Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study

Abstract

To assess accuracy of telephone triage in identifying need for emergency care among those with suspected COVID-19 infection and identify factors which affect triage accuracy.

Design

Observational cohort study.

Setting

Community telephone triage provided in the UK by Yorkshire Ambulance Service NHS Trust (YAS).

Participants

40 261 adults who contacted National Health Service (NHS) 111 telephone triage services provided by YAS between 18 March 2020 and 29 June 2020 with symptoms indicating COVID-19 infection were linked to Office for National Statistics death registrations and healthcare data collected by NHS Digital.

Outcome

Accuracy of triage disposition was assessed in terms of death or need for organ support up to 30 days from first contact.

Results

Callers had a 3% (1200/40 261) risk of serious adverse outcomes (death or organ support). Telephone triage recommended self-care or non-urgent assessment for 60% (24 335/40 261), with a 1.3% (310/24 335) risk of adverse outcomes. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (95% CI: 61% to 62%) for the primary outcome. Multivariable analysis suggested respiratory comorbidities may be overappreciated, and diabetes underappreciated as predictors of deterioration. Repeat contact with triage service appears to be an important under-recognised predictor of deterioration with 2 contacts (OR 1.77, 95% CI: 1.14 to 2.75) and 3 or more contacts (OR 4.02, 95% CI: 1.68 to 9.65) associated with false negative triage.

Conclusion

Patients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

SciScore for 10.1101/2021.06.24.21259441: (What is this?)

Please note, not all rigor criteria are appropriate for all manuscripts.

Table 1: Rigor

Ethics	IRB: Ethical Approval: The North West—Haydock Research Ethics Committee gave a favourable opinion on the PAINTED study on 25 June 2012 (reference 12/NW/0303) and on the updated PRIEST study on 23rd March 2020, including the analysis presented here. Consent: The Confidentiality Advisory Group of the NHS Health Research Authority granted approval to collect data without patient consent in line with Section 251 of the National Health Service Act 2006.
Sex as a biological variable	not detected.
Randomization	not detected.
Blinding	not detected.
Power Analysis	not detected.
Cell Line Authentication	Authentication: 15 Patients under the age of 65 were given a score of 1, since the score is not validated in this age group.

Table 2: Resources

No key resources detected.

Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

Strengths and limitations: Although telephone triage has been recommended and widely used during the pandemic in the UK to risk assess patients with suspected COVID-19 to limit potential spread of infection, this appears to be the first evaluation of accuracy.19 We have used a large cohort of patients identified from routinely collected telephone triage records and linked this to nationally collected, patient-level healthcare records to provide robust outcome data. We have assessed performance in a cohort of patients with suspected infection which, in the absence of accurate universally available rapid COVID-19 diagnostic tests, reflects the population which urgent and emergency care services must clinically triage. Unrestricted community testing for those with symptoms suggestive of COVID-19 infection was only available from 18/05/2020 and therefore it is not possible to estimate the proportion of confirmed infections. However, known factors associated with adverse outcomes in COVID-19 infection were found to be predictive of the primary outcome in our cohort including increasing age, male sex, diabetes and frailty.20–22 Due to the use of routinely collected data there were high rates of missing data for some variables, for example, ethnicity and frailty, which prevented inclusion in some analyses. We have also assumed that if co-morbidities were not recorded in the previous 12-months they are not present. The mechanism of how data are collected and recorded in the routine d...

Results from TrialIdentifier: No clinical trial numbers were referenced.

Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

Results from JetFighter: We did not find any issues relating to colormaps.

Results from rtransparent:

Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
No protocol registration statement was detected.

Results from scite Reference Check: We found no unreliable references.

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