TELE-TRIAGE: Improving the accuracy of a non-clinical operator-led telephone triage service for older adults seeking non-urgent, out-of-hours unplanned care

It is well known that older adults (over the age of 65) are especially difficult to triage over out-of-hours telephone triage (OOH-TT) services as they frequently present with atypical symptoms of common heath concerns. However, few efforts have been yet made to better understand how well existing services work to provide remote care to older segments of the population. Little is also known about how to improve existing methods to provide higher quality healthcare to older adults in the population.

The overall purpose of this doctoral dissertation was to better understand and improve the accuracy of non-clinical operator led TT services in older adults seeking OOH unplanned care across part of the Flemish region of Belgium. Particularly, we aimed to examine the use of the 1733 service – a national OOH-TT service led by non-clinical operators trained to use computer-software integrated medical dispatch protocols.  In our research, a special focus was given to medical dispatch protocols which have been found to be most relevant for use in 1733 calls concerning older adults. Knowing that existing protocols are currently designed for use in all populations seeking unplanned care using the 1733 OOH-TT services, our interest was also to investigate the key factors which may be related to improving the quality of these services for use in older adults.

First, a systematic review was conducted to summarize the existing literature on the use of computer-software integrated OOH-TT services. A total of seven studies showed that while very little is known about the consistency of decisions that are generated using software-integrated TT services, several factors have been identified to have an impact on the consistency of generated triage decisions. Given the overall scope of our interest evaluate the 1733 service, the next step of our research aimed to describe user trends and quality of non-clinical operator led OOH-TT decisions for older adults seeking unplanned care in Flanders (Belgium). We conducted descriptive analyses of 1733 call records merged with patient records from associated GP walk-in clinics to better under these associations. Key findings showed us that while most calls concerning all age groups of the population were generally appropriately triaged by 1733 operators, there was a notable proportion of over- triage was prevalent in calls involving older adults. Furthermore, our research also found that during the COVID-19 period, older adults were more likely to be dispatched to a higher level of urgency compared to younger patients but that very few calls related to COVID-19 were found to involve older adults in general. The third part of our research aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using the Belgian Manual for Medical Regulation (BHMR) protocols to manage calls involving older adults at the 1733 service. The findings of our research showed that the majority of panelists agreed that at least some content related modifications should to be made for all of the top 10 most frequently used BMHR protocols to improve the overall quality of triage for older adults. The final part of our research was conducted as a scoping review which aimed to identify, map and provide an overview of the current state of literature on economic evaluations and financial consequences related to the use of telehealth services by older adults seeking unplanned care. However, to align with the larger goals of this dissertation, we aimed to present only preliminary findings related to the use of OOH-TT services. A total of two relevant studies showed that there may be some promising results to suggest that overall, OOH-TT services may lead to avoidable costs as a result of savings on ambulance related costs, reductions on emergency department presentation and facilitated reallocation of healthcare resources for older adults. However, was not possible to draw any conclusions about the application of these findings within other international contexts, including the 1733 service in Belgium.

Overall, the findings of this doctoral dissertation suggest that while non-clinical operator led OOH-TT services may generally be a safe and efficient tool for managing unplanned care needs across the population, there still remains large room for improvement with regards to the use of these services in especially vulnerable segments of the population, such as older adults. Therefore, future efforts to further address the quality of non-clinical operator led TT services for older adults seeking OOH unplanned care is necessary and warranted.