Telephone advice lines can benefit patients, ED
It’s a challenge for pediatric EDs in competitive markets to stand out from the crowd. Several children’s hospitals in metropolitan areas have established medical advice hotlines as a community service. "We get a lot of calls from parents who go home and have a question later that night," says Mark Burns, RN, at Good Samaritan Regional Medical Center in Phoenix, which has a telephone advice line. "The advice line alleviates a lot of that anxiety for parents."
Administrators at Egleston Children’s Hospital in Atlanta made the decision to implement a telephone advice line in March 1994. "Certainly one of the major goals was to make Egleston’s telephone service the front door of the hospital, and public relations was a very big part of that, not only for families in the community but also for community pediatricians," says Dave McLario, DO, MS, FAAP, an emergency physician who developed the protocols with the division director of general pediatrics.
The service began with a handful of nurses on staff, with all documentation and record-keeping done on paper. "We were kind of a mom and pop service at that point," explains McLario.
Protocols were developed for about 70 chief complaints. "I noted which concerns would mandate immediate evaluation in an ED or urgent care center, or the doctor’s office if it was open," he says. Further down the list were concerns that didn’t mandate immediate evaluation but should be seen the following day. "We developed advice that would be sufficient until then," he says.
About half the callers didn’t need to see a physician and were told to treat the child at home. "However, we almost always suggest they contact their physician just to go over what’s happened." Developing the protocols took several months and was an ongoing process.
Record-keeping and documentation became a challenge as the use of the service increased exponentially. "We tugged along like that for the first two years," he says. In early 1996, the advice line switched to a computerized format. Now, instead of reading down a list, nurses use computerized algorithms with decision trees. McLario worked with a consulting group to develop the algorithms.
"It was somewhat difficult to create the computerized algorithms, but in many respects they’re better because they ensure the interview process is structured," says McLario.
Working with primary care
From 800 calls in March of 1994, the advice line is now up to 16,000 calls a month in peak periods, with 50 nurses working on the line. "At one point, we had to limit the number of subscribers we were willing to take on because we didn’t have the staff to handle it," says McLario. "Once the learning phase was over, we became more efficient at structuring the conversations with the right questions and right answers, so our timespan has decreased slightly."
The advice line has not only benefitted the community, but also local primary care practitioners. "Most pediatricians find telephone issues to be one of the most taxing and frustrating aspects of their practice," says McLario. "It’s been speculated to decrease their longevity, since many are literally on call 24 hours a day."
"We tried to increase our communication with the physicians subscribing so they know why we made the decisions we made," says McLario. "We’ve also given numerous talks so they understand what we’re about and how we compare to other systems."
One problem area was conflicting perspectives on advice. "There is a certain difference in practice styles between academic centers that tend to see the sickest of sick children vs. community physicians that tend to take care of a healthier population in general. It’s important that both parties be represented."
"At first, we sent more children in than was deemed necessary by our community subscribers," says McLario. "Since then, we’ve learned an awful lot from our community pediatricians and moved away from that."
Most late-night and after-hours calls involve relatively simple matters, he says. "The vast majority of those calls don’t involve matters that you need to go to medical school to handle." With an advice line in place, primary care practitioners are relieved of this burden, and their patients get quality care.
Practicing medicine by telephone involves certain legal risks. Egleston’s risk management department reviewed policies and protocols. "They set up checks and balances which are necessary for a service of this magnitude," says McLario.
Initially, the advice line erred on the side of caution. "I wanted us to be very careful entering this program since it was a new endeavor," he explains. "We were extremely conservative and an awful lot of children were referred into the ED who weren’t really emergent. Since then, we’ve tried to learn from our nurses and community pediatricians how we could ask certain questions differently to reduce unnecessary visits to the ED."
As a result of that learning process, the advice line has reduced its referral rate for immediate evaluation to after-hours facilities to below 15%. "That figure is as good or better than any other major service," says McLario. "It’s consistent with at least one published study with physicians doing the service, and we’re pretty happy about that."
Advice line could hurt ED business
Consequently, the issue of hurting business by keeping patients out of the ED was a concern. "That clearly is an issue. We’re sure that if everyone accessed the advice line, many people wouldn’t be going to the ED at 3 a.m.," says McLario. "But given the increasing scrutiny by health plans about the necessity of ED visits, this will be a very useful tool, especially in the era of capitation. Our goal is to defer nonemergency cases to physicians’ offices.
That also benefits the hospital’s emergency physicians. "This allows them to see a more select population," says McLario. "With the telephone screening, we triage the sickest people to the ED and do a very good job of keeping non-urgent cases out of the ED, which decreases cost and time spent contesting authorization, which can take as much effort to explain and debate it for 15 minutes. Often it’s easier to just see the patient and eat the cost."
The advice line often gets patients through the night and avoids unnecessary trips to the ED. "That has great potential for keeping emergency physicians happy because they want to take care of emergencies," says McLario.
Considerable costs have gone into the service, mostly from staffing. "It’s definitely a loss leader for the hospital, but it’s something Egleston chose to do," says McLario. However, the service results in significant public relations benefits for the hospital. "Surveys have shown that patient satisfaction is over 99%," he states.
The ED works hand in hand with the telephone advice line. "We can talk to the emergency physicians and tell them what patients will be coming in," he says. "The potential for a seamless system is great."
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