Discussion
fever, Non-Danish, ill, worry, tonsillitis
EAR INFECTIONS, MINOR, SECONDARY, TONSILLITIS
Our primary aim was to investigate if video triage could enable more ill children to stay at home, while also efficiently identifying potentially severely ill children with the need for assessment at hospital. There was not a difference in the number of patients triaged to stay at home or in the number of patients assessed at hospital within the follow-up period of 48 h after the call. However, several findings pointed towards video having been used at the discretion of the call-handlers, and not in every other call, as instructed. As such, the video triaged children more often were assessed as potentially more ill by the call-handlers, as they more frequently were referred directly to a PED as opposed to a PUCC reserved for minor illnesses. Moreover, among the children assessed at hospitals, children from the video triage group more often received paraclinical testing or in-hospital treatment and were more often hospitalized as compared to the telephone triage group. Equivalently, the children in the telephone triage group assessed at hospitals received less severe diagnoses, but more prescriptions, probably due to them being assessed in PUCCs with illnesses that could be treated at home with e.g. antibiotics, such as uncomplicated tonsillitis and ear infections.Our secondary aims related to the parents’ DOW. DOW was higher in the video group than in the telephone group, and there was a significant association between DOW and triage mode, that is, the parents’ degree of worry might have influenced what triage mode that was used. The conversation with the call-handler had in itself a reassuring effect on the parental DOW, as DOW decreased significantly after the call in both groups. Furthermore, high parental DOW both before and after having talked to a call-handler was significantly associated with the child being assessed face-to-face at a hospital. Hence, children of worried parents were actively allocated to video triage. After the call, where the call-handler confirmed the parents’ worry by referring the child to a hospital, the parent had a persisting high worry.Decision-making is the final product and essential element of call-handling [A systematic review of unscheduled pediatric healthcare visits found that patients do not find these visits as clearly distinguished from planned visits as professionals, and parents do not necessarily take the appropriateness of visits into account, when choosing where and when to seek help [Several studies have tried to estimate appropriateness of referrals made by call-centers by assessing patient outcome [Feverish children are highly prevalent in OOH care, and challenging to assess, as harmless and severe causes may be hard to separate. Furthermore, parents often expect a physical examination. Video triage might be beneficial, as it provides visual assessment and can assist in finding the most severely ill children. Several parents stated that it was a relief not having to go to a hospital after video triage as somebody already had “seen their child” [Video triage in other symptoms and age groups should be the subject of future studies, both to identify in which cases that video triage is most useful, and also how to implement the video findings most optimally in the decision-making protocols used at many call-centers. Randomized studies are needed to find the impact of video triage on triage outcome and subsequent patient outcome.By including DOW, a simple and time-efficient score, in the triage process, the incorporation of parental feelings of worry in the decision-making can be ensured. As worry is a main reason to OOH contact, this is crucial. By investigating how DOW has changed at the end of the call, it is possible to conclude if the contact has resulted in increased reassurance and empowerment. If not, the underlying reasons should be sought corrected.Some limitations to the study were identified. Although the participating call-handlers had been instructed to include patients to the video- or telephone triage group in a 1:1 ratio to get two comparable groups, the results show that children with potentially more severe or complex symptoms and/or with parents displaying a high degree of worry more often received video triage than telephone triage. Previously, the study group reported that several of the participating study call-handlers stated that they could not do without video in some situations, and therefore switched to video triage even if the allocation strategy stated telephone triage [Non-Danish and non-English speakers were excluded, to test this new tool in a setting that felt achievable to both call-handlers and parents. We also did not want to affect the waiting times in a negative way, as might have been the case if there would have been difficulties explaining the video triage setup and tool. For future purposes though, these situations should be studied as well, as it is possible that much is to gain when using a visual aid when experiencing language barriers.Regarding DOW, parents were asked AFTER the call about their DOW both before and after having talked to a call-handler. Recall bias might have an impact on the “before-rating”. Also, as the numbers of parents rating their DOW as low (1 + 2) were rather small, this generated some wide 95% CI’s.Lastly, it would have been preferable if the study had been conducted as a randomized controlled trial, but this was not possible due to several reasons. Firstly, the call-handlers did not have sufficient time for thoroughly informing the parents and obtaining written informed consent, and an oral consent, although it would have been stored in the MH1813 electronic patient chart, would not legally suffice. Furthermore, it was not possible to change the computer set-up to randomly allocate calls to video or telephone triage, or to change the introduction speech of MH1813 as would have been desired in terms of informing about the study. Due to this limitation, the study cannot yield fully valid answers to the impact of video triage on triage and patient outcomes.Finally, to sum the findings up, the study did not find an increase of video triaged patients staying at home. Video triage of young children with fever was feasible, acceptable and as safe at telephone triage at this medical helpline. However, video triage was more often used in situations with complex or potentially severe symptoms and when parents rated worry as high. High parental degree-of-worry was associated to assessment at hospital and can be used as a method to incorporate the caller’s subjective notion of worry and urgency into the triage process.