In pediatrics, the telephone rules—during hours, after hours, all hours. It’s not news to you that babies and children get
sick frequently, and subtle symptoms can mean something serious—or nothing at all. Your expert attention is required to tell
what’s wrong, especially in a preverbal patient. You must be accessible to patients and parents at all times, and the telephone
is the most direct route.
Most common symptoms* that prompt parents telephone calls
|
You need to be able to tell who requires emergency care, who must be seen that day, and who can wait it out at home for a
few days. But you also must delegate this task—or you run the risk of spending too much time on the telephone and not enough
seeing patients!
That is why, if you do not already have one, you should consider your need for a telephone triage nurse—a specially trained
nurse who uses protocols to handle patient calls. On average, a pediatrician receives 20 calls a day about sick patients—and
another 20 from parents who want an appointment for a sick child that day. A telephone triage nurse should handle about 10
calls an hour, not including appointment calls: just right for a small group practice.
The first rule of pediatric telephone work: Never play a recorded message when parents call. Instead, have the receptionist
pick up the phone and ask if it's an emergency; if it isn't, you can put the parent on hold.
What does a telephone nurse do?
When a parent calls your office with a question about a sick child, the first person reached ought to be, as noted, the receptionist.
If the parent requests an appointment, the receptionist gives it—no telephone nurse, no triage. If the parent isn't sure whether
the child needs to come in, or has a question for the nurse, the receptionist either transfers the call, puts the caller into
the nurse's voice mail, or takes a message. Any true emergency calls can go right to 911 or to you directly.
The telephone triage nurse must be available immediately. If the parent must leave a message, at least make sure the nurse
callback takes place within half an hour. An astute receptionist can convey the urgency the caller feels to the telephone
nurse or to you. Then, the nurse decides if the patient needs an appointment, by consulting with you.
Your nurses are, of course, highly skilled at their clinical and administrative tasks, but telephone triage requires a certain
aptitude as well as training.
Why do parents call?
In most instances, you don't need prepared protocols for your work; telephone nurses do. Triage protocols must balance carefully
whether patients need emergency care, an office visit, or home management only.
A telephone triage nurse must rely on printed protocols (an example is Pediatric Telephone Protocols by Barton D. Schmitt, MD, available from the American Academy of Pediatrics). It's easier to use a book such as Schmitt's
volume than to devise your own protocols. But you'll definitely want to review such prepared protocols carefully and customize
them for your own practice so that you and your colleagues are comfortable with them. The most frequent change pediatricians
make to these protocols is, based on the nature of the emergency, whether a certain problem should go to the office or the
emergency room. (Don't customize by physician in your practice, however—that would make life impossible for the triage nurse.)
At first, the telephone triage nurse should deal only with the top 20 or so symptoms. According to Schmitt, 25 symptoms account
for 90 percent of your calls.
The most common symptoms that parents call about are listed in the accompanying table. Some frequent symptoms are actually
"safe symptoms," says Schmitt: for example, yellow nasal discharge or green stools. Your nurse should have a list of safe
symptoms, too, so the caller can be reassured immediately.
Your telephone triage nurse needs to be familiar with these protocols from the beginning. She (he) also must be able to use
multiple protocols at times. If the complaint is a cough, for example, go to the cough protocol but, if the child also has
asthma, you may need to apply the protocol for that illness, too.
It's also important for nurses to be aware of possibly serious symptoms: for example, any problem in a newborn; any symptoms
that could suggest swallowing or aspiration of a foreign body; and a swollen or tender testicle. These are red flags for possible
problems; the telephone triage nurse may need to then talk to you and not just resort to the protocols, depending on your
clinical style.
After studying the protocols, there is no other way around it: Your nurse gets the real training on the job. Under the supervision
of a trained nurse (or a consultant you hire, possibly from a call center), the trainee listens in, and then she actually
takes calls with the supervisor listening.
A telephone triage nurse must have a calm voice and be a good listener—skills most nurses possess. She should not discourage
the concerned parent from bringing the child in for an office visit; triage isn't meant to keep children out of the office
if parents want to bring them in. Every pediatrician knows that a mother is likely to be able to pick up on subtle problems
that she can't quite put a name to in terms of symptoms. If she says, "I just think something's wrong with my baby," ask her
to come in regardless of what a protocol says.
How does your office deal with the "traffic jam"?
It's a good idea to have a telephone triage nurse in the office an hour or two before the office opens—especially on a Monday.
This helps avoid the telephone "traffic jam" that begins as soon as the phones are turned on at 9 a.m. and, sometimes, doesn't
end until 10 a.m.
If the parent has done "self-triage" and wants an appointment, don't spend time asking questions: Just offer the appointment.
You need to keep activity on the telephone line moving.
Making callbacks
Don't take personally the rise in the number of telephone triage nurses being used in pediatric practices—parents still prefer
your advice above all others', according to a study.1 Nurses were perceived as just as friendly and courteous as pediatricians but parents surveyed preferred a pediatrician's medical
advice, thoroughness, and competence.
So when parents request a callback from a physician, accommodate them. During hours, you can return calls in clusters (perhaps
save 15 minutes every two hours for this activity). The parent should be told at about what time you will be calling back.
This keeps anxiety and anger from mounting while the parent waits by the telephone. Of course, emergency or urgent calls must
be returned at once—if not answered on the spot or rerouted to 911.
Responding to emergency calls
There are two levels of emergency calls: life-threatening and possibly life-threatening. Your receptionist, as well as your
telephone triage nurse, must be familiar with both kinds. Calls that reflect a life-threatening emergency need to be rerouted to 911. Examples are: severe breathing problems (child stopped breathing; child is choking and turning
blue or unable to breathe; child has problem breathing that may be related to an allergic reaction to a bee sting, medication,
or food); severe bleeding (blood pumping or spurting or pouring out); severe neck injury; seizure in progress; and unconsciousness
(child can't be awakened). Emergency calls that must be returned within five minutes and may require referral to 911 include difficulty breathing; possible anaphylaxis;
severe bleeding; neurologic symptoms (seizure, loss of consciousness, fainting, confusion, hard to awaken, altered mental
status, stiff neck); poisoning; foreign body ingestion (inhaled, choked on, or swallowed); neck trauma; eye trauma; electric
shock; near drowning; and a suicide threat or attempt.
Because emergencies can have a bad outcome if mishandled (sometimes, even if handled appropriately), many pediatricians fear
three scenarios in telephone triage that may elevate their liability:
- a caller whose child has an emergency can't get through
- a telephone triage nurse doesn't tell the parent to bring the child to the office immediately
- a nurse fails to tell the parent of a child with a life-threatening emergency to call 911 and the parent instead brings the
child to the office herself.
To counter these fears, have a well-trained telephone triage nurse ensure that she documents everything in the chart that
transpires during the call, and be certain that she errs on the side of safety. A fourth fear—that the telephone triage nurse
instructs the parent to come in immediately but the parent doesn't—is beyond your control. But be certain that your nurses
are clear in their recommendations. Some parents refuse to believe that a situation is serious until a crisis has developed.
For routine calls
Not all calls are an emergency or urgent, or even require a visit. Nurses can easily call in prescription refills (depending
on state law) and handle calls about well children (such as minor behavioral and developmental matters that arise with new
parents).
When parents call, the nurse can, when appropriate, also use the conversation as an opportunity to remind them of the need
to schedule, say, a well-child or immunization visit.
After hours: Is a call center worth it?
Some pediatricians opt to contract with a call center instead of an answering service to take after-hours telephone calls.
This allows you sleep at night (except for the few calls the call center must reach you about). Whether you use a hospital-based
call center or a private business, be sure that the nurses who answer calls all have experience in pediatric care and access
to pediatric protocols as necessary. Pediatric-only call centers are highly recommended; they can be costly but, given that
night call—and that means telephone calls, not going to the hospital—is viewed as the most onerous part of pediatric practice,
it may be well worth it to contract with one—for your peace and your peace of mind.
MS. KNOPF is a medical writer and contributor to Contemporary Pediatrics. She has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an
interest in any part of this article.
REFERENCE
1. Lee TJ, Guzy J, Johnson D, et al: Caller satisfaction with after-hours telephone advice: Nurse advice service versus on-call
pediatricians. Pediatrics 2002;110:865
