The expression triage originates in the French verb trier, which means to separate or selected. It is used in the health area as a process through which the priority of care is determined on the basis of the patient's severity. When this judgment is reached by telephone, it can be called telephone triage (Wheeler, Greenberg, Mahlmeister, & Wolfe, 2015).
Telephone triage permits identifying the patient's problem, estimating the emergency level, and sending the appropriate aid while guaranteeing the safe, timely, and appropriate availability of care in view of the patient's symptoms (Gonsaga et al., 2013).
Being a recent theme, telephone triage still lacks more in-depth research for the development of effective, systemized, and careful methods to conduct it, considering that, until very recently, it took place intuitively, considered face-to-face, and used intrahospital screening forms (Wheeler, 2009).
In that sense, the importance of telephone triage in prehospital care is highlighted, guaranteeing quality and good care performance and bringing down the mortality and morbidity rates and the effective functioning costs of the prehospital trauma care services (Machado, Salvador, & O'dwyeri, 2011).
It should be noted that the improper use of emergency resources harms not only the victims of trauma but also the entire system, as sending a mobile care unit with nurses, physicians, and drivers to a case that does not need such comprehensive and sophisticated care entails increased spending and weaker care in view of a possible occurrence that lacks greater input. On the contrary, exposing a victim at imminent death risk to care by a vehicle with only technical professionals increases the chances of irreversible damage and death (Palma, Antonaci, Colì, & Cicolini, 2014).
To characterize the best practices that guide the effective practice of telephone triage, a systematic review is needed to search for evidence on the use of prehospital emergency telephone triage.
This research was developed on the basis of the approach proposed by evidence-based practice through a systematic review. This method permits the analysis of relevant studies that sustain decision making in practice, update specific knowledge on a given theme, and guide new studies, as it reveals the existence of research gaps (De Souza, Da Silva, & De Carvalho, 2010 ; Moher, Liberati, Tetzlaff, & Altman, 2009 ; Polit & Beck, 2012).
To respect the adopted method, this study was developed in six phases: (1) elaboration of the research question; (2) search for articles in the databases; (3) extraction of the necessary information to answer the research question; (4) evaluation of methodological rigor of primary studies; (5) analysis and synthesis of results found; and (6) presentation of evidence (Mendes, Silveira, & Galvão, 2008).
The first phase permitted the definition of the research question, using the “PICO” strategy as a conceptual base, in which “P” refers to the study population—prehospital emergency care; “I” refers to the intervention of interest—telephone triage; “C” refers to the comparison with another intervention—not used in this study; and “O” refers to the expected outcome—specific characteristics (Melnyk & Fineout-Overholt, 2011). Thus, the following question was established: How to perform prehospital emergency telephone triage?
The second phase was accomplished in March 2017 when a librarian experienced in article search strategies collected the studies. On the same day, one of the researchers in this study reapplied the specific strategy to each database in order to guarantee the quality of the searches. The following databases and search strategies were adopted: in Literatura Latino-americana e do Caribe em Ciências da Saúde (LILaCs) “Serviços medicos de emergência” OR “Triagem” [topic descriptor] AND “Telefone OR Telephone” [words]; in National Library of Medicine National Institutes of Health (PubMed), “Emergency medical services” [Mesh] AND “Assessment” AND “Telephone” were used; in Cumulative Index to Nursing and Allied Health Literature (CINAHL), the terms “Emergency medical services” AND “Assessment” AND “Telephone” were used; in Library and Information Science Abstracts (LISA) and in Information Science and Technology Abstracts (ISTA), the terms “Emergency” AND “Telephone” were used; and finally, in SCOPUS, the strategy used was “Emergency medical services” AND “Assessment” AND “Telephone.” The search results were presented as recommended by the PRISMA group (Moher et al., 2009). In the search, 574 primary studies were identified, 302 of which were removed because of duplicity. Then, 272 abstracts were selected for reading, 181 of which were excluded because they did not answer the research question. Thus, two different researchers fully read and analyzed 91 articles to avoid bias in the inclusion of the articles. The following eligibility criteria were adopted: eligible primary studies fully accessible, which answered the guiding question of this study and described the characteristics of the emergency telephone triage method used in prehospital care. The two researchers agreed on the selection of 13 studies, whereas a third researcher served as a judge for the selection of 12 others, aiming to guarantee the appropriate inclusion of the articles. At the end of the process, 23 articles were included for the purpose of qualitative synthesis (Figure 1).
In the third phase, we defined the information to be extracted from the selected studies. Therefore, a validated bibliographic data collection tool was used, which considered data on the identification of authorship, year and journal of publication, methodological design, intervention studied, main results, and conclusions (Ursi & Galvão, 2006).
The fourth phase corresponded to the assessment of the articles included for qualitative synthesis in this study, a procedure equivalent to the data analysis in a field research, in which appropriate tools are used to guarantee the validity of the review (Mendes et al., 2008). The reference framework of nursing studies (Polit & Beck, 2012) was used to classify the selected publication, and all were classified as nonexperimental. Therefore, we chose to use the assessment of observational studies by the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) checklist to analyze the methodological rigor of each article. Thus, the study could be classified into three quality levels: Good methodological quality, when the article complies with the entire STROBE checklist; medium quality when it partially complies; and bad quality when the article does not contain any of the items requested in the assessment (Malta, Cardoso, Bastos, Magnanini, & Da Silva, 2010).
In the fifth phase, the results were interpreted, discussed, and grounded in a careful assessment of the selected studies to permit the structured presentation of this review in the sixth and final phase.
The adopted method permitted the analysis of 23 primary studies, indexed in the databases PubMed, CINAHL, LISA, ISTA, and SCOPUS, published in 17 different journals, and originating in 13 countries from three distinct continents. Synthesis of the characteristics of the selected articles is displayed in Table 1.
On the basis of the reading and analysis of the articles, identity of common telephone triage characteristics and synthetic categories could be formulated to make it easier to answer the guiding question of this study: Category 1—Telephone triage developed on the basis of a protocol; Category 2—Technological support for telephone triage; Category 3—Professionals responsible for telephone triage; and Category 4—Premises to improve telephone triage.
The results of each study were classified according to the analysis categories (Table 2).
Considering the origin of the studies, seven (30.4%) come from the United States, four (17.3%) from England, two (8.6%) from Norway, and 10 (43.4%) from other countries in Europe and Asia. These results may be related with the fact that prehospital care is spread around the world, mainly in economically stable countries, representing an important component of global health systems; on the contrary, on the basis of the fact that no primary studies were found from countries in Central and Latin America, Oceania, and Africa, as few articles were located in the database LILaCs. Further research and professional activities are needed to develop protocols and technologies that support prehospital emergency telephone triage in those regions, because these actions are essential to guarantee the quality and safety of this type of care even if the cost of these investments is extremely high (Machado et al., 2011).
This theme arouses reflections on the importance granted to emergency care in countries from the southern hemisphere, where the morbidity rates due to cardiovascular conditions and traumas are high and where universal access to prehospital care could significantly bring down those rates (Hamill, Young, Boger, & Mihailidis, 2009 ; Lewis, Stubbs, & Eisenberg, 2013).
It should also be highlighted that the more efficient the prehospital emergency care, the better the chances of minimizing the damage these events provoke. Given the importance of telephone triage for successful care, it is fundamental to leverage funding for the implementation of protocols, software development, and continuing education for ambulance dispatchers, with a view to transforming this practice into a health promotion action, besides reducing the health problems (Singer, Infante, Oppenheimer, West & Siegel, 2012 ; Wheeler et al., 2015).
The use of the checklist from the STROBE initiative permitted analyzing the methodological rigor of the articles. The checklist contains 22 items, with recommendations as to what to include in a more precise and comprehensive description in observational studies (Malta et al., 2010).
Hence, the identification of eight (34.7%) articles that include all items on this list means that the results presented in those studies provide better descriptions of the practical reality. The remaining 15 (65.2%) partially complied with the requirements of this repertoire. Therefore, no study was selected that can be considered of low methodological rigor according to the criteria adopted. Studies on the methodology of evidence-based practice argue that the selection of methodologically rigorous studies permits inferring on better clinical conducts based on the literature and offers greater support to care professionals (Akobeng, 2005 ; Mendes et al., 2008).
Considering the language of the reviewed articles, 22 (95.6%) studies were published in English and one in French. These data were directly related to the investigated databases and the journals where these studies were published, which largely require articles in English because of their international circulation.
As for the analysis of the content needed to outline the panorama of prehospital emergency telephone triage, we chose to present the content in four important aspects: the use of protocols, technological support, professional responsible for the triage decision, and suggestions to improve the process.
In the first category, 21 (91.3%) of the selected studies affirm that at least one specific protocol is used to conduct the telephone triages. Several researchers (Lexow, 2012; Majed, Valette, & Devienne, 2009 ; Palma et al., 2014 ; Wheeler, 2009) defend the use of specific institutional protocols for the prehospital emergency care services, as this guarantees the standardization of telephone triage conducts.
Another aspect for discussion is found in Category 2, which clearly shows that 22 (95.6%) of the studies mentioned the use of software or mobile applications to support decision making during telephone triage. The technological devices associated with protocols were tools that facilitate and permit rapid conducts (Bošan-Kilibarda & Grba-Bujević, 2013 ; Clawson, Olola, Heward, & Patterson, 2007 ; Gibson et al., 2013).
In terms of the professional category that makes the decision to send help through telephone triage, as analyzed in Category 3, 12 (52.1%) declared that they were nurses, 10 (43.4%) did not specify the professional category of the dispatcher, and only one (4.3%) indicated that the physician was responsible for making the decision. These data support the assertion found in the literature that indicates that there is no need for a specific background to work as an ambulance dispatcher, as what determines the success of the process is the use of a well-established protocol, supported by specific software and continuing training for this professional (Clawson et al., 2007 ; Marklund et al., 2007 ; Wheeler et al., 2015).
With a view to envisaging future courses for telephone triage, the outcomes and the authors' opinions were identified in the considerations of each article. We observed that seven (30.4%) believed in training as a solution to problems in the area, four (17.3%) suggested the development of mobile phone applications that permit multiple audiovisual resources to support a better emergency care conduct, and the remainder did not suggest any conduct.
Nowadays, more mobile phones than people exist around the world, and the access to mobile applications can permit a new form of telephone triage, using other means to support the decisions (Marklund et al., 2007 ; Morimura et al., 2011 ; O'Neill & Deakin, 2007 ; Paredes, Fonseca, Cabo, Pereira, & Fernandes, 2014).
On the basis of the development of the study, a common feature could be identified in the telephone triages described in the investigated studies, which is the use of three steps for its efficient practice: The first comprises identification of the victim and the occurrence; the second relates to verifying the availability of the resources needed to respond to each call for help; and the third is the method the ambulance dispatcher or emergency medical service uses to prioritize care to the detriment of other calls, with the consequent sending of rescue teams. The identification of the similarity among these three steps in the studies analyzed reveals a trend in the telephone triage process.
This study joined 23 articles on prehospital emergency telephone triage in 13 countries on three different continents. All studies had a quantitative and nonexperimental, observational design. They were mostly published in English and their methodological rigor received positive assessments.
In response to the concern that inspired this study, it is concluded that prehospital emergency telephone triage frequently takes place in three steps: identification of the event; deduction of the need for support; and prioritization of calls to forward the rescue team. It is important for telephone triage to be based on specific institutional protocols, supported by technologies that guarantee the dynamic nature of the data and the constant training of the professionals responsible for deciding on the appropriate conduct.
Thus, telephone triage is a globally disseminated practice that permits agility and efficiency in prehospital emergency care, turning it into effective process to define the priority and care level for each emergency telephone call.
The use of six databases can represent the limitation of this study, although these were comprehensive electronic databases of scientific journals that granted access to a large number of viable articles for this research. This study is relevant because it clearly cites the characteristics evidenced for the prehospital emergency telephone triage process, thus supporting the best clinical practices to forward emergency medical care.
- Software or mobile applications support decision making in prehospital telephone triages.
- Telephone triage has spread around the world and enhances the speed and efficiency of emergency medical services.
- This article presents ways to improve clinical practice to nurses for the sending of rescue teams.
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