In Ireland, emergency department (ED) attendance is rising. According to the Department of Health, between 2012 and 2021, it increased by 13.3%. And more recently, according to the Health Service Executive, patients attended the ED on 387,000 occasions in the first three months of 2025, which is an increase of over 3,000 on the same period in 2024.  

Remote pre-hospital triage strategies are being considered to reduce unnecessary ED attendances in Ireland. So, to assess their safety and effectiveness, we at the HRB Evidence Centre conducted an evidence review using international literature at the request of the Department of Health.   

How remote triage works 

Remote pre-hospital triage for unscheduled care categorises patients based on how ill they are. It is conducted via telephone, video call or other online tool, and patients may be advised to attend ED, injury unit or their GP; to self-care; or be dispatched an ambulance.  

Undertriage occurs where patients are categorised to a lower service than needed and is an indicator of safety. Overtriage occurs when patients are categorised to a higher service than needed and is an indicator of effectiveness. 

General triage services sort patients based on how urgently they need care, while specific triage services focus on ruling in or out a specific event or condition such as stroke.  

What the HRB investigated 

Safety was the priority outcome, and to investigate this, we looked at studies reporting how many people: 

  1. Died after being remotely triaged to self-care or a service less urgent than ED.
  2. Were found to need a higher level of care than they were remotely triaged 

As safety was a priority, we only looked at effectiveness studies which also provided information on safety. To investigate effectiveness, we looked at studies reporting how many people:  

  • Were remotely triaged to a less urgent service 
  • Were remotely triaged to ED or ambulance but needed a less urgent service in reality 
  • Still attended ED despite being remotely triaged to a lower level 
  • Used other healthcare services where remotely triaged to self-care 

How we investigated 

  1. Our information specialist conducted a comprehensive search of literature on all relevant existing studies conducted in OECD countries and found almost 15,000 unique records. HRB research officers then screened all these records to find studies that could inform on the safety and effectiveness of remote pre-hospital triage and therefore be included in the review.  
  2. Ultimately, just 11 studies on general triage services and three studies on specific triage services were found. These 14 studies were then quality assessed and analysed before being written up in our full report.  
  3. As all the studies were so different, it was not possible for us to pool them by adding all the participants together and looking at overall outcomes. Instead, we summarised the findings of each and drew narrative comparisons where possible.  
  4. Finally, we graded the evidence for each outcome using the standardised GRADE approach to examine the certainty of the evidence. This takes into account factors such as study design; how many studies we had looking at each outcome; and publication bias i.e. the likelihood that there may be further studies completed on remote pre-hospital triage which were not published or found.  

What we concluded 

After completing all these steps, we concluded that there is a lack of strong evidence on whether remote pre-hospital triage is safe or effective. The evidence was very fragmented, with studies on general triage tending to focus on particular symptoms or callers assigned certain triage categories only. The evidence on specific triage services was also very low certainty and there was no existing reference guidelines for the conditions examined.  

In relation to general triage, we looked to guidelines from the American College of Surgeons Committee on Trauma, which provides a target for undertriage (less than 5% or one in twenty triaged to a lower urgency level than needed) and for overtriage (no more than 25-35% triaged to an urgency level higher than needed).  

However, only two of our identified studies included all users of a general triage service. Furthermore, the evidence from these was mixed and very low certainty in relation to safety and effectiveness. Importantly, this does not mean that remote pre-hospital triage is not safe or effective. It simply means we cannot yet tell based on the current evidence base.  

Key takeaway 

The key takeaway from this HRB evidence review is that more large studies reporting on all users of general triage services, and comparing to reference guidelines, are urgently needed to establish safety and effectiveness with greater certainty. In addition, if we are to implement a remote pre-hospital triage service here in Ireland, it must be continuously monitored in relation to undertriage and overtriage rates.      

The HRB evidence review, Safety and effectiveness of remote pre-hospital triage for appropriate emergency department attendances and service use, is available for download here  

Notes: 

Since the publication of this review in 2024, the Department of Health asked the Health Information and Quality Authority to further progress this work by completing a health technology assessment on an alternative telephone pathway for acute, non-urgent medical care needs in the pre-hospital setting in Ireland. This report was published in October 2025 and was informed by an Expert Advisory Group (including a representative from the HRB), as well as public consultation on a draft report. The assessment’s key finding was a non-urgent telephone or other electronic communication service could help people who are unsure of how to deal with an urgent medical issue, or face difficulties in seeing a GP   

The HRB Evidence Centre 

The HRB Evidence Centre was formed in 2011 and conducts evidence syntheses to inform health policy and decision-making. Our evidence supports the formulation of recommendations, which is the role of policymakers at the Department of Health. The Centre also contributes to the HRB’s key role in research on alcohol and other drugs.