This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Assessment by the NHS 111 telephone service provided by Yorkshire Ambulance Service reliably identified people with COVID-19 who needed urgent care. Research found that the telephone service distinguished between people who needed urgent care, and those who could safely look after themselves at home.
This research, carried out during the first wave of the pandemic, analysed NHS 111 telephone assessments (known as telephone triage) of people with suspected COVID-19 infection. It found that small numbers of people (1 in 100) were missed (considered non-urgent but then became seriously ill or died). But a similar proportion of people can be missed when in-person assessments are made in hospital.
People who were missed were more likely to be younger, to be living with diabetes, or to have rung 111 multiple times. Ringing multiple times is a potential indicator of increased risk – this finding has been fed back to the ambulance service.
Telephone triage could reduce the numbers of people with a low risk of complications who attend hospitals or other care settings. The authors say this was relevant during COVID-19, and potentially future pandemics.
For more information about NHS 111, visit the NHS website.
The issue: can NHS 111 identify people who need urgent care?
NHS 111 is a 24-hour national telephone service for health problems. During the pandemic, NHS England asked people with suspected COVID-19 infection to call 111. This was intended to reduce the risk of hospitals being overwhelmed by huge numbers of people who did not need to see a healthcare professional.
The volume of calls to 111 increased; the service therefore developed a telephone triage pathway specifically for people calling with suspected COVID-19. Where appropriate, a call could be passed from the initial call-handler to a clinician (usually a nurse or paramedic).
People considered to have non-urgent illness were advised to look after themselves at home or be assessed by their GP, for example. Those who needed urgent care were advised to come to the emergency department, or an ambulance was sent.
The study explored how accurately NHS 111 distinguished between those needing urgent care and those who could look after themselves at home.
What’s new?
The study included more than 40,000 calls to NHS 111 made by people with suspected COVID-19 infection. The calls were managed by Yorkshire Ambulance Service between March 2020 and June 2020 during the first wave of the pandemic when knowledge about COVID-19 was still emerging. Callers were 47 years on average.
The study looked at 2 groups of people. Those in the urgent care group were sent an ambulance or advised to attend A&E. Those in the non-urgent group were advised to care for themselves at home or seek non-urgent support. The researchers used the NHS Digital care record to find out whether callers had died or needed organ support (for failing kidney, heart, or lung) within 30 days of dialing 111.
Overall, 1,200 (3%) people either died or needed organ support.
Among people advised to care for themselves (non-urgent group):
- 1 in 100 (1%) either died or needed organ support; this is similar to the proportion of ‘missed’ people assessed in person, according to other studies
- younger people and those living with diabetes were more likely than others to be told incorrectly that they did not need urgent care
- calling the service multiple times was associated with an increased risk of needing urgent care and not receiving it; those who called 3 or more times were around 4 times more likely to not receive an emergency response and die or need organ support.
Among people in the urgent care group:
- people with long-term lung or kidney disease, or a weakened immune system, were more likely than others to be told incorrectly that they needed urgent care.
Why is this important?
The findings show that 111 triage has similar accuracy to the triage used in emergency departments and urgent care settings for other conditions. The risk of being incorrectly told not to seek urgent care is small; the researchers say it may have been the best accuracy that could be achieved (given knowledge of COVID at the time, and that information was via telephone).
The study showed that telephone triage can reduce demand on hospitals. The researchers calculate that it replaced 61 ambulance journeys or urgent clinical assessments each day per million people. Telephone triage arguably safely managed demand in this, and possibly future, pandemics.
However, small numbers of people were given incorrect advice. Calling multiple times was a strong indicator of the need for emergency care. Younger people and those living with diabetes were more likely than others to be incorrectly told not to seek urgent help. People with long-term lung and kidney disease, or a weakened immune system were more likely than others to be given urgent care they did not need.
This study was part of a larger NIHR-funded project on urgent public health priority. The project, called PRIEST, evaluated triage methods for people presenting to emergency departments, ambulance services and NHS 111 during the pandemic.
What’s next?
These findings will feed into future triage systems to improve their accuracy. Multiple calls about the same person could be flagged, for example; these people are more likely to need urgent care. The researchers have shared findings from this study with the Royal College of Emergency Medicine and have asked NHS 111 to amend its algorithms. Multiple calls could signal increased risk in other conditions, they say.
Call handlers could be prompted to explore more thoroughly, the symptoms of people with diabetes, for example. This could improve the advice they give.
You may be interested to read
The paper this Alert is based on: Marincowitz C, and others. Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study. British Medical Journal Quality and Safety 2022;0:1-12.
Research by the same team into tools that could improve the accuracy of telephone triage for suspected COVID-19: Marincowitz C, and others. Prognostic accuracy of triage tools for adults with suspected COVID-19 in a prehospital setting: an observational cohort study. Emergency Medicine Journal 2022;39:317-324. And Marincowitz C, and others. Accuracy of emergency medical service telephone triage of need for an ambulance response in suspected COVID-19: an observational cohort study. British Medical Journal Open 2022;12:e058628.
Information about NHS 111.
Information about COVID-19, including symptoms and testing.
Funding: This study was funded by the NIHR Health and Technology Assessment Programme. One author was funded as a NIHR Clinical Lecturer.
Conflicts of Interest: None declared.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
