Telephone Triage: Protocols for Adult Populations

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Caregivers of 94 private practice patients and nonprivate practice patients were given home treatment advice.

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Appointments to be seen at their primary care source were given for 78 private practice patients and nonprivate practice patients. Private practice patients are more likely to be referred to the ED. Calls for nonprivate practice patients are more frequent and these patients are more likely to be referred to their primary care source. This difference may be due to caregivers of patients from nonprivate practices seeking advice for less serious conditions. Physicians should address telephone medicine with caregivers proactively during health maintenance visits.

Pediatricians and family practitioners who provide primary care to children often receive numerous telephone calls, which may be due to several factors, both economic and behavioral. The current climate of medical economics emphasizing cost containment has led to increased demands on physicians to decrease the costs of office care and limit the use of emergency departments EDs and urgent care facilities as well as subspecialty services.

This tends to increase the use of "telephone medicine" to extend the presence of the physician provider. Caregivers of children tend to be young and less medically experienced, increasing their need for contact with their primary care provider via the telephone. This is compounded by the fact that children are often perceived as more vulnerable medically and their needs often receive priority in a family, sometimes at the expense of good judgment. Because many pediatric primary care providers find after-hours telephone coverage frustrating and unrewarding, 1 both financially and psychologically, they have sought methods to ease the burden of telephone medicine.

One method has been to use nursing staff as front-line providers to triage telephone calls and determine the need for physician interaction. However, this requires additional nursing time after regular business hours and training by the physician to ensure that good medical advice is given. This training tends to be time-consuming, varied in content and quality, and individualized to different practices. To enhance and ensure high-quality triage and advice skills for nursing staff, several authors have published telephone protocols designed to be followed by ancillary staff, usually nurses, so that optimal advice is given.

We recently instituted a demand management, computerized telephone triage and advice program designed for nurses based on the protocols of Schmitt. We report our early experience with the program and compare the types of calls, recommendations resulting from these calls, and compliance with these recommendations in these 2 diverse patient populations. The objectives of this descriptive study were 3-fold: 1 to examine and compare the different reasons for calls and recommendations resulting from these calls that were received from 2 different patient populations, private and nonprivate practice; 2 to assess and compare compliance with the program's advice that is given using these protocols; and 3 to determine the appropriateness of the advice and disposition given to caregivers by the nurses using the protocols.

This study was approved by the institutional review board of the Children's Hospital Medical Center, Cincinnati, Ohio.

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The patient populations studied came from 3 private pediatric practices in suburban Cincinnati and 1 urban, hospital-based, resident continuity clinic. All calls received after regular business hours 5 PM until 11 PM Monday through Friday and 7 AM until 11 PM on weekends and holidays were examined for the day period of September 1 through 15, , which included 5 weekend days, 1 holiday, and 9 weekdays.

All referrals for emergency care from the continuity clinic were made to the ED at the Children's Hospital Medical Center.

All referrals for emergency care from private practice patients were referred either to the Children's Hospital Medical Center or to 1 local urgent care facility. Telephone encounter documentation complaint, history, disposition, and advice given of all calls was reviewed by one of us R.

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By means of data entry into the computer as the call is being taken, complete documentation of the call is stored electronically and can be restored to hard copy as needed. Statistical analyses were performed using Epi Info, version 6. Patient ages were compared using the Student t test. The 3 suburban private practices whose calls were monitored during the study period serve a total of approximately 24, patients.

The urban, hospital-based clinic serves approximately 12, patients. The tabulation below shows the payment status of the 2 groups, by percentage of patients. HMO indicates health maintenance organization. The times of the calls are shown in Figure 1 and were distributed similarly in both groups. Time of calls to primary care provider from caregivers of patients in private and nonprivate practice.

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The age distribution of the patients is shown in Figure 2. Age distributions of patients in private and nonprivate practice for whom calls were made. Eighty-one calls were referred by the nurse directly to the physician caregiver demanded to speak to the physician, nurse unsure of appropriate disposition. Of these, 55 were regarding private practice patients in most instances, the caregiver had demanded to speak directly to the physician and 26 were regarding nonprivate practice patients in most instances, the nurse was unsure of the appropriate medical management.

The remaining calls private, nonprivate were used to compare compliance with disposition Table 1. Office visit referrals were grouped together and included referrals for a physician encounter in 4 hours, 24 hours, 48 hours, 72 hours, and 2 weeks. There were no differences in compliance with these dispositions. Just fewer than half of patients referred for an immediate evaluation complied with that disposition.

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About two thirds of patients who had been referred for an office visit for evaluation complied with that disposition. The results of this descriptive study of an after-hours telephone call triage service do not differ from the results of previous studies of after-hours calls for medical advice in either the types of calls received or the times the calls were received. Some of the download is provided and some was illustrated.

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Logistic regression was used to assess the association between IS status with adherence to the call recommendation. Multivariable models were used to adjust for potential confounding effects of gender, CCI score, call duration, person who placed the call surrogate or self , and recommended action. Interactions were assessed and those found to be significant were presented using stratified models to compare the association of IS status with call follow through by recommended action and by caller surrogate or self.

The median Q1, Q3 age of callers was 53 36, 67 years and callers were more frequently female in both groups. Among the IS callers, the most common languages were Somali There was no significant difference in the number of calls placed between the two groups. Nurse recommendations for higher acuity care, call an ambulance, visit the ED, or schedule an acute appointment were more frequent for IS callers than non-IS callers These differences remained significant after adjustment for comorbidities data not shown.

There were no significant differences in the chief symptom for calls between the two groups.

Telephone Triage:  Protocols for Adult Populations Telephone Triage: Protocols for Adult Populations
Telephone Triage:  Protocols for Adult Populations Telephone Triage: Protocols for Adult Populations
Telephone Triage:  Protocols for Adult Populations Telephone Triage: Protocols for Adult Populations
Telephone Triage:  Protocols for Adult Populations Telephone Triage: Protocols for Adult Populations
Telephone Triage:  Protocols for Adult Populations Telephone Triage: Protocols for Adult Populations

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