After-hours Calls Research Articles

Reducing After-Hours Referrals by an After-Hours Call Center With Second-Level Physician Triage

One-third of practices signing-out to The Children's Hospital Call Center in Denver, Colorado, choose to do second-level physician (SLP) triage for calls judged by the Center to require after-hours referral (AHR). We examined: 1) the effect of SLP triage on the rate of AHRs and 2) reasons for physicians' decisions. From January 1998 to August 1998 all calls from patients using a 5-member suburban pediatric practice judged by the Call Center to require AHR were referred to the practice's on-call physician who did SLP triage and completed a questionnaire. There were 955 eligible calls, 22% (N = 216) of which were initially given an urgent disposition by Call Center nurses. Physician questionnaires were completed for 97% (N = 209). Of patients initially triaged for AHR, 49% (N = 103) were subsequently given an AHR, 17% (N = 35) a next day office referral, and 34% (N = 71) home care and advice. Reasons for not urgently referring included the following: 1) medical problem didn't require urgent evaluation (95%, N = 99); 2) change in the patient's condition; (40% N = 43); 3) prior knowledge of family's ability to evaluate and care for the patient (40%, N = 43); and 4) knowledge of the patient's medical history (18%, N = 19). After SLP triage the overall urgent referral rate was 11%. Signing out to a Call Center decreased physicians' after-hours calls by 77% and SLP triage halved the number of urgent after-hours referrals.

Parents Adhere to Residents' Telephone Advice

Residents often give advice, but how often do patients (or their parents) follow it? In this study, pediatric residents used a standard telephone protocol to handle after-hours calls concerning patients enrolled in their continuity-of-care clinic at the Medical College of Georgia. Most patients …

Hospice care using home-based telemedicine systems.

A pilot study of telenursing for terminally ill patients at home was launched as a collaborative effort between KUMC and the Kendallwood Hospice. The service used the public telephone network. Interactive video equipment was installed in the homes of three nurses who received after-hours calls and in the homes of six hospice patients living in either Kansas or Missouri. Data concerning the utilization patterns were gathered for two separate three-month periods. Patients and caregivers reported general satisfaction with the telehospice system. Both the nurses and social worker providers became comfortable about video-calls. Nurses conducted video-assessments to determine whether an 'in person' visit was necessary. This was particularly helpful for rural patients who were living a long way from the base station. In addition, Kendallwood serves an urban population and, in certain areas, night-time nursing visits raise safety concerns.

Physicians' opinions on compensation for telephone calls.

To describe the attitudes of pediatricians and other physicians practicing in a fee-for-service environment toward compensation for telephone encounters with patients. Survey by mail. The 67 pediatric and 634 other private physicians and medical school faculty of Albany County, NY. A total of 479 of all the physicians (68.3%) and 55 of the pediatricians (82.1%) returned the questionnaire. Of these, 69.9% of the total (95% confidence interval, 65.5% to 74.1%) and 58.2% of the pediatricians (95% confidence interval, 44.1% to 71.3%) indicated physicians should be compensated for calls with patients, especially for after-hours calls. This opinion was significantly associated with greater concern about liability for calls, more negative sentiments about after-hours calls, and a longer reported duration of calls. After adjusting for these factors, surgeons and pediatricians were significantly less likely to favor compensation than the group as a whole. Pediatricians in favor of compensation suggested charging a mean of $9.18 (SD $5.05) for 1 to 5 min, $14.00 (SD $8.87) for 6 to 10 min, and $22.27 (SD $12.62) for >10 min. Pediatricians reported documenting in patients' charts a mean of 35. 3% (SD 39.9%) of after-hours calls. In a mostly noncapitated environment, the majority of pediatricians and other physicians favor compensation for telephone calls with patients. Some specialists, in particular pediatricians and surgeons, are, however, less likely to support this. Additional research into the reasons for these interspecialty differences may help to guide policy decisions on the financing of health care.

After-hours telephone calls to general and subspecialty internists

To study the after-hours telephone calls received by practicing general and subspecialty internists. Observational study. Forty-four internal medicine private practices in Long Island, New York, consisting of 70 physicians (31 general internists, 39 internists with subspecialty training). All calls received by an answering service after office hours with the caller requesting to speak to one of the physicians in the study. Of the 8,444 total calls, 2,950 were to generalists and 5,494 were to subspecialists. For both groups, most calls came from patients (46.3%), followed by physicians (26.0%), then hospitals (22.2%). For patient calls to the generalists, those concerning infectious disease (15.4%), nonspecific symptoms (11.1%), medication-related questions (9.7%), and gastrointestinal (GI) complaints (9.4%) were the most common. For those calls to the specialists, GI (14.2%), infectious disease (10.9%), medication-related (10.0%), and nonspecific symptom (9.0%) complaints represented the most common patient calls. Although GI and cardiology specialists received proportionally more patient calls related to their specialities, the specialty group, like the generalist group, received calls in all the major areas of internal medicine. Patient calls for problems well outside the traditional scope of internal medicine accounted for 2.9% of the calls to the generalists and 1.9% of the calls to the specialists. About 44% of the patient calls to both groups were for potentially serious problems. After 11:00 PM both groups saw a decrease in the proportions of minor and trivial calls. These observations support the concept of broadly based medical training for both internal medicine generalists and subspecialist in preparation for the variety of telephone calls they will deal with after office hours. Practitioners should take steps to reduce the high number of medication-related patient calls.

After-Hours Telephone Coverage: The Application of an Area-Wide Telephone Triage and Advice System for Pediatric Practices

After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.

The Effect of the Initial Family Interview on a Pediatric Practice

To examine the effect of initial family interviews by health care providers on patients' use of health services, 177 patients and their families were randomly assigned to an interviewed (I) or a non-interviewed (NI) subgroup. Initial interviews would encourage families to bring their children in for health supervision visits, but discourage families from making after-hour telephone calls, using the emergency room and bringing the children to the clinic frequently for problem visits. The I families had an initial interview, attended by all family members. Both a physician and a nurse elicited patient histories and explained use of the emergency room, when to make after-hour calls, how to schedule appointments and other information about the clinic. If I families failed to have an initial interview, they were deleted from the study. In the NI subgroup, patient histories were elicited during a routine health supervision visit without the entire family in attendance, and information about emergency room visits, after-hour calls and appointment scheduling was provided during the same visit. After one year (1987) into the study and two years (1988) into the study, all patient charts were examined. Data analysis was performed using analysis of variance for repeated measures (ANOVA) and step-wise multiple regression of Statistical Analysis System. For 1987, the interview intervention explained a significant (p = 0.01) amount of variance in the number of problem visits (less in I) after controlling for months in the study and age of the child.(ABSTRACT TRUNCATED AT 250 WORDS)

Clarifying Expectations in Therapy Relationships:

This article discusses written guidelines as an aid to clarifying expectations for clients in therapy. Despite the relative affluence and sophistication of clients, misunderstandings and erroneous assumptions often affect therapy in a negative manner. Specific recommendations are noted for areas such as confidentiality and record-keeping, appointments and fees, and after-hours calls and emergencies.

Operational Issues for Hospital-Based Home Infusion Pharmacies

This article focuses on a nonprofit, hospital-based comprehensive home infusion service in which all intravenous (IV) drugs or nutritional admixtures, professional services, supplies, and reimbursement services are performed solely by inpatient pharmacists, IV therapy nurses, and pharmacy assistants. By modifying an inpatient work load measurement system, additional staff are justified by total time for home infusion service work units. Twenty-four-hour back-up by cross-trained inpatient pharmacists and IV therapy nurses has contributed to the number of patients served by the home infusion service, which has grown steadily. A permanent and complete outpatient medical record is maintained for each patient (separate from inpatient records) in the infusion service and is available for 24-hour easy access for after-hour calls. All multidisciplinary team members participate in formal, weekly patient-care case conferences to review and update all patient therapies. Services covered, billing procedures, procedure codes, allowable charges, prior approval requirements, copayment arrangements, claims processing schedules, and related billing arrangements were first identified. The overall success of the program's reimbursement remains at 85% of charges when combining all patients. Structure, process, and outcome criteria unique to a comprehensive home care quality assurance program evolved from our high volume (total parenteral nutrition [TPN]), high risk (pain management, antibiotics), and problem-prone (TPN, pain management) therapies. Reimbursement remains the most troublesome aspect of initiating a successful hospital-based program. The success of our program depends heavily on the ability to attract and retain a highly motivated professional staff and to maintain strong referral networks with local physicians, hospital discharge planners, and other health care professionals.

Strategies for reducing inappropriate after-hours telephone calls

Strategies for reducing inappropriate after-hours telephone calls

Strategies for reducing inappropriate after-hours telephone calls.

It is essential for pediatricians to allow telephone access after office hours, but the volume and the nature of such calls is occasionally resented. This study tests the hypothesis that employment of two interventional strategies could reduce the number of after-hours calls without an increase in emergency room visits. The interventions were: 1) an educational program; and later, 2) a recorded message that revealed the phone number for a second call to reach the pediatrician. The call rate remained the same before and after the educational intervention alone, but after the recorded message was inaugurated, the rate declined 28 percent. After-hours emergency room visits were similar before and after each intervention. This study suggests a simple strategy to modestly reduce after-hours calls.

Physicians' attitudes to after-hours callers: a five year study in a university based family practice centre.

A study of 8179 after-hour calls over a five year period is reported from a single training family practice centre. The analysis of the perceived validity of after-hours calls and the physicians' reactions to these contacts showed important differences with regard to patients' race, sex and age and frequency of calls per patient. Negative attitudes were particularly evident in relation to frequent users of after-hours services, black female patients, psychological problems and calls for prescriptions. Possible explanations for these differences are discussed.

Characteristics and perceptions of after-hours callers.

After-hours care remains an important aspect of community practice although little is known about the views of either physicians or patients. This study presents an analysis of 12 499 after-hours calls made to a family practice centre over a five-year period, and 798 follow-up telephone interviews conducted with people who called for help after hours. Fifty per cent of the callers requested care for themselves while the remainder made the call for another family member, usually a child; most had discussed the problem with family or friends before calling. A majority stated that they would go to a hospital emergency room if they could not use the after-hours service. Physicians tended to perceive the calls as being due primarily to physical problems, while almost one-third of the callers stated that the motive for their call was anxiety or concern rather than physical discomfort. Although there was a lack of agreement between physician and caller on several aspects of the contact, most of the callers were satisfied with the contact.

Telephone encounters in a university pediatric group practice. A 2-year analysis of after-hour calls.

The records of off-hours calls received by the University of Colorado Pediatric Group Practice from 4:30 p.m. throughout 8:00 a.m. weekdays and all day Saturday, Sunday, and holidays were audited. An answering service and pageboy system ensured 24-hour, 7-day-a-week accessibility through a single telephone number. The four practices received 2386 after-hours calls from November 1978 to October 1980. An average of 104 calls per month were received with approximately four calls per day on weekday evenings and six calls per day on Saturday, Sunday, and holidays. Five concerns accounted for 49 percent of all after hours calls: fever, vomiting and/or diarrhea, upper respiratory infection (URI), earache, and rash. While 75 percent of families made fewer than four calls per year, 4 percent made at least 12 calls per year, accounting for 18 percent of all calls. Families calling three or more times a month were defined as "frequent users" and accounted for 22 percent of a given month's calls. Most calls from the same families (55%) occurred within a 24-hour period and dealt chiefly with parental concerns about fever, vomiting and diarrhea, URIs, ear infection, accident, and rashes. The additional responsibility that residents assume in taking calls for the Pediatric Group Practice while on other off-hour assignments was not excessively demanding, and cost of the answering service was easily absorbed by group practice revenues.

Original Research : After-Hours Calls: A Forgotten Item of Education in Family Practice

After-hours care is an essential ingredient of family practice and other primary care disciplines. In various countries, between three and 70 per cent of all after hours calls are handled over the telephone without the patient being seen. Little medical education is provided to train medical students or physicians to deal with clinical problems that are more frequent after surgery hours and with communication and decisionmaking over the telephone. An after-hours record card, developed by the authors, has been used over the past three years for clinical care and educational activities.