final urgency and (ii) the final diagnosis TIA or stroke was calculated with univariable and multivariable logistic regression analyses. Statistically significance was considered with a p-value <0.05.

Results: Of the 1,955 patients, 732 (37.4%) had a TIA or stroke. 368 (18.8%) calls were overruled, mostly to a higher urgency (70.0% upgrading, 30.0% downgrading), with more often upgrading in males than females (77.9% vs. 62.3% p = 0.996). High urgency generated by NTS compared to presence or absence of TIA/stroke had a sensitivity of 0.69, specificity of 0.45, a positive predictive value of 0.59 and a negative predictive value of 0.56. These relations were for the final urgency: sensitivity 0.76, specificity 0.38, positive predictive value 0.58 and negative predictive value 0.58. There was no significant effect of overruling the NTS on the final diagnosis of TIA or stroke.

Conclusion: Triage nurses overruled the NTS urgency level in nearly one out of five patients calling the OHS-PC for neurological deficit symptoms. They most often upgraded the urgency level, and overruled more males than females. Overruling of the NTS, however did not improve the accuracy of detecting or excluding TIA or stroke.