Using Video Transmission for Telephone Triage of Children
Condition: Telemedicine; Triage; Respiratory Tract Diseases; Pediatrics
MeSH terms: Respiratory Tract Diseases
Study type: Interventional

Summary: 
      Background

      The medical helpline 1813 in Copenhagen, Denmark handles telephone calls regarding
      non-life-threatening medical emergencies. Next to 200,000 calls/year concern children and
      afterwards about 30% are referred to a pediatric urgent care center. However, most of these
      children have very mild symptoms, which do neither require treatment nor any tests, but
      merely parental medical guidance.

      Initial assessment; triage, of children on the telephone is difficult, especially when the
      operator does not know the child or the parents, and when it is difficult to describe the
      symptoms in medical terms. This may result in both too many not-so-sick children getting
      unnecessarily referred to hospitals, and perhaps also too few more severely sick children
      sent to the hospital.

      Purpose

      This project will study if triage of children by videocalls (video triage) provide greater
      security for parents and health care personnel in the decision that more children can stay at
      home after medical guidance, thus causing at least 10% fewer visits to a pediatric urgent
      care center.

      Furthermore, the investigators will study if video triage identifies more children with the
      need of urgent admission to a Department of Pediatrics.

      Method

      Children aged 6 months to 5 years with symptoms from the respiratory tract will be triaged by
      either video or telephone by an operator every other day, in order to compare the results
      between these two similar groups. In cases of video triage, the parent will receive a text
      message to their smartphone with a video link.

      The safety of video triage will be assessed by reviewing the hospital case reports of all
      patients for contact within the 48 hours after the 1813 call.

      Perspectives

      Video assessment at call centers may "give eyes to the operators" and revolutionize telephone
      triage. The study may result in fewer children referred to hospitals, more appropriate use of
      resources and better experiences for the families.
    

Detailed description: 
      Background

      Each year the Copenhagen Emergency Services receives approximately 190,000 calls to the
      medical helpline 1813 regarding sick children younger than 12 years (injuries excluded)
      (Rasmussen MV, ref. 1). These children are not so sick that the parents call the emergency
      helpline 112, but the parents need to contact the health care system outside their general
      practitioners' (GP) opening hours.

      After contact with the parents the medical helpline 1813's health professionals have several
      possibilities for the children; e.g. admitting the children to a Department of Pediatrics,
      referring them to assessment in Børnelægevagten (a pediatric urgent care center), guiding
      them to self-care at home, or referring them to their GP the next workday.

      Of the 190,000 calls annually regarding sick children, the majority of the calls concerns
      small children; in 2018, about 175,000 of the calls concerned children younger than 6 years.
      About 30% of these children were referred to assessment in a pediatric urgent care center.
      Most of these patients have mild symptoms which do neither require treatment nor paraclinical
      testing, but merely parental medical guidance. These consultations can be experienced as
      unnecessary and inappropriate for the sick child and its parents. Moreover, the visits are
      expensive for the health system.

      Telephone triage is difficult, especially when the operator does not know the child or the
      parents, and when it is difficult to describe symptoms in medical terms. Telemedicine, i.e.
      the use of communication- and information technology within the healthcare system, is gaining
      increasing influence in the medical society, also within pediatrics (Olson CA et al, ref. 2).
      The American Academy of Pediatrics has urged both general pediatricians and pediatric
      subspecialists to use telemedicine to serve more children (Marcin JP et al, ref. 3).

      Two studies both found good agreement between face-to-face and video-assisted assessment of
      children with respiratory symptoms (Siew L et al, Gattu R et al, ref. 4, 5). Another study
      about children with acute worsening of asthma, reported that the parents felt safer when the
      triage of the child was done by a health professional who could watch the child on video, and
      the health professionals also felt safer with the video triage (Freeman B et al, ref. 6).

      Purpose

      Does triage of children by videocalls (video triage) provide greater security for parents and
      health care personnel in the decision that more children can stay at home after medical
      guidance, thus causing at least 10% fewer visits to Børnelægevagten (a pediatric urgent care
      center)? Furthermore, doses triage of children by videocalls (video triage) identify more
      children with the need of urgent admission to a Department of Pediatrics?

      The project will investigate the safety of video triage, by subsequently reading in the
      children's hospital case reports and study if the children have been examined at a pediatric
      department within the first 48 hours after the 1813 call.

      The investigators will also examine the parents' and the operators' experience with the video
      call, regarding feelings of safety and the technical quality.

      The project thus aims to evaluate the value of improving triage with the new technology,
      video calls.

      To our knowledge, there are no other studies of the effect of video calls in the initial
      triage of children.

      Methods

      Study design and structure:

      The project is a prospective quality improvement study investigating the results of a new
      intervention.

      Initially, a smaller group of nurses is trained in video triage. They will offer video triage
      every other work day, i.e. one-day video triage and the next day ordinary telephone triage,
      etc. Consequently, the operators are always the same, and the only difference between the
      groups will be if video triage is performed.

      During the project period, more nurses will be trained in video triage. There will thus be a
      step-by-step inclusion of nurses who carry out video triage. The project thereby has the
      character of a stepped wedge randomized trial (Hemming K et al, ref. 7).

      The results from video triage days will be compared with results from non-video triage days.
      The control group will thus be the patients from non-video triage days.

      Method of video triage:

      Initially 20 operators, all nurses, will be trained in video triage. During the project
      period, on video days, the operators will offer video triage to children aged 6 months up to
      and including 5 years, with respiratory symptoms.

      The parents will receive a text message with a link on their smartphone, which upon
      activation starts a video call with the operator at 1813.

      The operators will use the medical history as well as the video, i.e. both video and audio,
      to make a plan for the child together with the parent.

      Immediately after the call, the parents will receive a text message with a link to an
      electronic questionnaire regarding their experience with the call and the assessment of their
      child.

      After the call, the operators at 1813 will also answer an electronic questionnaire, about the
      experience regarding the call.

      On non-video days, the operators will enroll corresponding children to telephone triage.
      Similarly, these children's parents will receive a text message about their experience with
      the call, and the nurses will also fill out a questionnaire after these calls.

      Within 2 to 8 workdays after the call the project group will read the child's hospital case
      report, to investigate if the child has been at a hospital within 8 hours or 48 hours after
      the call to 1813. If the child has been at a hospital, there will be noted for example date,
      time and diagnosis, and if the child was admitted to an intensive care unit, or in the worst
      case, got lasting injuries or died.

      The data department at the Copenhagen Emergency Services will daily extract data on the
      children enrolled in the project from a patient treatment database at the Copenhagen
      Emergency Services, which was established with the approval of the regional information
      security department. The data sheet will include data on the patient and the call.

      Sample size:

      In 2018 there were 177,000 calls regarding children up to and including 5 years. Of the
      177,000 calls, 9% were referred directly to admission at a department of Pediatrics, 30% were
      referred to assessment at pediatric urgent care center, 31% were guided in self-care, 25%
      were advised to call their GPs the next workday and 5% were referred to other options. That
      is, 56% stayed at home the day the parents called 1813.

      The investigators hypothesize that video triage can result in at least 10% more parents
      staying at home with the child on the day they call 1813, i.e. an increase from 56% to 66%.
      With a power of 80% and two-sided significance of 95%, a total of 774 children distributed on
      two equal sized groups of 387 patients should be included according to openepi
      (http://openepi.com/SampleSize/SSCohort.htm).

      If, on the other hand, video triage results in 15% more parents staying at home with the
      child the day they call 1813, i.e. an increase from 56% to 71%, it is only necessary to
      include 346 children in total to identify such a difference.

      In contrast, if video triage results in 7% more parents staying at home with the child at the
      day, they call 1813, i.e. an increase from 56% to 63% 1582 children divided into two groups
      must be included, and if video triage only results in 5% more parents staying at home with
      the child at the day of the call to 1813, i.e. an increase from 56% to 61% 3102 children
      divided into two groups must be included. In all cases in according to openepi
      (http://openepi.com/SampleSize/SSCohort.htm) with a power of 80% and two-sided significance
      of 95%.

      Statistics:

      Non-parametric statistics, two-sided and with significance at p-value <0.05.

      Interim analyses:

      After the first 200 video calls, an interim analysis to study the effect of the video triage
      will be performed, including the period of time it has taken to enroll these children, as
      well as how the video triage technically has worked, in order to be able to correct possible
      problems. The safety will also be reviewed, in order to make sure that the children assessed
      on video do not have higher admittance rate and/or mortality rate, as a sign that they arrive
      too late to the hospital.

      After the first 400 first calls, another interim analysis to study the effect of video calls
      will be made. This will also include a study of whether there is a significant difference
      between the number of children staying at home the day the parents call 1813 using video
      triage and using common telephone triage.

      If no significant difference is revealed the study will go on and the effect of video triage
      will be evaluated when 774 patients has been enrolled.

      If a significant effect is still not revealed between the patients using video triage and
      using common telephone triage the project will go on until 1600 patients have been included.

      If no significant difference is revealed the study will go on and the effect of video triage
      will be evaluated when 3500 patients has been enrolled. However, the study will not go on
      more than 6 months.

      Perspectives and possible yield

      At the end of this initial project, the project group expect to know if use of video triage
      can increase the number of children who safely can stay at home the day their parents call
      1813, i.e. the children are referred to self-care or to their GP. This may be beneficial for
      the sick child and its parents and there may be a socio-economic win. It will also be known
      if children with more severe symptoms more often are referred directly to a Department of
      Pediatrics, rather than to an initial assessment in a pediatric urgent care center.

      After the study of the video triage, the management at the Emergency Services Copenhagen can
      decide if video triage will be an integrated option at the medical helpline 1813.
    

Intervention name(s): Video triage
Intervention type(s): Other
Intervention description(s): The operator will offer the parent calling regarding the sick child to assess the child on video, as compared to the current standard; on the telephone.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: The operators at the medical helpline 1813 will triage children meeting the inclusion criteria using video every other day they are at work, and over telephone the other days. Consequently, the operators are always the same, and the only difference between the two groups of patients will be if video triage or telephone triage is performed.
Masking: None (Open Label)
Primary purpose: Other
Keywords: Telemedicine; Triage; Call Centers; Respiratory Tract Diseases; Pediatrics