Using Video for Triage of Children With Fever at the Medical Helpline 1813 in Copenhagen, Denmark
Condition: Fever; Telemedicine; Pediatrics; Triage
MeSH terms: Fever
Study type: Interventional

Summary: 
      Background:

      The Medical Helpline 1813 in Copenhagen, Denmark handles acute, non-life threatening medical
      emergencies. Approx. 200,000 calls/year concern children, and about 30% are referred to a
      pediatric urgent care center. However, most of these children have very mild symptoms, which
      require neither treatment nor tests, merely parental guidance.

      Initial assessment; triage, of children on the phone is difficult, especially when the
      operator does not know the child or family, and when it is difficult to describe the symptoms
      in medical terms. This may result in too many not-so-sick children and too few more severely
      sick children getting sent to hospital.

      Many parents are very worried about their sick child, but it is not known if this worry can
      be integrated in the triage process.

      Purpose:

      It will be studied if triage by video calls; video triage; provide greater security for
      parents and call operators so that more children can stay at home after medical guidance,
      causing at least 10% fewer visits to pediatric urgent care centers. The degree of worry of
      the parents will also be registered.

      Method:

      Children aged 3 months to 5 years with fever will be triaged by either video or telephone
      every other day, to compare the results between these to otherwise similar groups. Operators
      and parents answer surveys about their experiences.

      Yield:

      Video triage can "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 approx. 190,000 calls to the
      Medical Helpline 1813 regarding sick children younger than 12 years (injuries excluded).
      These children are not so sick that the parents call 112, but the parents need to get in
      contact with the health services outside their general practitioners' (GP) opening hours.

      The health professionals at 1813, have several options after the conversation with the
      parent. They can for example admit the children at a Pediatric Emergency Department (PED),
      refer them to assessment in a pediatric urgency care clinic (Børnelægevagten), guide the
      parents in care for the child (self-care), or advise them to see their GP the next working
      day. Of the 190,000 calls annually regarding sick children, the majority is concerning young
      children; in 2018, just over 175,000 of the calls concerned children under the age of 6.
      Approx. 30% of these children were referred to assessment in a pediatric urgency care clinic.
      Most of these children reveal to have quite mild symptoms, and most are sent back home with
      good advice after an assessment by a doctor.

      Phone triage is difficult, especially when the operator does not know the child nor the
      parents, and it may be difficult to describe symptoms with words. Many visits to the
      pediatric urgency care clinic can be perceived as unnecessary and inappropriate for the sick
      child and its parents, whom, with advice and proper guidance could have stayed at home.
      Moreover, the visits are expensive for the health system.

      A Danish study, which was conducted the first year after the 1813 helpline was launched,
      showed that most calls concerned children aged 0-1 years and that the calls seldom were about
      serious conditions. The author interpreted the results as if the parents were primarily
      calling 1813 to feel safe about the child's condition.

      In a Danish study from 2013, 28% of the urgent inquiries outside the GP's opening hours
      concerned just 2.5% of the children. These children had at least 4 of such urgent inquiries
      in one year. The median age of these children was 2.9 years old, as compared to 7.3 years in
      the whole group of children. The five most common working diagnoses among the children with
      many contacts were acute bronchitis, viral disease, seizures (not classified elsewhere),
      abdominal pain and gastroenteritis, that is, conditions where children are likely to have a
      fever. The authors mention that fever in itself causes many contacts to the health services
      and that the parents are very concerned about fever, which is also shown in several
      international studies.

      It is recommended that all febrile children younger than the age of 3 months shall be seen by
      a doctor urgently. This is due to it being difficult to assess so young children and that
      such young children are likely to have a serious infectious disease. The initial assessment
      of the older febrile children can also be difficult. A study conducted in Belgian GPs
      involving 4,000 children with acute disease showed that only 0.8% of children had a serious
      infectious disease demanding hospitalization. The doctor's feeling that "something is wrong"
      was the most important factor in identifying these seriously ill children during the initial
      medical consultation. The authors then developed a "five step decision tree", where
      "something is wrong" is the first step. The tool has proven to provide the best results in
      terms of diagnostic safety in a validation study. The low incidence of severe infectious
      diseases in industrialized countries has also been shown in other studies.

      In 2017, a novel scale grading the worry of patients was developed in a Ph.D. project at
      1813. It is called degree-of-worry (DOW). The patients scored their worry from 1-5, with 1
      being minimally worried and 5 being maximally worried, and it was subsequently studied if the
      DOW could predict the risk of the patients being hospitalized. The question of if DOW also
      can be used by parents calling 1813 about their sick child is not yet answered.

      Telemedicine is gaining greater and greater acceptance in the medical world, also within
      pediatrics. The American Academy of Pediatrics has urged both general pediatricians and
      pediatric subspecialists to use telemedicine to be able to help more children. In Denmark,
      there are also several initiatives within telemedicine regarding adults. While these
      initiatives are being introduced, it must be remembered that there is a limited amount of
      evidence-based knowledge about the use of video in the health care field, not least in the
      field of triage.

      An American study examined if febrile children could be evaluated on video using the Yale
      Observation Scale. The Yale Observation Scale is an assessment tool designed to predict
      serious illness in febrile children. The American scientists filmed febrile children in a
      Pediatric Emergency Department and found that assessment by the Yale Observation Scale of the
      children on film corresponded to the assessment made by the doctors who conducted a regular
      bedside examination.

      The project group launched a video triage project at 1813 earlier in 2019, using video in
      calls regarding children with respiratory symptoms. The initial results show that the setup
      works and that there is a high level of satisfaction in both parents and operators. This
      project concerning febrile children is analog to the latter project, only with minor changes
      and also with a new focus on the degree of worry.

      Purpose It will be investigated if video calls using the parents' smartphones can improve the
      assessment of febrile children when contacting the Medical Helpline 1813. The hypothesis is
      that video calls can optimize the referral within the next 8 hours after the call, so that
      more parents can feel safe staying home with their only slightly ill child, and that more
      children with severe symptoms are referred directly to admission at a Pediatric Department.

      It will be studied if such video triage is safe and if the patients don't get under-triaged,
      as well as studying the operators' and parents' experiences of the video call, regarding
      safety and degree of worry. The project thus aims at improving the triage with new
      technology, with better patient courses as a result, so that patients without the need for
      urgent medical assessment and treatment safely can stay at home, and patients with urgent
      medical attention are directly referred to the hospital. All in all, video triage can thereby
      reduce the strain on the sick child, its parents and the health services. To the knowledge of
      the authors, there are no other studies of the effect of video calls in the initial triage of
      children, and therefore this project will contribute with new knowledge in this area.

      Method Project setup A small group of operators, all nurses, has been trained in video triage
      as part of the above-mentioned project on children with respiratory symptoms. They will offer
      video calls every other day they are at work, i.e. one-day video triage and the next day
      regular telephone triage, and so on. During the project period, more operators will be taught
      in video triage, so that more operators can participate. There will thus be a step-by-step
      inclusion of operators who carry out video triage. The project thus has the character of a
      stepped wedge randomized trial.

      The results of video days will be compared to results from non-video days. The control group
      will thus be patients from non-video days.

      Patient population: The effect of video triage will be studied on young children with fever,
      as this patient group is large and frequently contact 1813, and it is expected that the
      assessment of the general state of these children by video calls is better than by phone
      calls.

      Method of video triage On video days, the operators will offer video calls to anyone who
      meets the inclusion criteria.

      The parents will receive a link on their smartphone, which upon activation starts a video
      conversation with the operator at 1813. The operator will use the medical history and the
      video, i.e. both pictures and sound, to make a plan for the child, together with the parent.
      Apart from the video conversation, the operator has all the normal possibilities as in
      not-project calls. For example, there is a call-back option, where the operator can call back
      to the parents after a few hours to hear how the child is after paracetamol administration,
      amongst other possibilities.

      Immediately after the call, the parents will receive an SMS with a link to a questionnaire.
      They will for example be asked how confident they feel about the assessment of the child; how
      safe they feel about the plan laid out for the child and what their DOW was before and after
      the call to 1813. All parents will get a reminder about the questionnaire by SMS 24-48 hours
      after the call.

      After the interview, the operators at 1813 will answer a questionnaire as well. They will be
      asked about how it was to have additional information about the child's condition by watching
      and hearing the child on video and how worried they were for the child, among other
      questions.

      On non-video days, the project operators will include similar children for the telephone
      group . Correspondingly, these parents will also receive an SMS with a link to a
      questionnaire about their experience of the conversation, and a reminder to respond. As with
      video days, the operators will have the possibility to use options as in calls that are not
      part of a project, i.e. for example the possibility of call-back and that parents can send
      pictures if the operator finds it relevant. It will be noted when these options are being
      used.

      Within 2 to 8 business days after the call, the doctors in the project group will read all
      enrolled children's hospital reports in the hospitals' electronic records system, to
      investigate if the children have been at a Pediatric Department within 8 or 48 hours after
      the 1813 call. If a child has been at the hospital, it will be noted if it was seen at a
      pediatric urgent care clinic or at the PED, time and diagnosis, temperature measured in
      hospital, optimally including how temperature was measured, if the child was admitted to the
      pediatric ward, and if so, for how many days. It will also be registered what kind of
      paraclinical testing and treatment the child received, if the child was transferred to an
      intensive care unit, or at worst, got lasting injuries or death.

      The data department at the Emergency Services will daily identify the children involved in
      the project, in that the operators mark the calls in the 1813 record system. The data sheet
      will include call date and time, symptom code and disposition, i.e. what the child was
      referred to. The data sheet will also include the calls that have met the inclusion criteria,
      but where the parent did not want to participate.

      Technical set-up for video calling The video solution is provided by GoodSAM
      Instant-on-Scene, which is already used in several locations in Australia and in the UK and
      can be used on Apple, Windows and Android phones (https://www.goodsamapp.org/instantOnScene).

      Sample size In 2018, there were 177,000 calls concerning children under the age of 6. Of the
      177,000, 9% were referred to admission at a Pediatric Department, 30% were referred to a
      pediatric urgency care clinic, 31% were counseled about self-care and 25% were recommended to
      contact their GP the next working day, i.e. that 56% stayed at home the day the parents
      called 1813.

      It will be investigated if video triage can result in 10% more parents staying at home with
      the child in the next 8 hours after the call, i.e. an increase from 56% to 66%. With a power
      of 80% and two-sided significance of 95%, 774 children divided into two groups should be
      included, according to openepi (http://www.openepi.com/SampleSize/SSCohort.htm).

      The project will be tested for a maximum of 6 months.

      Statistical calculations Non-parametric statistics, double-sided and with significance at
      p-value <0.05.

      Possible yield After the completion of the project, the project group expect to know if video
      calls is an effective new technique that optimizes the triage process, so that more slightly
      ill children can stay at home the day their parents call 1813. That would be a benefit for
      the sick child, its parents and a significant socio-economic gain. It will also be known if
      more severely ill children are referred directly to a Pediatric Emergency Department to a
      greater extent than today, rather than to an initial assessment in a pediatric urgency care
      clinic or being referred to staying at home.

      At the end of the project, the management of the Copenhagen Emergency Medical Services can
      use the project's results to decide if video calls should be a permanent option when
      contacting the Medical Helpline 1813.

      It is expected that video triage will support the health services' work to create the most
      appropriate courses for the children and their families, while at the same time reducing
      resource consumption.
    

Intervention name(s): Video triage
Intervention type(s): Other
Intervention description(s): The operator at the Medical Helpline will offer the parent who's calling regarding the sick child to assess the child on video, as compared to the routine way; 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 by video every other day they are at work, and by telephone the other days. The children will hence be randomized to either video or telephone depending on what day they are calling and which operator they are talking to.
Masking: None (Open Label)
Primary purpose: Other
Keywords: telemedicine; Triage; Call centers; Fever; Pediatrics