SAFETY AND EFFECTIVENESS OF NURSE TELEPHONE CONSULTATION IN OUT-OF-HOURS PRIMARY-CARE - RANDOMIZED CONTROLLED TRIAL

Objective To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse ev ents and the management of calls. Design Block randomised controlled t rial over a year of 156 matched pairs of days and weekends in 26 block s. One of each matched pair was randomised to receive the intervention . Setting One 55 member general practice cooperative serving 97 000 re gistered patients in Wiltshire. Subjects All patients contacting the o ut of hours service or about whom contact was made during specified ti mes over the trial year. Intervention A nurse telephone consultation s ervice integrated within a general practice cooperative. The out of ho urs period was 6 15 pm to 11 15 pm from Monday to Friday, 11 00 am to 11 15 pm on Saturday, and 8 00 am to 11 15 pm on Sunday. Experienced a nd specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advic e; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral t o the emergency service or advice to attend accident and emergency. Ca lls were managed with the help of decision support software. Main outc ome measures Deaths within seven days of a contact with the out of hou rs service; emergency hospital admissions within 24 hours and within t hree days of contact; attendance at accident and emergency within thre e days of a contact; number and management of calls in each arm of the trial. Results 14 492 calls were received during the specified times in the trial pear (7308 in the control,, and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients i n the intervention and control groups, though male patients were under represented overall. Reasons for calling the service were consistent w ith previous studies. Nurses managed 49.8% of calls during interventio n periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% r eduction in patient attendance at primary care centres and a 23% reduc tion in home visits was observed during intervention periods. Statisti cal equivalence was observed in the number of deaths within seven days , in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments, Conclusions Nurse telephone consultation produced substantial changes in call management , reducing overall workload of general practitioners by 50% while allo wing callers faster access to health information and advice. It was no t associated with an increase in the number of adverse events. This mo del of out of hours primary care is safe and effective.