After-hours telephone triage affects patient safety

Analysis of phone calls classified by patients as nonemergent

In our previous study,¹ we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.

For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.

Results

Survey of primary care physicians’ answering services

Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”

After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,⁵ and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.

Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.

A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.¹

Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.

Analysis of phone calls classified by patients as nonemergent

Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).

TABLE 1
Telephone triage summary by specialty

TABLE 2
Sample of calls classified as nonemergent by patients