Practice recommendations
- All clinical after-hours calls should be forwarded to the on-call physician, and no triage decisions should be made by the answering service or the patient, who may erroneously and dangerously delay medical care.
- Physicians in this study who reviewed the content of after-hours calls judged not to be emergencies said they would have wanted to talk to the patients in approximately half the cases. As only 10% of after-hours calls are judged nonemergencies, talking to all the after-hours clinical calls would result in only a small increase in the number of cases handled by the on-call physician.
ABSTRACT
Objective: To describe the management of after-hours calls to primary care physicians and identify potential errors that might delay evaluation and treatment.
Study Design: Survey of primary care practices and audit of after-hours phone calls. Ninety-one primary care offices (family medicine, internal medicine, obstetrics, and pediatrics) were surveyed in October and November 2001. Data collected included number of persons answering the calls, information requested, instructions to patients, who decided whether to contact the on-call physician, and subsequent handling of all calls. We evaluated all after-hours calls to an index office that were not forwarded to the on-call physician. Four family physicians independently reviewed the calls while unaware that these calls had not been forwarded to the physician on call to determine the appropriate triage.
Population: Primary care physicians and their telephone answering services.
Outcome Measures: (1) Who decided to initiate immediate contact with the physician? (2) Percentage of calls identified as emergent or nonemergent by patients. (3) Independent physician ratings of nonemergent calls.
Results: More than two thirds of the offices used answering services to take their calls. Ninety-three percent of the practices required the patient to decide whether the problem was emergent enough to require immediate notification of the on-call physician. Physician reviewers reported that 50% (range, 22%–77%) of the calls not forwarded to the on-call physician represented an emergency needing immediate contact with the physician.
Conclusions: After-hours call systems in most primary care offices impose barriers that may delay care. All clinical patient calls should be sent to appropriately trained medical personnel for triage decisions. We urge all clinicians that use an answering service to examine their policies and procedures for possible sources of medical error.
We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.1 In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.
The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,2,3,4 and the management of these calls by professional and nurse triage services have been studied.5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.
Methods
This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study1 that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.
Survey of primary care physicians’ answering services
The physicians in each specialty were identified in their respective section of the telephone book,7 and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.
Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.
If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.