{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T19:20:36Z","timestamp":1773861636330,"version":"3.50.1"},"reference-count":49,"publisher":"BMJ","issue":"7","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2019,6,3]]},"published-print":{"date-parts":[[2019,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>In the Netherlands, the \u2018Netherlands Triage Standard\u2019 (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>An observational study in which 3000 telephone triage recordings (period 2014\u20132016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers\u2019 own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)\/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA\/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>The Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2018-027477","type":"journal-article","created":{"date-parts":[[2019,7,2]],"date-time":"2019-07-02T06:15:16Z","timestamp":1562048116000},"page":"e027477","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":17,"title":["Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study"],"prefix":"10.1136","volume":"9","author":[{"given":"Daphne CA","family":"Erkelens","sequence":"first","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Loes TCM","family":"Wouters","sequence":"additional","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dorien LM","family":"Zwart","sequence":"additional","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roger AMJ","family":"Damoiseaux","sequence":"additional","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Esther","family":"De Groot","sequence":"additional","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arno W","family":"Hoes","sequence":"additional","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frans H","family":"Rutten","sequence":"additional","affiliation":[{"name":"Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2019,7,1]]},"reference":[{"key":"2025121508121222000_9.7.e027477.1","doi-asserted-by":"publisher","DOI":"10.1136\/emermed-2016-206295"},{"key":"2025121508121222000_9.7.e027477.2","unstructured":"Netherlands Triage Standard. http:\/\/de-nts.nl\/ (cited 22 Jun 2018)."},{"key":"2025121508121222000_9.7.e027477.3","unstructured":"National guidelines for telephone triage and advice in Family Practice. https:\/\/www.nhg.org\/winkel\/producten\/nhg-triagewijzer-versie-2016 (cited 22 Jun 2018)."},{"key":"2025121508121222000_9.7.e027477.4","doi-asserted-by":"crossref","first-page":"737","DOI":"10.7326\/M16-2776","article-title":"The development and performance of after-hours primary care in the netherlands: a narrative review","volume":"166","author":"Smits","year":"2017","journal-title":"Ann Intern Med"},{"key":"2025121508121222000_9.7.e027477.5","doi-asserted-by":"publisher","DOI":"10.1093\/fampra\/cmq097"},{"key":"2025121508121222000_9.7.e027477.6","doi-asserted-by":"crossref","first-page":"1747","DOI":"10.11124\/JBISRIR-2016-003139","article-title":"Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review","volume":"15","author":"Nishi","year":"2017","journal-title":"JBI Database System Rev Implement Rep"},{"key":"2025121508121222000_9.7.e027477.7","doi-asserted-by":"crossref","first-page":"678","DOI":"10.1016\/j.jemermed.2015.09.008","article-title":"Performance of the manchester triage system in adult medical emergency patients: a prospective cohort study","volume":"50","author":"Steiner","year":"2016","journal-title":"J Emerg Med"},{"key":"2025121508121222000_9.7.e027477.8","doi-asserted-by":"publisher","DOI":"10.1136\/emj.2008.065508"},{"key":"2025121508121222000_9.7.e027477.9","first-page":"315","article-title":"Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the Principality of Andorra: Can triage parameters serve as emergency department quality indicators?","volume":"5","author":"Jim\u00e9nez","year":"2003","journal-title":"CJEM"},{"key":"2025121508121222000_9.7.e027477.10","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1186\/s12913-017-2564-x","article-title":"The quality, safety and governance of telephone triage and advice services - 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