339 research outputs found
An evaluation of service user experience, clinical outcomes and service use associated with urgent care services that utilise telephone-based digital triage : a systematic review protocol
Get PDFBackground: Telephone-based digital triage is widely used by services that provide urgent care. This involves a call handler or clinician using a digital triage tool to generate algorithm-based care advice, based on a patient’s symptoms. Advice typically takes the form of signposting within defined levels of urgency to specific services or self-care advice. Despite wide adoption, there is limited evaluation of its impact on service user experience, service use and clinical outcomes; no previous systematic reviews have focussed on services that utilise digital triage, and its impact on these outcome areas within urgent care. This review aims to address this need, particularly now that telephone-based digital triage is well established in healthcare delivery. Methods: Studies assessing the impact of telephone-based digital triage on service user experience, health care service use and clinical outcomes will be identified through searches conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus. Search terms using words relating to digital triage and urgent care settings (excluding in-hours general practice) will be used. The review will include all original study types including qualitative, quantitative and mixed methods studies; studies published in the last 20 years and studies published in English. Quality assessment of studies will be conducted using the Mixed Methods Appraisal Tool (MMAT); a narrative synthesis approach will be used to analyse and summarise findings. Discussion: This is the first systematic review to evaluate service user experience, service use and clinical outcomes related to the use of telephone-based digital triage in urgent care settings. It will evaluate evidence from studies of wide-ranging designs. The narrative synthesis approach will enable the integration of findings to provide new insights on service delivery. Models of urgent care continue to evolve rapidly, with the emergence of self-triage tools and national help lines. Findings from this review will be presented in a practical format that can feed into the design of digital triage tools, future service design and healthcare policy. Systematic review registration: This systematic review is registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO 2020 CRD42020178500)
Clinician-led secondary triage in England's urgent care delivery : a cross-sectional study
Get PDFClinician-led secondary triage, following primary triage by the NHS 111 phone line, is central to England's urgent care system. However, little is known about how secondary triage influences the urgency attributed to patients' needs. To describe patterns of secondary triage outcomes and call-related factors (such as call length and time of call) associated with upgrading/downgrading of primary triage outcomes. Cross-sectional analysis of secondary triage call records from four urgent care providers in England using the same digital triage system to support clinicians' decision making. Statistical analyses (mixed-effects regression) of approximately 200 000 secondary triage call records were undertaken. Following secondary triage, 12% of calls were upgraded (including 2% becoming classified as emergencies) from the primary triage urgency. The highest odds of upgrade related to chest pain (odds ratio [OR] 2.68, 95% confidence interval [CI] = 2.34 to 3.07) and breathlessness (OR 1.62, 95% CI = 1.42 to 1.85; reference: abdominal pain) presentations. However, 74% of calls were downgraded; notably, 92% ( = 33 394) of calls classified at primary triage as needing clinical attention within 1 h were downgraded. Secondary triage outcomes were associated with operational factors (day/time of call), and most substantially with the clinician conducting triage. Non-clinician primary triage has significant limitations, highlighting the importance of secondary triage in the English urgent care system. It may miss key symptoms that are subsequently triaged as requiring immediate care, while also being too risk averse for most calls leading to downgrading of urgency. There is unexplained inconsistency between clinicians, despite all using the same digital triage system. Further research is needed to improve the consistency and safety of urgent care triage
Patients’ and carers’ experiences of urgent care telephone-triage: UK-based semi-structured interview study
No full textSocioeconomic differences in help seeking for colorectal cancer symptoms during COVID-19
No full textSafety and accuracy of digitally supported primary and secondary urgent care telephone triage in England: an observational study using routine data
No full textBackground: England’s urgent care telephone triage system comprises non-clinician-led primary triage (NHS111) assessment followed, for approximately 50% patients, by clinician-led secondary triage. Digital decision support is utilised by both. We explore the system’s safety and accuracy relative to patients’ use of emergency departments (EDs) and in-patient care in the subsequent 24 h. Methods: descriptive analyses were used to investigate outcomes of 98,946 calls that underwent primary and secondary triage. We investigated sensitivity (safety) and specificity (efficiency/accuracy) in relation to subsequent ED attendance and in-patient hospital admission. Mixed effects regression models were used to explore potential under-estimation of clinical risk (under-triage). Results: sensitivity was greater in primary triage, whilst specificity was greater in secondary triage. The positive predictive value for attending ED after being assigned a triage urgency level of within 2 h was 46.0% for secondary triage compared to 20.7% for primary triage; for inpatient admission it was 18.0% and 9.2% respectively. 1.5% (n = 1468) patients triaged to same-day or less urgent care at secondary triage were subsequently admitted for in-patient care. In relation to in-patient admission within 24 h, there were greater odds of potential under-triage for calls made between midnight and 6am, and for shorter duration calls, respectively OR = 1.71; CI:1.32–2.21 and OR: 1.66, CI: 1.30–2.11. The service provider (e.g., service provider 2, OR = 5.61; CI:3.36–9.36) and individual clinician (OR covering the 95% midrange = 16.15) conducting triage were the characteristics most greatly associated with this potential under-triage; p < 0.001 for all. Conclusions: clinician-led urgent care triage is more accurate in identifying the likelihood of a need for ED or in-patient care than non-clinician triage. Non-clinician primary triage is risk averse, reflected in its high sensitivity but low specificity. Service and clinician characteristics associated with potential under-triage need further investigation to inform ways of improving the safety and effectiveness of urgent care telephone triage. Clinical trial number: Not applicable.</p
Service use, clinical outcomes and user experience associated with urgent care services that utilise telephone based digital triage: a systematic review
No full textObjective: to evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care.Design: systematic review and narrative synthesis.Data sources: Medline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020.Eligibility criteria for selecting studies: studies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care.Data extraction and synthesis: two reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings.Results: thirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients' adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions.Conclusions: further research is needed into patient level service use, including patients' adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery
'The cracked mirror': Anne Sexton's poetics of self-representation
No full textThis thesis re-evaluates the work of the poet Anne Sexton (1928-1974), concentrating, in particular, on the indeterminacies, contradictions and aporia which it finds to be characteristic of her ostensibly frank and self-revelatory writing. The study is based on a close textual
analysis of Sexton's writing, is informed by oststructuralist theories, and is sustained by an
examination and discussion of archive collections of her previously unpublished papers. In seeking an understanding of Sexton's poetics, the thesis identifies and interrogates the strategies of denial and obfuscation apparent in her own explication of her work - principally, by scrutiny of the unpublished, and previously unresearched, drafts of a series of lectures
which she delivered in 1972. Chapters One and Two consider the origins of `confessional' or - Sexton's preferred term - 'personal' poetry and reassess her place within contemporary poetry. They suggest that
Sexton's writing is engaged in a process of negotiation and contestation, both with the boundaries and expectations of confessionalism, and with the strictures of T. S. Eliot's theory of `impersonality'. In support of these arguments, Chapter Two offer a reading of Sexton's
little-known poem, `Hurry Up Please It's Time', alongside its intertext, Eliot's The Waste Land. Chapter Three reassesses received views of the supposedly beneficial interrelationship between confessional speaker and reader. It examines Sexton's appropriation of dramatic
masks and personae and her use of metaphors of striptease and prostitution, and suggests that these are employed simultaneously to appease and to repel an intrusive audience. Similarly, Chapters Four and Five trace Sexton's problematisation of two previously-accepted tenets of confessional poetry: its status as autobiography and its truthfulness, drawing attention to the techniques employed in order to give the impression of both. Chapter Six considers Sexton's
problematic engagement with a language which is not malleable, transparent, and referential but, rather, is experienced as uncooperative and occlusive. Finally, the thesis recuperates Sexton from the common charge of narcissism, arguing that it is the writing, rather than the poet, which is self-reflexive and self-conscious. In this respect, it concludes that her work - perhaps unexpectedly - anticipates many of the tendencies of postmodernist writing
Images of Self: A Study of Feminine and Feminist Subjectivity in the Poetry of Sylvia Plath, Anne Sexton, Margaret Atwood and Adrienne Rich, 1950-1980
No full textPhDThe thesis explores the poetry (and some prose) of Plath, Sexton,
Atwood and Rich in terms of the changing constructions of self-image
predicated upon the female role between approx. 1950-1980.1 am
particularly concerned with the question of how the discourses of
femininity and feminism contribute to the scope of the images of the
self which are presented.
The period was chosen because it involved significant upheaval and
change in terms of women's role and gender identity. The four poets'
work spans this period of change and appears to some extent generally
characteristic of its social, political and cultural contexts in America,
Britain and Canada. (Other poets' work, for example Rukeyser, Lorde,
Levertov, is included too. ) The poets were not chosen to illustrate a
pre-feminist vs. feminist opposition since a major concern is to explore
what I see to be the symbiotic relation between femininity and feminism
(as also between orthodoxy and heresy). However the thesis is organised
chronologically because periodisation is important for a consideration
of the poetry's social setting.
In wanting to connect the poetry with cultural and political
circumstances as much as possible I have taken Edward Said's assertion
of a text's position of 'being in the world', its potential as a cultural
product to help reshape reality, and its value as a 'powerful weapon of
both materialism and consciousness'. This is the starting point for the
study which is circular and cumulative in shape, fundamentally thematic,
though each chapter is a chronological exploration of the work of one
specific poet, beginning with Plath and completing with Rich. A
conclusion attempts to pull the strands of each together and consider
the implications raised.
The thesis has four general concerns which run through its particular
focus on each poet. The first involves the relations between cultural
practice and ideology; the second involves the ideology of gender
(through exploration of femininity and feminism); the third involves
authorial ideology (through the construction of self-image in relation to
femininity and feminism) while the fourth involves these concerns in
terms of the overall arena of women's struggle for meaning and selfdetermination
in cultural practice.
More specific elements of the study include collating and comparing
self-images and attempting to make connections or chart changes where
images such as witch, queen, handmaid, shamaness, goddess, earth mother,
whore, madwoman, etc., re-occur. Usage of myth (particularly Persephone).
the Gothic, 'and articulation of lesbian desire are also explored. The
emergence of a female 'hero' self-image, in opposition to 'victim', seems
to be a corollary of the impact
,
of feminism in Rich's poetry
particularly, but this tendency can be traced back through Plath. I
explore the celebration of nature and the power of essentialism in the
construction of heroic female images, particularly in the figure of the
mother flowing with milk at the centre of 'ecriture feminine'.
The concluding chapter suggests that femininity did not constitute
such a repressive constraint on self-image and writing practice for
women as perhaps might be supposed; and that feminism, while opening up
many empowering changes for women, has raised further disturbing and
unresolved questions about identity, and even helped, in some of its
aspects, to create a new 'orthodoxy' in which various aspects of
experience cannot easily be articulated. My example is Rich's later work
where it seems to admit itself limited by its own initially liberating
strategies and looks further on towards new 'heresies.
A mixed-methods evaluation of telephone based digital triage used in urgent care within the United Kingdom
Get PDFBackground
Telephone-based urgent care in England typically involves an initial ‘primary’ triage conducted by a non-clinician in the NHS 111 telephone service. Approximately 50% of these patients are subsequently referred for ‘secondary’ clinician-led triage. This ‘two-step’ model contrasts with other parts of the UK and other countries, where patients typically undergo a single clinician-led triage.
Digital triage is widely used in these services by call takers to support the provision of referral and/or self-care advice, based on the patient’s symptoms. Despite wide adoption, there is limited evaluation of patterns of triage outcomes and patient experience, particularly in the context of England’s two-step triage.
Methods
Convergent mixed methods, including analyses of routine data from four urgent care providers in England to evaluate patterns of triage outcomes, including clinicians’ overriding (decision to upgrade or downgrade the urgency level) from: 1)primary triage outcome and 2)digitally recommended triage outcome generated by the clinician in secondary triage. Semi-structured interviews and thematic analysis were used to explore callers’ experiences of ‘two-step triage’ and ‘direct clinician triage’ in England and Northern Ireland respectively.
Results
Non-clinician triage was risk averse, with over 70% of calls being subsequently downgraded in urgency following secondary triage. However, urgency appeared to be underestimated in primary triage in some calls. In secondary triage, there was variation between services and clinicians in how likely they were to upgrade/downgrade calls. Complexity and delays in two-step triage, and variation in call takers conduct of triage was evident in patients’ experiences.
Discussion
This research indicates inefficiency in two-step triage. Well-resourced secondary triage may help promote the efficient use of urgent and emergency care by patients following triage. Further research is required to investigate variation in triage outcomes between secondary triage providers and individual clinicians. Service providers should monitor calls where variation between call takers is most evident
From Verse to Free Verse, Alaska Poetry from 1867 until 1966.
No full textAt this event, poet Tom Sexton presents part two of his talk on a brief history of Alaska poetry from 1867-1966. Part one was recorded on October 24, 2017 at the UAA Campus Bookstore. Poet Tom Sexton is a Professor Emeritus of English at the University of Alaska Anchorage and was Alaska's Poet Laureate from 1994 until 2000. He is the author of several collections of poetry including For the Sake of the Light and I Think Again of Those Ancient Chinese Poets, both from University of Alaska Press
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