Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance

Congruency of Symptom Choice Between Patients Performing Online Self-Triage and Nurse Phone Triage

Introduction: Online self-triage/symptom checkers are a relatively new e-Health modality. We aimed to evaluate the degree to which patient's chosen symptom during the use of an online self-triage tool was congruent with that chosen by a nurse performing phone triage. Methods: Patient encounters from September 1, 2022, to September 30, 2023, were reviewed for patients who completed both online self-triage and a subsequent nursing phone triage within 24 hours. The symptoms chosen by the patient for their self-triage encounter and the symptoms chosen by the nurse during the subsequent nurse triage were reviewed. The symptoms chosen in these two triage encounters were then compared for congruency. A subset of our database was evaluated for congruency between the self-triage and the nurse phone triage endpoint recommendations. Results: There were 5,443 encounters meeting inclusion criteria to study for congruency between self-triage and nurse triage symptom choice. The range of time between self-triage and nurse triage ranged from 0 min to 1,439 min (23.9 hours) with a median of 23 minutes between self and nurse triage encounters. Symptom congruency between the two methods found 74.2% (4,038) to be completely congruent while 989 (18.2%) were somewhat congruent. Only 7.6% (416) had no apparent congruency. Out of 1,705 self and nurse triage dyads eligible for study for agreement between endpoint recommendations, 244 (14.3%) were under-triaged, 1,110 (65.1%) were triaged to the same level of care and 351 (20.6%) were over-triaged. Conclusion: Congruency between symptoms chosen by the patient for triage and nurse triage were highly congruent with only 7.6% of the sample showing no apparent congruency between the self-triage symptom and the nurse triage symptom. When compared to nurse triage, most self-triage endpoint recommendations were either triaged to the same level of care or were over-triaged to a higher level of care.

Use of Emergency Telemedicine Physicians for Telephone Triage Disposition of Pediatric Patients

OBJECTIVES

Telemedicine is a growing field, with limited data around its utility supporting pediatric emergency care telephone triage. We instituted telemedicine physician support for nurse telephone triage decisions. When the nursing protocols recommended urgent or emergent care, a telemedicine physician reviewed and modified care urgency if appropriate. Our primary study objectives were to evaluate the proportion of patients who were downgraded to less urgent care and assess for potential harm related to the downgrade in care urgency.

METHODS

We conducted a retrospective observational cohort study of pediatric telephone calls to the Mayo Clinic Health System nurse triage line that were directed to the emergency department telemedicine physician from January 1, 2019, to December 31, 2019. Electronic medical records of patients whose care urgency was downgraded and presented to medical care within 72 hours of the triage call were reviewed.

RESULTS

There were 8559 nurse line calls regarding pediatric patients, 882 of which were referred to the telemedicine physician. Among these, 396/882 (44.9%, 95% confidence interval 41.6-48.3) were downgraded. Of downgraded cases, 198 (50.0%) patients sought care within 72 hours of the original call, of which 193 (97.5%) patients were discharged home from that medical visit and 5 (2.5%) patients required admission. No patients were determined to have suffered harm due to the downgrade of visit urgency.

CONCLUSIONS

Our data suggests that telemedicine physicians can safely downgrade nurse triage care recommendations for pediatric patients. Most downgraded patients sought outpatient care, avoiding unnecessary utilization of the emergency department without evidence of associated harm.

Implementation of After-Hours Nurse Line in an Academic Pediatric Endocrinology Practice

Background

After-hours triage of pediatric patients by trained nurses improves consistency of triage decisions, access, and quality of care, and decreases burden on physicians on-call. There is a lack of published experience with this approach in the pediatric diabetes population.

Methods

An after-hours call service was established in September 2019 in our large urban pediatric teaching hospital. Barton Schmitt guidelines, which are widely accepted as the standard for telephone triage care, were modified to include institution specific diabetes management protocols. We analyzed demographics, reasons for call, clinical presentation to the emergency room, and clinical disposition of the callers.

Results

The after-hours call service handled 70% of calls without physician involvement. There were no patients triaged to home care who subsequently required an emergency room visit or hospitalization. Patients who called the after-hours nurse line prior to coming to the emergency room were less sick and were discharged more often from the emergency room. Spanish-speaking parents utilized the service less than English speakers. There were no disparities in utilization based on the insurance status or race.

Conclusions

The after-hours service accurately triaged calls and reduced physician burden. Patients of all races and insurance statuses utilized the after-hours service equally well. Language was a barrier in the utilization.

Telephone Referral to a Paediatric Emergency Department: Why Do Parents Not Show Up?

Medical call centres can evaluate and refer patients to an emergency department (ED), a physician or provide guidance for self-care. Our aim was (1) to determine parental adherence to an ED orientation after being referred by the nurses of a call centre, (2) to observe how adherence varies according to children's characteristics and (3) to assess parents' reasons for non-adherence. This was a prospective cohort study set in the Lausanne agglomeration, Switzerland. From 1 February to 5 March 2022, paediatric calls (<16 years old) with an ED orientation were selected. Life-threatening emergencies were excluded. Parental adherence was then verified in the ED. All parents were contacted by telephone to respond to a questionnaire regarding their call. Parental adherence to the ED orientation was 75%. Adherence decreased significantly with increasing distance between the place the call originated and the ED. The child's age, sex and health complaints within calls had no effect on adherence. The three major reasons for non-adherence to telephone referral were: improvement in the child's condition (50.7%), parents' decision to go elsewhere (18.3%) and an appointment with a paediatrician (15.5%). Our results offer new perspectives to optimise the telephone assessment of paediatric patients and decrease barriers to adherence.

Improving Utilization of an After-Hours Phone Triage Service: A Resident Quality Improvement Initiative

BACKGROUND/OBJECTIVE

Phone triage systems are increasingly used by primary care clinics to improve patient satisfaction and direct low-acuity patients to appropriate care settings. Despite the prevalence of telephone triage, the majority of pediatric training programs do not include this practice in their curricula. Our aim was to increase the volume of after-hours patient phone calls per week by 25% and to secondarily reduce "treat and release" emergency department (ED) visits by 5% over the course of a 9-month quality improvement (QI) study.

METHODS

A resident-led QI project was conducted from 2017 to 2019 at a mixed faculty-resident pediatric primary care practice providing care for an urban, primarily immigrant, underserved population. Eight Plan-Do-Study-Act cycles were developed on the basis of identified key drivers and included efforts to increase the visibility of the call service to patient families. After-hours calls were tracked and compared with similar practices, and ED visits for the first week of each month were reviewed using the electronic medical record system.

RESULTS

After promoting the service via various modalities, the number of after-hours calls increased by 30%, from an average of 6.5 calls per week to 8.5. Treat and release ED visits decreased by 6%, from a baseline of 64.3 to 60.3 visits per week.

CONCLUSIONS

The increased patient awareness of and availability of a reliable after-hours call service in pediatric practices are promising tools for reducing unnecessary ED visits, leveraging resident direction and implementation to promote the service through varying modalities.

To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study

National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote healthcare services going forward.

The evolution and utilization of telehealth in ambulatory nutrition practice

The term telehealth is often used interchangeably with telemedicine. Telemedicine involves the electronic exchange of medical information between two remote sites for the optimization of patient care, whereas telehealth is the application of all electronic communication and delivery systems in the provision of healthcare. Telehealth gives patients an opportunity to communicate with their healthcare providers and, overall, access ambulatory care that otherwise is not available in their area of residence. Several telehealth delivery systems are available for electronic communication. Telehealth and other communications technologies used in the delivery of healthcare services are regulated at both the federal and state levels. Coverage and payment policies vary among the different insurers (e.g., Medicare, Medicaid, and private plans), and policies may further be defined by state telehealth parity laws. Telenutrition involves the use of digital technology to provide nutrition care to patients and caregivers and shows potential to optimize nutrition care and outcomes. The coronavirus disease 2019 pandemic has contributed to sweeping legislative and regulatory changes that allowed the temporary expansion of telehealth delivery and reimbursement to maintain continuity of care for patients who were not able to come in for an in-person office visit with their healthcare provider. The purpose of this review is to introduce key concepts of telehealth delivery systems including policy, legal, and regulatory considerations for ambulatory care as well as the role of telenutrition in nutrition care, and highlight the evolving role of telehealth in optimizing patient and nutrition care during a pandemic and beyond.

Tele-Triage Outcomes For Patients With Chest Pain: Comparing Physicians And Registered Nurses

We took advantage of a change in protocol in an integrated delivery system's telephone consultation service-routing callers complaining of chest pain to physicians instead of registered nurses, whenever feasible-to explore whether tele-triage outcomes differed by staffing type. Comparing outcomes of 11,315 physician-directed calls to those of an equal number of nurse-directed calls in 2013, we found that the physician-directed calls were briefer (eight minutes versus thirteen minutes), produced fewer ED referrals (10 percent versus 16 percent), and resulted in higher patient adherence to the providers' site-of-care recommendation (86 percent versus 82 percent). Mortality rates at seven days were low for both physician- and nurse-directed calls (0.1 percent). We suspect that providers' immediate access to callers' comprehensive electronic health records and patients' rapid access to outpatient care likely contributed to the program's success. Our findings suggest that tele-triage can be used to safely and effectively manage an emergent complaint, and that physicians' expertise may bring additional efficiency to the process.

Emergency Department Attendance after Telephone Triage: A Population-Based Data Linkage Study

OBJECTIVE

To investigate compliance with telephone helpline advice to attend an emergency department (ED) and the acuity of patients who presented to ED following a call.

DATA SOURCES/COLLECTION METHODS

In New South Wales (NSW), Australia, 2009-2012, all (1.04 million) calls to a telephone triage service, ED presentations, hospital admissions and death registrations, linked using probabilistic data linkage.

STUDY DESIGN

Population-based, observational cohort study measuring ED presentations within 24 hours of a call in patients (1) with dispositions to attend ED (compliance) and (2) low-urgency dispositions (self-referral), triage categories on ED presentation.

PRINCIPAL FINDINGS

A total of 66.5 percent of patients were compliant with dispositions to attend an ED. A total of 6.2 percent of patients with low-urgency dispositions self-referred to the ED within 24 hours. After age adjustment, healthdirect compliant patients were significantly less likely (7.8 percent) to receive the least urgent ED triage category compared to the general NSW ED population (16.9 percent).

CONCLUSIONS

This large population-based data linkage study provides precise estimates of ED attendance following calls to a telephone triage service and details the predictors of ED attendance. Patients who attend an ED compliant with a healthdirect helpline disposition are significantly less likely than the general ED population to receive the lowest urgency triage category on arrival.

Pursuit of Value in Connected Healthcare

INTRODUCTION

Potential for direct patient care through remote exchange of health-related information has expanded enormously with the proliferation of technologies leveraging ubiquitous connectivity, but implementation of connected care has been slow and controversial.

MATERIALS AND METHODS

This review demonstrates that controversy regarding connected care arises largely from the fact that proponents and critics are generally considering distinctly different care models. Differences are highlighted to mitigate controversy and to distinguish capacities of these different models.

RESULTS

Distinguishing capacities is essential for establishing the evidence base supporting safety, effectiveness, and efficiency. In care of a particular patient's problem, value is achieved when resources allocated meet requirements for diagnosis and intervention but do not exceed them. Robust evidence supports the value of some well-defined connected care models, exemplified by the Health-e-Access Telemedicine Model.

CONCLUSIONS

The pursuit of value in connected care is fundamentally the same as with in-person care. Provider organizations, legislators, regulators, and payers face not only a complex task in defining standards and enabling appropriate use, but also a heavy burden of responsibility for unleashing connected care that will benefit the entire community.

Using Video from Mobile Phones to Improve Pediatric Phone Triage in an Underserved Population

BACKGROUND

Video-capable mobile phones are widely available, but few studies have evaluated their use in telephone triage for pediatric patients. We assessed the feasibility, acceptability, and utility of videos sent via mobile phones to enhance pediatric telephone triage for an underserved population with asthma.

MATERIALS AND METHODS

We recruited children who presented to an urban pediatric emergency department with an asthma exacerbation along with their parent/guardian. Parents and the research team each obtained a video of the child's respiratory exam, and the research team conducted a concurrent in-person rating of respiratory status. We measured the acceptability of families sending videos as part of telephone triage (survey) and the feasibility of this approach (rates of successful video transmission by parents to the research team). To estimate the utility of the video in appropriately triaging children, four clinicians reviewed each video and rated whether they found the video reassuring, neutral, or raising concerns.

RESULTS

Among 60 families (78% Medicaid, 85% Black), 80% of parents reported that sending a video would be helpful and 68% reported that a nurse's review of a video would increase their trust in the triage assessment. Most families (75%) successfully transmitted a video to the research team. All clinician raters found the video reassuring regarding the severity of the child's asthma exacerbation for 68% of children.

CONCLUSIONS

Obtaining mobile phone videos for telephone triage is acceptable to families, feasible, and may help improve the quality of telephone triage in an urban, minority population.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Evaluation of an after-hours call center: are pediatric patients appropriately referred to the emergency department?

BACKGROUND

There is concern that after-hours nurse telephone triage systems are overwhelming the emergency department (ED) with nonemergent pediatric referrals.

OBJECTIVES

This study aimed to critically review a nonpediatric hospital-based call center with the aim of identifying the algorithms responsible for the majority of nonessential referrals.

METHODS

This is a retrospective observational study performed at a tertiary medical care facility over 1 year. Telephone triage forms of children and adolescents younger than 18 years, exclusively referred by triage nurses using the Barton Schmitt protocols, were reviewed, and their ED course was evaluated by consulting the electronic medical record. "Essential" referrals to the ED were classified as presentations warranting immediate evaluation or referrals requiring "essential interventions" such as serum laboratory tests, imaging, complex procedures, intravenous medications, subspecialty consultation, or admission.

RESULTS

A total of 220 patients were included in this study. Of these, 73 (33%) were classified as nonessential, whereas 147 (67%) were classified as essential. Nonessential patients were significantly younger compared with essential referrals (P < 0.05). They also had lower triage scores (P = 0.026) and shorter ED stays (P < 0.0001). The algorithms for "fever-3 months or older" (12.3%), "vomiting without diarrhea" (8.2%), "trauma-head" (8.2%), "headache" (6.8%), and "sore throat" (5.5%) were determined most likely to result in a nonessential referral.

CONCLUSIONS

Our study identifies that a third of unnecessary pediatric visits to the ED occurred as a result of the nurse triage telephone system in question. We recommend review of the algorithms stated to reduce strain on local ED resources.

Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support

Background

Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN^©.

Methods

We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety.

Results

Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68).

Conclusions

CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.

Satisfaction and public health cost of a statewide influenza nurse triage line in response to pandemic H1N1 influenza

BACKGROUND

The 2009 H1N1 pandemic strained healthcare systems. There was a need for supportive services, rapid antiviral access, and minimization of unnecessary healthcare contacts particularly face-to-face interactions. In response, the Minnesota Department of Health (MDH) launched a telephone-based nurse triage line (NTL) called the Minnesota FluLine coordinating all major MN healthcare systems with NTLs to form a single toll-free number triage service. Callers were evaluated for symptoms of influenza-like illness (ILI) and were prescribed an antiviral if indicated, using nurse administered protocols.

METHODS

To determine caller outcomes, associated healthcare seeking, and satisfaction a telephone survey of Minnesota FluLine callers was conducted using a 5% random sample of those who completed the protocol and those who did not.

RESULTS

Of 6,122 callers with ILI who began the nurse protocol administered by the contract NTL, 1,221 people were contacted for the survey and 325 agreed to participate; response rate was 26%. Of those who completed the nurse protocol 73% said they would have sought healthcare without the Minnesota FluLine, 89% reported the service was moderately or very helpful, and 91% reported being satisfied or very satisfied. Of those not completing the protocol, 50% reported the service was moderately or very helpful and 50% reported being satisfied or very satisfied. 72% of qualitative responses to open-ended questions were positive regarding the MN FluLine. Cost to MDH for operating the Minnesota FluLine service was $331,226 to service 27,391 callers ($12.09/call).

DISCUSSION

The Minnesota FluLine diverted patients with mild ILI symptoms away from acute care visits at low cost and had a high rate of satisfaction among callers. Early intervention likely prevented morbidity and possibly additional cases. NTLs are powerful and flexible tools for pandemic response and should be considered as an important tool for future emergency responses.

The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis

AIM

This paper is a report of the synthesis of evidence on the appropriateness of, and compliance with, telephone triage decisions.

BACKGROUND

Telephone triage plays an important role in managing demand for health care. Important questions are whether triage decisions are appropriate and patients comply with them.

DATA SOURCES

CINAHL, Cochrane Clinical Trials Database, Medline, Embase, Web of Science, and Psyc Info were searched between 1980-June 2010.

DESIGN

LITERATURE REVIEW

Rapid Evidence Synthesis.

REVIEW METHODS

The principles of rapid evidence assessment were followed.

RESULTS

We identified 54 relevant papers: 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision, and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44-98% and compliance ranged from 56-98%. Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care may have lower compliance than decisions to contact emergency services or self care.

CONCLUSION

Telephone triage services can offer appropriate decisions and decisions that callers comply with. However, the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged.

Patient compliance with telephone triage recommendations: a meta-analytic review

OBJECTIVE

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

METHODS

Findings from 13 studies identified through interdisciplinary research databases (1990-2010) were meta-analyzed. Separate pooled analyses compared patients' compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

RESULTS

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients' intentions and health beliefs.

CONCLUSION

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

PRACTICE IMPLICATIONS

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.

Caller self-care decisions following teletriage advice

AIM

To examine caller self-care decisions following teletriage advice provided by nurses.

BACKGROUND

The use of teletriage is gaining popularity as one way of enhancing capacity for self-care. Research from several countries suggests that teletriage reduces the use of other healthcare services without compromising safety. However, there is little or no research related to how often self-care advice is provided and whether or not callers follow the advice.

DESIGN

A descriptive survey design was used with a random sample of 312 callers who were advised by a teletriage nurse to engage in self-care.

METHOD

Callers were randomly selected from all calls to a teletriage service each day of the month for nine months. Data were collected using a researcher-developed interview guide and analysed using a variety of inferential statistics for forced choice questions and content analysis for open-ended questions.

RESULTS

The majority of callers who were advised to engage in self-care reported doing so. Callers with greater self-efficacy and satisfaction with the nurse interaction were more likely to follow advice to self-care. All callers would call the teletriage service again for the same or a different issue.

CONCLUSION

Teletriage callers were confident in the advice provided and were willing to continue to use the service.

RELEVANCE TO CLINICAL PRACTICE

This study indicates that teletriage programmes are a cost-effective way of addressing self-care needs of individuals who might otherwise visit an emergency department.

Can an office practice telephonic response meet the needs of a pandemic?

INTRODUCTION

the H1N1 (subtype hemagglutinin 1 neuraminidase 1) influenza pandemic of 2009 was associated with a large increase in demand for primary care office visits. However, many patients with H1N1 symptoms or exposure could be assessed and treated with telephone protocols.

METHODS

specific H1N1 influenza telephone protocols were developed by Mayo Clinic physicians using Centers for Disease Control recommendations. Using symptom calls to a primary care practice in the United States, we captured nurse telephone triage recommendations, telephone antiviral prescriptions, and what callers would have done without telephone advice. We retrospectively analyzed all symptom calls from July 2009 through January 2010.

RESULTS

call volume was 5,596 calls monthly during the peak influenza months, which was 56% above the monthly average of 3,595 calls for the nonpeak months (p  <  0.001). The calls during October 2009 were 111% over the nonpeak months (p  <  0.001). In October 2009, telephone triage nurses gave 412 prescriptions for antivirals accounting for 5.4% of calls and 39% of all telephonic prescriptions for that month. In the peak H1N1 month of October, there were 1,522 callers who intended to stay home for their care. For the same month, triage nurses suggested 3,250 of the callers stay home. For an October 2009 appointment capacity of 35,126 visit slots, a potential 5% capacity was preserved.

CONCLUSIONS

a telephone triage solution for the acute demands of influenza H1N1 demonstrated how patients had needs met telephonically while preserving medical access for others.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median child's age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or caller's part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.

Acute asthma management by a pediatric after-hours call center

To describe an asthma management protocol used in a nurse-staffed pediatric After-Hours Call Center (AHCC) that incorporates severity-based home treatment recommendations and follow-up call assessments. Call records for asthma advice from January 1, 2004 to June 30, 2004 were identified retrospectively and reviewed. Descriptive statistics were used to report patient demographics, frequencies of symptom severity zones (Red, Yellow, or Green) at initial calls, frequencies of call dispositions designating care advice provided (including home treatment recommendations and seeking emergency department [ED] care), and changes in severity zones between initial calls and follow-up calls when nurses reassessed patients after recommended home treatment. During the study period, 3,632 asthma calls (2,439 initial; 1,193 follow-up) were managed by AHCC nurses. Initial calls were classified mostly as Red (28%) or Yellow (42%) severity zones; 27% were Green zone and 3% could not be categorized. Fifty-two percent of initial calls with Red or Yellow severity zones involved home treatment recommendations; 50% of those Red zone and 63% of those Yellow zone calls had improved severity zones at follow-up call assessments. Twenty-eight percent of patients with home treatment recommendations were referred to the ED at the time of follow-up call nurse reassessment. This telephone-based nurse-staffed pediatric acute asthma management protocol includes provision of severity-based home treatment recommendations and follow-up assessments, and improved symptoms for many children with acute exacerbations. This protocol may also be successful in other locations and may improve outcomes, such as reduction in ED visits.

Patients' Return to Referring Physicians and Its Relation to Their Infertility Duration

OBJECTIVE

To determine if length of patient-reported infertility prior to referral to a specialist is related to the likelihood that the patient will return to the referring physician for obstetrical care.

METHODS

A review of our medical record database identified 430 consecutive pregnant patients, discharged between January 1, 2003, and March 1, 2004. The name of the referring and discharge obstetrician(s), duration of infertility, prior use of clomiphene citrate, and number of previous clomiphene treatment cycles were recorded.

RESULTS

Of the 430 patients, 305 (71%) had information about the referring and discharge obstetrician(s) and complete records regarding prior treatment. Median duration of infertility was 1.3 years (range 0.2-12 years). Fifty-five percent (167 of 305) of patients returned to their referring physician for obstetrical care. If patients were referred prior to 6 months of treatment by the referring obstetrician, 76% (35 of 46) returned. If patients were referred after 6 months to 1 year of treatment, 67% (82 of 122) returned. If after 1-2 years, 35% (33 of 94), and after more than 2 years, 40% (10 of 25) returned to their referring physician. Overall, 25% of patients (77 of 305) patients had preliminary treatment with clomiphene citrate. If the referring physician did not give the patient clomiphene citrate, 55% (128 of 232) returned to that physician; if the patient had been given one to four clomiphene cycles, 54% (37 of 69) returned, and if given more than four cycles, 25% (2 of 8) returned.

CONCLUSIONS

Although many factors may affect a patient's decision to return to the referring doctor, patient satisfaction with the referring physician may be related to timely referral to a specialist.

Clinician practice patterns: linking to community resources for childhood aggression

Creating links to community resources for childhood aggression is one component of office-based violence prevention. Evidence is lacking regarding the effect of training clinicians to make these referrals and families' responses to them. Clinicians who received training (n=47) and parents (1093) were queried on the provision of referrals immediately after the visit. Fewer than half of clinicians (45%) reported making a community referral. A third of providers (37%) noted difficulty in identifying local resources. Training clinicians to utilize community resources for childhood aggression does not often result in creating community links for this purpose.

Payment for telephone care

Telephone care in pediatrics requires medical judgment, is associated with practice expense and medical liability risk, and can often substitute for more costly face-to-face care. Despite this, physicians are infrequently paid by patients or third-party payors for medical services provided by telephone. As the costs of maintaining a practice continue to increase, pediatricians are increasingly seeking payment for the time and work involved in telephone care. This statement reviews the role of telephone care in pediatric practice, the current state of payment for telephone care, and the practical issues associated with charging for telephone care services, a service traditionally provided gratis to patients and families. Specific recommendations are presented for appropriate documenting, reporting, and billing for telephone care services.

How safe is triage by an after-hours telephone call center?

OBJECTIVES

Our goals were to assess (1) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center.

METHODS

The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in > 4 hours but within 24 hours), later visit (visit in > 24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations.

RESULTS

Of the 32,968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within < 1 week after the after-hours calls. The rate of potential underreferral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls. In multivariate modeling, age of < 6 weeks or > 12 years and being triaged after 11 pm were associated with higher rates of potential under-referral.

CONCLUSIONS

Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome.

Triage telefónico realizado por médicos en urgencias de pediatría

OBJECTIVE

To determine the applicability and utility of a telephone triage performed by physicians in a pediatric emergency department (PED).

PATIENTS AND METHOD

All the telephone consultations registered between 2003-10-1 and 2004-10-3 were reviewed. The variables analyzed were: telephone call record (n = 2,560), compliance with the advice given (randomized sample of patients who were not referred to the PED and all patients who were referred) and parent satisfaction (callers over a 1-month period were contacted). A protocol for answering queries was organized and residents received specific training.

RESULTS

There were 59,088 episodes and 2,560 calls were registered (1 call/23 episodes). Forty-eight percent of the calls were received between 5 and 11 pm. All calls were answered by a physician (72% residents, 28% attending physicians). The most frequent reason for calling was to seek advice on symptoms. Eighty-two percent of the calls were resolved through telephone instructions to be carried out in the home. A total of 274 patients were advised to attend the PED, but 29% did not attend, usually because the child's symptoms improved. Twenty patients were admitted to the hospital (6 to wards, 14 to the observation unit). Of the patients not advised to attend, 21% attended the PED and 0.9% were admitted (compared with 7.2% in the referral group, p = 0.0001). More than 90% of the families questioned were satisfied with the advice given. Seventy-five percent would have attended the PED if telephone consultation had not been available. By giving telephone advice, we avoided 115 visits in 1 month.

COMMENTS

If special training programs and answering systems are established after a training period, telephone consultation in a PED is a safe and useful method of performing patient triage. Satisfaction among families was high.

Compliance with Poisons Center Referral Advice and Implications for Toxicovigilance

BACKGROUND

When Poisons Information, or Poisons Control Centers (PCC) give directive advice in response to general public calls it is usually assumed that the advice will be followed, but it is difficult to measure the actual compliance of callers to a PCC. Epidemiological data regarding the incidence of poisoning incidents (Toxicovigilance) often utilizes reports of calls to a PCC.

METHODS

Retrospective review of advice given to all callers to the New Zealand National Poisons Centre (NZNPC) from a defined area for the calendar year 2001. Callers to the NZNPC telephone hotlines who were advised to attend or not to attend the hospital Emergency Department (ED) were subsequently matched with actual ED visits.

RESULTS

The compliance rate for those advised to attend the ED was 76.1%, whereas those advised not to attend had a compliance rate of 98.7%. The overall compliance rate was 94.1%. Of the patients presenting to the ED with a potential poisoning, only 10.2% were referred by the PCC. The callers referred by PCC and direct ED visitors appeared to differ in some respects.

CONCLUSIONS

Compliance with PCC telephone advice is similar to the compliance rates in many other health interventions. Comparisons between populations calling a PCC and those self-presenting to an ED show that PCC data may not reflect the true burden of poisoning to health care systems.

Paediatric telephone triage and advice: the demand continues

Kidsnet was established in 1997 at the Children's Hospital at Westmead as a paediatric telephone triage service. The demand for Kidsnet increased from 18 327 in 1997/98 to 22 844 in 2001/02, with an average of 1669 callers per month. Most callers were able to proceed to seeking care at a more appropriate time and were satisfied with the service provided. The service is highly valued and the advice given perceived to be accurate. Kidsnet has shown that it can play a key role in providing safe advice to families.

Parental compliance with after hours telephone triage advice: nurse advice service versus on-call pediatricians

To compare parental compliance with after-hours triage advice provided by telephone advice nurses and on-call pediatricians, a randomized controlled trial was undertaken at a university general pediatrics practice that enrolled parents or guardians calling for after-hours advice. Advice calls were randomized to a call center advice nurse or the on-call pediatrician. Parental compliance with the triage advice and agreement of the parental report of advice with the pediatrician/nurse report of advice given was evaluated. There were 566 participants in the pediatrician and 616 in the nurse group. Compliance with advice (pediatrician v. nurse) was not significantly different for emergent/urgent care (75.8% v. 72.6%) and self care (74.3% v. 77.2%) but was significantly higher in the pediatrician group for office care (51.5% v. 29.6%; 95% CI of difference, 8.9%-34.2%). Overall agreement between the caller reported and physician or nurse advice was 84.5% for emergent/ urgent, 42.7% for office care, and 93.7% for self-care.

Outcomes associated with pediatric after-hours care by call centers: a multicenter study

OBJECTIVES

To assess 1) parental opinion regarding appropriateness of triage, 2) utilization outcomes, and 3) the frequency of underreferral with subsequent hospitalization for children triaged by nurses at pediatric call centers.

DESIGN/METHODS

From August 19 to October 1999, after-hours calls were randomly sampled from computerized records at 4 call centers at children's hospitals. Telephone surveys were conducted 3 to 7 days after the index calls. An expert panel to assess appropriateness of disposition reviewed audio recordings of calls given a nonurgent disposition and then hospitalized within 24 hours.

RESULTS

Surveys were completed for 70.5% (N = 1561). Parental agreement with urgent or home care recommendations was >70% but with intermediary recommendations was <50%. Hospitalizations were more common among children urgently referred (4.6% vs 0.45%; P =.0003). Calls judged urgent by call center nurses and referred to a physician for secondary triage had lower rates of urgent visits (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.53-0.65; P <.0001) and higher rates of never having a visit (OR 1.37; 95% CI 1.24-1.51; P <.0001) than those referred directly by nurses. The weighted rate of underreferral with hospitalization was 0.3% (95% CI 0.1-0.7%) or 1 in 481 calls (95% CI 1/152 to 1/1538).

CONCLUSIONS

Our data demonstrate an underreferral rate with subsequent hospitalization of 1 in 500 calls and a significant reduction in visits when those cases judged urgent by call center nurses undergo secondary triage by physicians.

Caller satisfaction with after-hours telephone advice: nurse advice service versus on-call pediatricians

OBJECTIVE

To compare caller satisfaction with after-hours medical advice provided by a for-profit nurse advice service with advice provided by on-call pediatricians.

METHODS

The study setting was the general pediatrics faculty practice of an urban university medical center. Participants were parents or guardians of a population of approximately 6000 children calling for after-hours medical advice over a 10-month period from January 18 to November 20, 2000. After-hours medical advice calls were randomized to either a nurse advice service or the on-call pediatrician. Caller satisfaction and subsequent health care utilization were measured by a telephone survey of callers and review of all health care visits within 3 days of the initial telephone advice call.

RESULTS

Five hundred sixty-six (48%) callers were enrolled in the on-call pediatrician group, and 616 (52%) were enrolled in the advice nurse group. Caller satisfaction was rated as very good or excellent significantly more often for the on-call pediatrician than for the nurse advice service as follows: telephone call overall (68.5% vs 55.0%; 95% confidence interval [CI] of difference: 8.0%-19.0%), thoroughness and competence of the person they spoke with (74.0% vs 59.1%; 95% CI of difference: 9.6%-20.2%), courtesy and friendliness of the person they spoke with (77.4% vs 73.9%; 95% CI of difference: -1.4%-8.4%), length of time spent waiting (70.8% vs 60.1%; 95% CI of difference: 5.4%-16.2%), time spent talking with the on-call pediatrician or advice nurse (68.2% vs 52.4%; 95% CI of difference: 10.2%-21.3%), and the medical advice given (68.6% vs 53.9%; 95% CI of difference: 9.2%-20.1%). Compliance with the advice given was significantly higher for office care in the on-call pediatrician group (51.5% vs 29.6%; 95% CI of difference: 8.9%-34.2%). Repeat calls for advice were significantly more frequent for the nurse advice service, both within 4 hours (13.0% vs 4.8%; 95% CI of difference: 5.0%-11.4%), and within 72 hours (23.4% vs 13.3%; 95% CI of difference: 5.8%-14.5%).

CONCLUSION

Callers were less satisfied with medical advice provided by a nurse advice service compared with the traditional on-call pediatrician. The lower satisfaction was associated with somewhat poorer compliance with recommended triage dispositions and more frequent repeat calls for medical advice.