Screening after-hours calls can hurt patients, study finds

Physician answering services should always direct clinical calls to doctors, authors of a new study conclude.

By Kevin B. O’Reilly — Posted Oct. 9, 2006

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A 21-year-old pregnant woman called a Denver family medicine residency clinic after business hours and reported that she was leaking fluid. When someone at the clinic's answering service asked the woman whether the matter was an emergency that should be forwarded to a physician on call, the woman demurred.

The doctor wasn't contacted, and the woman had extreme pain and nausea for three days before an ambulance took her to a hospital emergency department. There she was diagnosed and treated for pyelonephritis. Though the woman emerged relatively unscathed, the authors of a study published in the September/October Journal of the American Board of Family Medicine say she was not alone in being harmed unnecessarily.

Researchers said just 10% of the nearly 3,000 after-hours clinical calls studied were not forwarded, suggesting that using the emergency question as a screening device does not greatly reduce volume, while retaining the potential to harm patients.

"There are between 2 million and 5 million after-hours calls to physicians every year," said David Hildebrandt, PhD, lead author of the study. "If 10% don't get through to a physician, that's 200,000 to 500,000 calls with perhaps 1% of patients being harmed. In that group, some of those people are going to die."

Researchers examined a year's worth of patient calls and medical records to see what exactly was happening to patients who called after hours. From April 2000 to March 2001, 3% of patients whose clinical calls were not forwarded were seriously harmed, 26% experienced discomfort due to delay; 4% need a medication change and 1% required emergency transport to the ED.

The emergency-screening practice is widespread, according to the researchers, who surveyed 35 physician offices in seven states. They found that of the 40% of offices that use answering services to handle after-hours calls, 65% ask patients to decide whether to have their call forwarded to a doctor on call, 21% let the service decide whether to forward the call and 14% use a nurse triage system.

"Once the person has made a decision that their concern is worth calling about, then why do we put up another barrier for them to get through?" said study co-author Wilson D. Pace, MD, who holds the Green-Edelman Endowed Chair for Practice-based Research in Family Medicine, at the University of Colorado School of Medicine.

The "Is this an emergency?" question "emanates from a provider-centered approach to patient care," Dr. Pace said. "If you think it's important to talk to me, I should talk to you."

Charles M. Kilo, MD, MPH, an internist and president of a six-physician practice in Portland, Ore., said more primary care doctors are, wrongly, seeking greater "protection" from their patients.

"We should be working harder to serve our patients' needs and to get closer to them, not to get further away from them," Dr. Kilo said via e-mail. "I would prefer for a patient to call me any time of the day or night rather than going to an urgent care center or emergency room unnecessarily."

Bruce Bagley, MD, medical director for quality improvement at the American Academy of Family Physicians, said doctors should not put clinical decisions into the hands of patients or an answering service.

"You want the highest level clinical person determining what's an emergency, not a person at an answering service who knows nothing from nothing," Dr. Bagley said. "There's a tremendous hesitancy about calling the doctor, anyway -- especially after hours. The people who call are already tremendously filtered. To filter it further is nuts."

Dr. Hildebrandt said the research team is working on securing a National Institutes of Health grant to persuade doctors to change how their answering services handle clinical calls.

Meanwhile, the clinic the 21-year-old woman called, part of the University of Colorado Health Sciences Center, changed its practice immediately after learning of the incident and now all clinical-related calls are forwarded to a doctor.

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Is it an emergency?

Examples of calls to a Denver family medicine residency clinic that were not forwarded to an on-call physician because the patient decided the matter was not urgent.

Age/gender Reason for call (Days before follow-up) Outcome
46/F Pain in chest, going down left arm (Same day) Went to ED, admitted for medication interaction, psychological problems
62/M High blood sugar (1) Went to office with blood sugar 497, 6 weeks polyuria, polydipsia, muscle cramps in lower extremities, ketones present; no prior history of diabetes; sent to ED for fluids
16/F 8 months pregnant, pelvic pain (1) and vaginal infection for 3 months Admitted to hospital; cesarean section for acute chorioamnionitis; hospitalized 4 days postsurgery
27/F Chest pain, hard time breathing (2) Went to office with a presyncopal episode; set up for Holter monitor

Source: "Harm Resulting from Inappropriate Telephone Triage in Primary Care," September-October Journal of the American Board of Family Medicine

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